Plato is often quoted as having said, “Necessity is the mother of invention.” In times of intense need, humans tap into their innate abilities to be resilient and figure it out.
The mass redetermination effort for close to 90 million people in the United States who have been covered by the Medicaid program during the COVID-19 public health emergency (PHE) is imminent. The public servants who support these programs in the federal government and all states and territories have been actively planning for the inevitable increase in workload due to this event. Intensifying the perfect storm is the likely advent of a recession and the national deficit of labor that has plagued both the private and public sector for the past few years. These are the times Plato’s quotes were made to describe.
As we wait for word on exactly when the PHE will end, there are some lanes of opportunity that can be explored to help ease the strain on the program. States are already doing some of these things, while others they may be considering or are in the process of designing.
1. Flexible Location Requirements for Resources Supporting Enrollee Confusion
The number of people working remotely increased dramatically during the pandemic, and millions still prefer to work from home rather than in an office. As states seek to recruit, train and model staffing plans to support anticipated high call volumes once they execute their outreach strategies, incoming traffic has the capacity to overwhelm an already beleaguered workforce.
Some states have successfully released restrictions requiring call center employees to live in-state, thereby expanding their capacity to support enrollees. If your state currently has requirements preventing out-of-state hires, identifying ways to remove these constraints could go a long way toward facilitating innovative ways to ease local labor shortages. These innovations can also serve to offer Medicaid recipients options to engage with you at the most opportune times. Having a multi-site call center also allows states to avoid the expense of non-prime time rates for workers who can support your needs in different time zones.
2. Automate. Automate. Automate.
During the COVID-19 pandemic, the entire world found ways to accelerate technology projects that improve the service experience and allow critical programs to continue serving their recipients. More processes have been digitized during the PHE than ever before. In an article published (Sirina Keesara, 2020) in The New England Journal of Medicine, the authors state, “In a very real sense, the spread of Covid-19 is a product of the digital and technological revolution that has transformed our world over the past century.”
Some of the most forward-looking states have very brilliantly applied a risk-based model to accelerate and prioritize the systems and processes within their operations that simply cannot fail and are the most labor intensive to manage. Other states have used Lean and risk models to make a business case with their leadership and legislature to remediate the risk of workload and recruiting during the PHE.
Most states have already done yeoman’s work in fine-tuning or at least reviewing for optimization, and are working at breakneck pace to automate as many processes as possible, from identification to outreach. Routine processes that don’t require human intervention have also provided ripe opportunities for states to implement automation and speed up back-office processes, reduce human error and get more done with greater efficiency.
Of course, the most important benefit of automation is that it eases the burden on staff. With less time spent handling repetitive tasks, employees have more availability to provide high-touch and complex support to enrollees who have questions, confusion and need assistance.
3. Getting Ahead of the PERM Game
Even before the PHE, designing strategies to reduce the Payment Error Rate Measurement (PERM) have been one of the many things keeping Medicaid directors up at night. Many of the errors within the DNA of each state’s PERM rates come not from incorrect determinations but from the operational missteps that occur during normal business — particularly when conducting enrollment and redeterminations for both providers and Medicaid recipients.
The unwinding will undoubtedly exacerbate the risk of payment errors, as will new employees trained to support this surge work. Identifying ways to create an “in-process,” pre-audit function would serve to buy down the risk associated with increased volume and decreased resources. Much like security systems have designed a book of business around pen testing to proactively identify weaknesses in their security walls, states could proactively self-audit their processes to ensure redeterminations are being done accurately. Self-auditing would also enable states to course correct more quickly and effectively if a process or operational challenge causes a payment error.
Having a comprehensive redetermination preventive quality oversight plan that has the ability to assess accuracy in real time could allow some states to maintain a much higher level of accuracy for eligibility determinations. When errors do occur, internal checks and balances can identify and correct them before they become bigger problems.
4. Consider Outsourcing Traditionally Governmental Roles
Over the past decade, the federal government has benefitted from advances within the Medicare Appeals program, which has accelerated the government’s ability to increase the effectiveness of their operations in a big way. This has been the result of the creative leadership at CMS continuously innovating and pressure testing old posits about what is inherently governmental and what can successfully be contracted with efficiency. It is possible that there are places within the Medicaid ecosystem that could be reassessed in the same way. Identifying tactical, operational, or repeatable transactions that could either be automated or subcontracted may free up state resources to focus on ensuring that redeterminations are effectively staffed. This would bolster states’ abilities to ensure the most vulnerable members of the population are accurately determined eligible for Medicaid coverage or to receive insurance on the federal or state exchange programs.
These are bold solutions, but the unwinding will require multiple departments of government — not simply those related to healthcare — to join for the common good.
5. The Next Phase of Optimization in Access: Accelerating Integration for Eligibility and Enrollment
In most states, recipients must navigate between several different agencies and departments to apply for benefits like Medicaid and CHIP, food stamps, housing and social services. While states focus on the current emergency, some are identifying strategic changes that will position them to be more camera ready when they move implement technology to simplify and centralize these processes.
Investing in a foundational change now that could streamline the enrollment process across these programs in the future is a state-level investment that could ease the burden on our citizens in need as well as the workforce. For example, forward-thinking states like California are making plans now to create the next generation of population health management tools that will make healthcare more effective, efficient, and equitable, and provide the state with risk-based situational awareness to identify who needs the most and why.
Leveraging the Moment
We know without a doubt the end of the public health emergency is going to be a challenge for the health system in many areas. Times like this call for out-of-the-box thinking, creative problem solving and a true team approach to dealing with the crisis. The good news is that this event can be a catalyst for the acceleration of some of the great ideas that many have been excited to implement for quite some time. All progress is good progress and can yield benefits now and for years to come.