8 Ways to Modernize Your Medicaid Program in the New Year

8 Ways to Modernize Your Medicaid Program in the New Year

Out with the old, in with the new.

That’s a common refrain repeated every January. And as states look to shift from monolithic Medicaid Management Information Systems (MMIS) to modular Medicaid Enterprise Systems (MES), here are eight modernization strategies to help you move forward in the new year.  

1. Build a Strategy Based on Business Processes

As states modernize, it’s tempting to start with technology. But business and operational processes should always be at the heart of modernization. Identifying opportunities for process improvement and employing technology as the enabler will ensure systems and operations are aligned toward program outcomes. 

2. Go Modular

Modularity can help states achieve desired business outcomes, allowing complex MMIS systems to be divided into separate scalable components that address a specific business function.

These components work together seamlessly, helping ensure the timely delivery of services and a better user experience for everyone. Modular systems will make it easier for recipients to enroll for benefits and find providers, and for providers to submit and process claims quickly. And once modular systems are in place, states are expected to save costs on IT — money that can instead be used in providing benefits.

3. Modernize in Place

States can also achieve the modernization goals of the Centers for Medicare & Medicaid Services (CMS) by using a more risk-averse method we call modernization in place. In reality, the majority of monolithic MMIS systems already manage Enterprise Data Warehouse (EDW), Pharmacy, Independent Verification & Validation (IV&V) and Integrated Eligibility as separate modules. Modernization in place keeps the existing, working MMIS in place, while taking a phased approach to modernization.

4. Opt for Configurability Over Customization

As states look at modernizing strategic business processes — combating fraud, for instance — building a customized system might sound good. However, this approach can be both costly and limiting.

Configurability offers distinct advantages over customization. A configurable system is often a fraction of the cost. And when built on a modular, cloud-hosted platform, configurable systems allow for the adoption of new features as they become available and adaptability to the ever-changing healthcare landscape.

5. Unwind — and Reset

The COVID-19 public health emergency (PHE) expiration could hit states hard as an already overburdened workforce begins the process of redetermination — or “the unwinding.” States can take efficiency-enhancing steps now to manage PHE-related challenges while modernizing their operations. It’s an ideal time to automate as many processes as possible, adopt lean practices and rethink burdensome policies.

“Times like this call for out-of-the-box thinking, creative problem solving and a true team approach,” says Karen Shields, Gainwell’s chief client engagement officer. “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.”

6. Modernize Beyond Mandates

Commit to modernization as a culture rather than waiting for the enforcement of a rule or the arrival of a catastrophic event such as COVID-19 to create urgency. States can start enhancing their systems now and evolve with both the market and technology to avoid a steep learning curve later. 

“To view the rule as just a technology implementation is a short-sighted interpretation,” says Ignatius Cruz, director of Interoperability Solutions for Gainwell. “There’s the short-term goal of compliance and then there’s the ultimate goal of a truly connected healthcare system. What happens in between is innovation.” 

7. Embrace a Digital Mindset 

Break free from the constraints of on-premises architecture and consider the long-term, far-reaching value of the cloud — speed, configurability, agility and the ability to scale resources up or down as needs fluctuate.

Cloud allows organizations to reimagine just about everything they do — and do it better. Take security, for example. “The cloud opens the door to more security capabilities than ever before,” says Jacob Sims, Gainwell’s chief technology officer. “But more than that, the cloud allows states to push the innovation bubble beyond the high-level security that already exists in the cloud, enabling them to weave security and compliance into the fabric of their operations.”

8. Go for It

CMS published its Modularity Final Rule seven years ago, in 2015. As Gainwell’s Rajesh Sharma points out, “There are sufficient data points and lessons learned to guide states on how to go about their modular MES journeys.”

So get on board. Early movers have already paved the way, allowing the industry to learn from their successes and failures. And in 2023, Gainwell has even bigger things in store for the industry, using the power of the cloud to elevate experiences and unlock opportunities for recipients and those who serve them.

Move ahead with modernization. Make this year the year to say, out with the old … and in with the transformational.

The editorial staff had no role in this post's creation.