Under the 2010 Patient Protection and Affordable Care Act (ACA), it is estimated that approximately three-quarters of 7 million children who are uninsured in the United States would be eligible for Medicaid, the State Children’s Health Insurance Program (CHIP) or the new premium tax credit. However, the ACA focus on insuring the newly eligible adult population provides for a potential gap in children’s coverage during the period of 2015 to 2019, as CHIP will not be funded beyond September 30, 2015.
The Maintenance of Effort clause in the ACA requires states to maintain CHIP and the Medicaid eligibility and enrollment standards, which were in place as of March 2010, through 2019. Therefore, without CHIP funding, states will need to evaluate options for keeping children currently on CHIP from becoming uninsured during the transitional implementation of ACA and the initial use of Health Insurance Exchanges.
Some options being considered by States include:
- Continuing coverage for CHIP enrollees as-is for those children that will not meet Medicaid eligibility requirements or qualify for an Advance Premium Tax Credit.
- Not continue coverage, but provide transition period with options for referrals to other programs through the Health Insurance Exchange (HIX), such as a child only policy available in the HIX.
- Define and provide an alternative benefit package to CHIP enrollees, only providing selected services.
Additionally, depending on a State’s individual budget circumstance, any unspent CHIP allotment funds for 2015, may be held over to fund the State’s CHIP in subsequent years.
Public Knowledge, LLC specializes in helping health and human service agencies with research and options analysis studies in support of the Patient Protection and Affordable Care Act and other state and federal mandates.
States that have elected to implement a State-based Exchange (SBE) instead of using the Federally-facilitated Health Insurance Exchange (FFE) are navigating new territory that reveals some unique challenges. States looking to CMS for clarification on key design and development issues are met with delayed guidance as HHS and CMS work to meet their own deadlines for the FFE. This is making it difficult for States to work confidently toward their deadlines.
Two specific questions that continue to perplex State health and human services budget offices are:
- How will States manage very sick populations and what will these populations do to the State health insurance exchange risk mix pool?
- For States that opted for the SBE approach, and initially rejected federal exchange money prior to the 2012 U.S. presidential election, how will they now fund the development and implementation of a SBE?
States anticipate that very sick populations will increase cost of health insurance premiums significantly. It is unclear whether HHS has any suggested approaches for managing this population so that premiums aren’t inflated for everyone. Similarly, States are required to submit a description of their risk adjustment methodology to HHS for review and certification, but more guidance in this area is needed in order for States to flush out their risk adjustment models. Forecasters believe that by 2014, all States, including SBE States, will likely default to a federal risk adjustment model. HHS suggests that risk adjustment models should be designed to align with the associated health insurance exchange it supports.
Regarding determining how States will pay for the development and implementation of SBEs the Patient Protection and Affordable Care Act (ACA) does not clearly address this topic. This is particularly acute for states that originally rejected federal funding. This leaves State’s to question whether they will be able to re-request federal monies that were initially turned down.
Public Knowledge, LLC specializes in helping health and human service agencies with planning and implementation activities in support of the Patient Protection and Affordable Care Act and other state and federal mandates.
Did you know you that you must be able to accept Health Insurance Exchange (HIX) applicants (new applicants or redeterminations) through the web, on the phone, in-person, AND through the mail? To be clear, in support of a new single streamlined application, you must support all four application entry points when you launch your HIX with the exception of Modified Adjusted Gross Income (MAGI) based eligibility determinations (In person interviews cannot be required for theses individuals). Most states determine eligibility via forms submitted through the mail and are not prepared for making eligibility determinations or redeterminations in person, on the web, or through a phone call. A significant restructure of policies, business procedures, and technology (like phone systems) is going to be necessary for most of our clients.
We’ve noticed a tendency for states to focus on the information technology (interfaces to eligibility systems and web sites) aspects of HIX assuming the in-person and phone processes can be easily figured out later. All of these are important and will take longer to develop than you might think, particularly as they require coordination and simplification across benefit programs. As part of HIX readiness you want to consider a comprehensive architecture for your HIX that includes not only the information technology but also other technologies (like cloud-based telephone contact center solutions), processes, and policies.
Public Knowledge, LLC specializes in developing comprehensive architectures for business needs that include not only technical considerations but also the process and policy architectures.
Just want to wish all of you a happy holiday season this year. It’s been a great year and we look forward to working with you in 2013.
– The PK Crew
One of the biggest complaints we have with the way Quality Assurance is typically performed for large systems projects is that the process is reactive rather than predictive. This means most QA consultants wait for failure to happen (for example a project deliverable has defects), report the defect occurred, and then figure out what to do about the problem after the fact. It’s an approach that evolved from financial auditing and is a bit like driving a car while only looking in the rear view mirror: all we can say is either “Everything has been OK so far” or “Oops we hit a tree back there”. The issues this raises are pretty obvious:
- You have some crisis or failure to deal with;
- Dealing with this takes time that could be better spent elsewhere;
- Relationships can be strained and trust lost; and
- You have a quality problem.
So what do we do differently? Over the years PK has developed a “toolkit” of techniques we use to help identify potential issues and avoid them. We call it “Predictive Management”. The techniques range from developing mathematical models that predict project performance and schedule delays to conducting facilitated workshops that proactively identify, prioritize, and avoid potential risks. Some of these we have developed based on our experience (declining balance work graphing) and others are industry standard tools (Failure Mode and Effects Analysis). Combined these serve as a powerful toolkit to avoid quality issues. Do they identify and avoid all issues? Of course not, you’ll never predict everything. What we have found is through the rigorous application of these techniques most major issues that significantly delay projects and raise costs can be identified ahead of time and if not avoided at least mitigated to optimize project performance.
Performance measurement has had an uneven history in public sector agencies. Very few government entities have successfully implemented performance measurement and use the measures well. Even when successfully implemented we find many times that measures are eventually ignored and discarded. There are four overarching reasons for failure:
- Defining meaningful measures is a technically challenging task in public sector. Governments don’t manage to increase the “bottom line”. This means the key measurements are different than in private sector. We often see governments try and emulate private sector measures which doesn’t work.
- Measures chosen have too many technical flaws or are too complex. If the collection of measures itself is a heavy burden, there aren’t staff available to collect the data (and who has extra staff these days), or the measures themselves have technical flaws support for measurement will wane in the organization. We’ve seen many efforts die on the vine because of technical flaws in the measures or measurement process.
- Lack of support or intermittent support from senior management. The single best predictor for success of performance measurement is that it has the support of at lease one senior manager who values quantitate information and consistently uses it to management.
- Lack of collaboration and participation of agency staff and third parties. To work well, performance measures must have broad participation of staff and, at times, even external partners.
There are multiple reasons performance measurement initiatives fail. However, if you are aware of the reasons for failure and take care to avoid them when developing and implementing your measurement system you can be successful.
Public Knowledge, LLC has a comprehensive approach to developing and training you in the use of measures on your projects and programs. We have helped many clients implement measures in support of their initiatives. We’ve found that, when applied correctly and consistently, performance measures increase the odds of successfully implementing a program or project, improve efficiencies, and lower costs.
IT World has an interesting article about using the tools and techniques of agile development and scrum for projects other than software development. Many of the techniques are similar to PK’s own Predictive Management (PM) toolset. For example, the use of regular short meetings (stand ups in scrum and targeting sessions in PM) and the focus on remaining work rather than work completed (burn down charts in scrum and declining work balance graphs in PM).
The goal of both approaches is to get people to think about what they can really accomplish and keep them on track by focusing on what’s important. We’ve used PM internally and taught it to our clients for their use for over 20 years. Internally we’ve found the techniques allow us to:
- Accurately predict the costs and duration of our projects,
- Deliver services at a lower cost than others, and
- Keep the quality of deliverables and services high.
We have seen these benefits accrue to any project using the Predictive Management toolset. Consider using agile and scrum on your next “non-IT” project. Or better, yet contact us about using Predictive Management. After we complete our series on Performance Measurement we’ll discuss some of the Predictive Management tools.