Here is an overview:

• The project was authorized by the State Legislature to find a more precise way than client/staff ratio to determine the number of staff needed to provide services (although truth be told they really wanted to prove that the agency had too many staff) and to identify process improvements and other cost savings (who wouldn’t want that).
• We studied Food Stamp and Medicaid Eligibility, Adult Protective Services, Case Management in Long Term Care and TANF, Vocational Rehabilitation Counseling and Employment Related Day Care and Medicare Part D.
• Our methodology was rather innovative. Historically staffing or workload studies are often done to determine federal reimbursement and use Random Moment Time Studies where workers carry a beeper and record what they are doing when the beeper goes off. This produces a lot of data but only quantifies what workers are doing now -  not what has value or what could be done differently and how much time could be saved. We developed a “triangulation” method – using multiple sources to quantify workload and improvement opportunities. We typically used site visits with staff interviews, direct observation and process mapping (much of the site visits protocols we now use were developed here); electronic surveys of all program staff (with “reasonableness” checks); best practice searches,  and focus groups.
• Our results were presented as high level process maps that showed tasks, how long each task took, and how often the task would be done each month. For example, we calculated how many minutes it takes to process a food stamp application multiplied by the expected number of applications and divided by the number of minutes available per worker to give us a staffing level. We could demonstrate the savings in time and dollars if tasks were done differently. We also proposed some major changes in the model for doing case management and vocational rehabilitation counseling – using the case manager as a team leader with para-professionals doing tasks that did not require case management credentials and expertise.
• Much to the delight of the legislature -we showed the  expected cost savings for process improvements. For example, one of the easiest process improvements recommended and subsequently implemented was to synchronize eligibility redeterminations for clients. Clients were typically receiving multiple services from the agency (Food Assistance, Medicaid, etc.) but the time periods for re-determining eligibility for each service was different. Agency staff would review the same information for a client for one service and then later review the same information for the same client for a different service. By synchronizing the time periods for these reviews the agency could save approximately 2.6 million dollars per biennium (one-half of which was the state’s share).

We have used this methodology in both large (as noted above) and small studies as well such as a study of clerical services for a county senior services office and found equally successful results.

We base our advice on empirical data.  The most conservative stance (from a business perspective) we can take based on the data available to us is that our clients should continue to prepare for the implementation of the law.  We’re in for a long road ahead (both the legal battles associated with and work required to implement the ACA) and the deadlines are looming

• Many of these initiatives are falling on state insurance commissions to implement because of their knowledge of state insurers. The interface for an HBE is required to determine eligibility and enroll eligible participants on the spot. This part of an HBE makes it more like an entitlement or grant program (Medicaid, TANF/SNAP etc). There are two technical challenges here. First, insurance commissions don’t have experience running large scale eligibility and enrollment programs. Second the IT staff of insurance regulators is typically quite lean, i.e. they don’t have the staff necessary to build and run the infrastructure required for such programs.
• States will need to make a decision early if they will support a single solution for all HBE needs or have separate solutions for individuals and small businesses. The needs of these two groups are different and alternatives must consider requirements for both groups.
• Developing an effective user interface (UI) to compare plans will be difficult. Insurance plans are not developed in a manner that promotes easy comparison. Different insurance companies often use variations in the way plans are presented to market their strengths. In addition to the policy implications associated with this there are also technical development considerations: How can plans be displayed and prepared? Should there be other features on an HBE site (e.g. health education information)? And, what are the best ways to design sites focused on consumers?
• The Federal Government recommends that states have a common web based front end for HBE Subsidies, CHIP and Medicaid programs (section 1413 and 2201 of the ACA). This includes both determination of eligibility and enrollment for these programs. Developing effective web front ends for any application is challenging. Finding an effective means of utilizing other state information services (eligibility determination and enrollment for these other programs) represents a challenge few states have conquered. Collaboration between agencies running entitlement and grant programs and the insurance agencies technology divisions will be a must to make an HBE work.
• Related to eligibility and enrollment, the volume of potential enrollees in an HBE supported plan will dwarf the current number of Medicaid users in a state. They will enroll over a relatively short time period. Insurance providers will need to be in the system. HBE projects need to plan an approach that gets insurance providers in the system and can screen a large number of applicants in a short time.

We are working with our clients to address these challenges. As common solutions emerge we’ll share those with you (along with other challenges we find!).

The CIO was engaged in the procurement of a Medicaid Management Information System (MMIS). The project was stretching his resources thin and he was relying on us (PK) to supplement his staff with MMIS procurement expertise. We were leading a discussion of procurement strategies and the question came up “Why can’t we just outsource the whole thing, why do we need to buy an MMIS – can’t we just rent one like other people rent applications like Salesforce?” The CIO had been reading a lot about Software as a Service (SaaS) and this seemed to make some sense to him. The potential benefits are large:

• He’s already being asked to cut his capital (one time expenditure) budget and this could provide a significant reduction. It may even offer operating budget cuts as well;
• He has been worried about getting and keeping the staff required to implement and maintain a large system. He has had a lot of staff attrition due to retirement and difficulty in recruiting and training new staff;
• He has wanted to devote his staff efforts to more strategic projects (as opposed to the operational nature of an MMIS) that would better support the agency.

There were some obvious roadblocks:

• A waiver from CMS would be required – the law technically says states have to construct and maintain an automated system to handle Medicaid claims;
• Most MMIS vendors, despite what their marketing literature tells you, are not prepared to run Medicaid as a software service;
• He believed vendors would try and create lock-in with their product through proprietary data formats and unique features. After some discussion the realization dawned this is the case with the way things work now.
• There was a long discussion about privacy and security. How would that be ensured? The technical staff in the discussion assured us through the use of Virtual Private Network technology such a set up would be no less secure than their existing systems.

Overall it was a thought provoking discussion. Though we didn’t reach any definitive conclusions we all realized this approach has significant potential. The recent elections emphasized government agencies will have to live with less. This CIO is on the forefront of identifying ways to deal with these budget shortfalls and on effectively using technology to further the mission of his agency.  We’re continuing to work with the agency to flesh out the implications of this strategy.

You can find it here: http://healthreform.kff.org/timeline.aspx

Public Knowledge has a history of assisting its customers with the planning and development of Health Management Programs that improve quality of care, improve health outcomes, lower total costs, and better-educate providers and Medicaid clients.

Recently, we helped a State implement a unique Health Management program for its entire Medicaid population.  The program included even healthy Medicaid clients, who are usually ignored in traditional disease management programs.  The program itself consisted of:

• A Disease Management component for certain chronic diseases such as asthma, diabetes, and others;
• A preventive education and outreach component for all Medicaid clients; and
• A comprehensive case management component for catastrophic/high risk medical cases.   The broad scope of this program is unique.

So what have the results been?  In its first 6 months of operation the program saved the State’s Medicaid program more than $15 million.   Greater savings are being realized in its first few years of operation.  Further, based on our regular reviews of the program, the quality of care to clients has improved.  Pretty much a win/win.

The graph shows most of the effort in large system development goes into removing defects. Defects can occur in the feasibility, requirements, analysis, design, and coding phases of a project. The sooner a defect is detected in the development life cycle the less expensive it is to correct. So, defects detected in requirements are relatively inexpensive to correct whereas a defect in code is significantly more expensive to correct. Once a system is in operation defects are very expensive to correct. Think about it: not only do you have to fix the code but potentially you fix documentation, retrain users, etc.

So this all begs the question – where do you put your effort and resources during the development of a large system like an MMIS? Focus on quality early (rather than waiting for the testing phase of a project) saves money.  A modest investment in quality assurance or independent validation and verification up front results in real dollar savings down the road.

To access the SHIE Toolkit, visit: http://statehieresources.org/

If you would like some help learning how to use the toolkit please contact us at info@pubknow.com.

CMS’s proposed rule would phase in more comprehensive criteria for demonstrating meaningful use in three stages.  Stage 1 would begin 2011 and focus on electronically capturing health information and using that information to track major clinical conditions, increasing communication between care providers, and initiating the reporting of clinical quality measures and public health information.  Clinical quality measures would need to be directly submitted to CMS starting 2012.

CMS will build upon findings in Stage 1 to propose two additional Stages of meaningful use.  Stage 2 will likely add criteria in the areas of disease management, clinical decision support, medication management, patient access to their health information, transitions in care, quality measurement and research, and increased communication with public health agencies.  Stage 3 may further expand on Stage 1 and 2 to focus on achieving improvements in health care quality, safety and efficiency, decision support for national high-priority conditions, providing patient access to self-management online tools, and improving overall population health outcomes.

In addition, an interim final regulation (IFR) issued by the Office of the National Coordinator for Health Information Technology (ONC) proposes an incremental approach to adopting initial standards, implementation specifications, and certification criteria for EHR technology to support meaningful use.  Subsequent rules will contain standards with greater detail to achieving interoperability.

Both CMS and ONC encourage public comment on each regulation.

For more information on the proposed rule, visit:

CMS: http://www.cms.hhs.gov/Recovery/11_HealthIT.asp

ONC: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1153&mode=2

• State, local, tribal, or territorial government entity with a public health focus
• Integrated delivery network or health system with broad community partnerships
• Independent physician association or consortium of medical groups
• Public/Private partnership aimed at health system improvement and/or community health improvement
• ONC-funded regional extension center with the capacity to expand its services

Eligible applicants are expected to demonstrate an existing infrastructure for health IT and exchange, or previous success in either a community-level practice redesign and care coordination or community-level evaluation that advances health IT and exchange infrastructure.  Applicants are required to provide a detailed approach describing how they plan to advance current health IT and exchange capabilities to achieve a more cost-effective and higher-quality patient care.

An additional $15 million will be provided for technical assistance to the communities to evaluate the success of the program.

An electronic Letter of Intent is required to be submitted by January 8, 2010. Final applications for the grants are due on February 1, 2010.  Award decisions are anticipated in March 2010.  The grants will last for a 36-months.

For more information, visit the HITECH website.