Becker's Hospital Review

42 EXECUTIVE BRIEFING 2 EXECUTIVE BRIEFING SPONSORED BY Modernizing Medicaid: How technology is readying the new workforce era and improving provider participation + patient access Healthcare continues to grapple with employee burnout, anticipated waves of retirements and limited prospective candidates with the requisite skills for both clinical and administrative positions. The healthcare "brain drain" is real and it presents challenges for Medicaid programs. As hiring and retaining state employees becomes harder and fewer providers participate in Medicaid programs, access to healthcare for states' most vulnerable populations could be in jeopardy. Becker's Healthcare recently spoke with three experts from Gainwell Technologies — Aneesh Kumar, chief product officer; Gary Call, MD, chief medical officer; and Jeff Reid, senior vice president of Medicaid management — about the current Medicaid landscape and how modernizing Medicaid management systems can help alleviate workforce-related pressures that stakeholders face in this important public health insurance program. Competition for talent and provider abrasion are worsening Medicaid workforce challenges When it comes to managing the Medicaid program at the state level, institutional knowledge is dwindling. Between 2017 and 2021, 46 percent of state and local public health employees 1 left their organizations. If this trend continues, by 2025, close to 130,000 people 2 will have resigned. Additionally, private sector competition is fierce for individuals with skills like population health management, data science and information technology. This has led to a reduced ability to modify and maintain critically important Medicaid management systems. "Many of these systems were developed years or even decades ago," Mr. Kumar said. "They are often not well documented, and newer graduates don't have relevant programming skills. When experienced employees leave due to retirement or burnout, states have to scramble to address their Medicaid program objectives." Mr. Reid agreed. "We need expertise to drive program adoption," he said. "If you don't have the talent in place to develop and analyze programs and then drive next steps, Medicaid programs falter and don't generate the desired outcomes." On the provider side, the complex systems and processes required to serve Medicaid members are overwhelming physicians. Most states now use Medicaid managed care entities to handle benefits for members. A single state may rely on more than a dozen different managed care entities. If Medicaid beneficiaries change their managed care plan, which they can do frequently, their medical history may not carry over from one plan to the next. "When a clinician's Medicaid population comes from half a dozen or more managed care organizations that all have slightly different processes, it really fragments workflows and adds to provider administrative burden," Mr. Kumar said. "Providers also have to incorporate information from managed care entities into their electronic medical record system, which isn't the easiest system to begin with." Medicaid patient enrollment, coordination of benefits, prior authorizations and reimbursement are all sources of provider abrasion. On top of these processes, it's next to impossible to coordinate across providers or obtain analytics about patient risk profiles, which would enable physicians to treat people in more effective and cost-efficient ways. "There are a lot of obstacles to being a Medicaid provider," Dr. Call said. "Many physicians participate in the program out of a sense of social duty. But, every time it's inefficient, they're less excited about being part of that. Sometimes, providers eliminate the lowest payers or the payers who are the most difficult to work with. If that's Medicaid, it impacts access to care. It's imperative that we make Medicaid systems easier to use." System improvements can increase Medicaid efficiency and the stakeholder experience These challenges call for modernized and simplified Medicaid management systems. Modernization of Medicaid management systems focuses on general improvements to information systems and workflows, while modularity focuses on creating cutting-edge systems. "Traditionally, Medicaid core systems have come from two or three vendors," Mr. Kumar said. "The hypothesis is if you can break systems down into smaller chunks of functionality and smaller procurement initiatives, there will be greater competition." System integration platforms are a promising area of innovation. These tools promote interoperability and workflow standards. In the Medicaid field, Gainwell Technologies has codified its domain expertise into solutions. "We know how to connect the dots across different parts of Medicaid, and we serve as a systems integrator for our own modules," Mr. Kumar said. "That helps us as we help Medicaid management ecosystems that include vendors other than Gainwell."

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