Tag: Tech

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Let it ride another 8 years.

 
 

Clipped from: https://finance.yahoo.com/news/csg-government-solutions-selected-department-120000724.html

CSG Government Solutions, a national leader in government program modernization, today announced that it has been selected by the Department of Vermont Health Access to provide Independent Verification and Validation (IV&V) services for the design, development, and implementation of Vermont’s Medicaid Enterprise System Modernization Project, which includes the Medicaid Management Information System, Integrated Eligibility and Enrollment system, and Health Information Exchange.

CHICAGO, May 23, 2023 /PRNewswire-PRWeb/ — CSG Government Solutions, a national leader in government program modernization, today announced that it has been selected by the Department of Vermont Health Access to provide Independent Verification and Validation (IV&V) services for the design, development, and implementation of Vermont’s Medicaid Enterprise System Modernization Project, which includes the Medicaid Management Information System, Integrated Eligibility and Enrollment system, and Health Information Exchange.

CSG began its engagement with Vermont on this project in 2015. Under the new contract, CSG will continue to provide assessment and monitoring of Medicaid program operations, procurements, implementation activities, and adherence to the Centers for Medicare and Medicaid Services system certification requirements for federal funding.

“As Vermont’s Medicaid Enterprise IV&V partner, CSG has supported the federal certification for five system modules,” says Robin Dufresne, Director of CSG’s Healthcare and Human Services practice. “As we continue to leverage our expertise across the enterprise, we are well positioned to help assure the State achieves its goal of providing next generation health and human services capabilities.”

Media Contact

Robin Dufresne, CSG Government Solutions, 312.444.2760, rdufresne@csgdelivers.com

SOURCE CSG Government Solutions

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Some decent arguments on why the tech money guys should place more bets in Caid.

 
 

 
 

Clipped from: https://www.beckerspayer.com/leadership/why-medicaid-is-ripe-for-innovation.html

Medicaid startups receive significantly less outside investment compared to Medicare Advantage organizations, but there’s still key opportunities to innovate under the program and serve enrollees in new ways.

According to a Feb. 27 article in Health Affairs, the top 10 MA-focused startups have raised more than $20 billion combined in venture funding, compared to $1.5 billion for the top 10 Medicaid-focused startups. But in 2021, CMS spent $734 billion on Medicaid, compared to $427 billion on MA in 2022.

“Medicaid is ripe for innovation, as startups serving Medicaid enrollees have received an order of magnitude less funding than their MA peers, despite almost double the market size,” the authors wrote. “COVID-19 has removed cultural and regulatory barriers to technological adoption, and increased interest by private investors.”

According to the authors, Medicaid has noticeably less outside investment compared to MA because the program is different in each state and caring for beneficiaries can be more challenging. 

Still, they wrote that four key opportunities exist for Medicaid startups to better serve members in the future: improve thin margins by utilizing new software and technology solutions, address social determinants of health to improve care quality, focus on health equity as an opportunity for cost savings, and move to align payments with improved care outcomes.

“So much of Medicare innovation has been about revenue optimization,” Rajaie Batniji, MD, PhD, co-founder and CEO at Waymark, told Becker’s. “In Medicaid, there’s no revenue optimization game to be played. What you need to do is actually improve care delivery.”

San Francisco-based Waymark is eighth on the list of Medicaid startups that have raised the most outside capital — the company closed on a $45 million financing round in January 2022.

Launched in 2021, Waymark manages a network of community health workers, pharmacists, behavioral health therapists and coordinators in clinics to manage care between Medicaid patients and primary care providers. Starting this year, the company has partnered with Aetna’s managed care plan in Virginia to provide community-based care services in the Richmond and Tidewater areas. 

“There’s a lot more stability and a lot more opportunity in Medicaid because of the fact that you’re actually forced to focus on truly improving outcomes rather than improving risk scores,” Dr. Batniji said, referring to recent MA risk adjustment changes from CMS.

Dr. Batniji shared that while there are many different Medicaid programs across the country, there are also many commonalities that allow beneficiaries to receive community-based care. 

He believes investors have stepped away from Medicaid largely for two reasons: lower margins compared to MA, and because Medicaid enrollees spend less time enrolled in the program compared to MA members on average, meaning desired outcomes need to be achieved more quickly. But Dr. Batniji also points out that there’s significantly more Medicaid members out there, suggesting that a lot more opportunity exists — if the right care model does.

CMS reported 81 million Medicaid members in 2022, compared to about 31 million MA members as of February 2023. 

“There’s a huge opportunity to bring proven interventions around community-based care in partnership with local providers that health plans are already working with to improve outcomes and to meet the goals and objectives of patients, providers and state regulators in one maneuver,” Dr. Batniji said.

 

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Automatically enrolling Medicaid kids in free lunch programs moving forward in NH. Right now the argument is whether to have an opt-in model or just do it.

 
 

 
 

Clipped from: https://newhampshirebulletin.com/2023/03/29/house-moves-toward-using-medicaid-data-to-enroll-families-in-free-and-reduced-price-lunch-program/

 
 

Allowing Medicaid direct certification could help the state sign up an additional 7,000 students for free and reduced-price lunches who qualify now. (Amanda Mills | Centers for Disease Control and Prevention)

For families making up to 185 percent of the federal poverty level, New Hampshire public schools offer free or reduced-price lunches, a federal program intended to reduce childhood hunger among low-income residents. But first comes an application. 

In order to get the discounted prices for lunches, a parent or guardian must write down the income of everyone in the family – including kids, if they are working – note how often the income arrives, and record any additional payments like alimony or regular support from relatives. Then, the parent must send the application back to the school, whether through their child, in person, or online.

This year, New Hampshire is considering a different approach: Medicaid. A federal program created in 2010 would automatically enroll students in free and reduced-price lunch plans using Medicaid enrollment data. That data includes families’ incomes already, eliminating the need for an application in most cases. 

Last year, Gov. Chris Sununu opted against signing up the state for the program. At the time, he said he wanted the Legislature to direct him to do it in statute. That decision meant that the state cannot participate in the program in the upcoming 2023-2024 school year; the earliest it can participate if it applies to join this year is the 2024-2025 school year. 

This year, lawmakers appear prepared to give Sununu that direction. The House Finance Committee voted to recommend House Bill 601 on Tuesday, requiring the state to enter the program, known as Medicaid direct certification.

Hunger prevention advocates are optimistic. Allowing Medicaid direct certification could help the state sign up an additional 7,000 students for free and reduced-price lunches who qualify now, said Laura Milliken, executive director at New Hampshire Hunger Solutions. That change could make a meaningful difference to many lower-income students’ nutrition, she said. 

“It’s disappointing to us that we couldn’t get it done sooner, but we’re hopeful that it does get done because people are having a hard time right now,” Milliken said in an interview. 

But House Republicans have also added an amendment to the bill that would require participants to opt in to the direct certification program, an addition that would make New Hampshire’s program unique among the 39 states that currently participate. 

“We are opposed to opt-in language and worry that it would not be consistent with the goals of the Medicaid direct certification pilot program,” Milliken said. “Thirty-nine other states are participating in the pilot program and none of them uses an opt-in.” 

Still, Milliken said the organization is supporting the broader bill. 

For many families that meet the income requirement for free and reduced-price meals – up to $55,000 per year for a family of four – entering the program can be a major boost; children receiving reduced-price meals pay 40 cents for each lunch, compared to up to $4 per lunch for those not qualifying. But not every family applies, and schools must adopt strategies to persuade them to participate. 

Proponents say joining the Medicaid direct certification program would help school districts recoup more money from the federal government for their meal programs. It would also lead to a more accurate count of the number of students receiving free or reduced-price meals, a key number that determines how much each district receives in state adequacy funding.

States are barred by federal law from accessing their residents’ Medicaid data without express permission. The Medicaid direct certification program grants that permission to the states that have enrolled. 

But some Republican lawmakers have voiced skepticism over entering the state into the program, a move they said could subject the state to more federal rules. Instead, those opponents have suggested finding ways to utilize the state’s Medicaid data without federal involvement. 

“Though the necessity of providing funding for an adequate education is clearly a matter of interest to this committee, so too is our duty to jealously guard our state sovereignty,” wrote Rep. Arlene Quaratiello, an Atkinson Republican.

Supporters say the program would provide schools a new tool to help students whose families may not be signing up for free and reduced-price lunch due to lack of awareness, forgetfulness, or stigma. Some kids and families are reluctant to sign up, fearing embarrassment at school, advocates say.

The issue gained new urgency last year, when a COVID-era temporary federal initiative came to an end that allowed all students to receive meals at school, regardless of income. That change forced schools to kick off awareness campaigns to remind parents that they now needed to apply for free and reduced-price lunches if eligible.

“In most school districts, free and reduced meal participation is still down,” Milliken said, comparing current numbers to pre-COVID-19 numbers. “You have to think about the fact that there are families whose kids started school during the pandemic who didn’t know that there was (an application) because they didn’t need to apply for free and reduced-price lunch.”

She added: “I think schools are doing their darndest to get people to know if they can sign up, but I think it underscores why something like Medicaid direct certification is so important, because people at this moment in time have so much on their plates.” 

The amended bill must survive a vote on the House floor next week, as well as the Senate process. A bipartisan group of senators endorsed the idea last year, indicating that there could be support this year. But a number of new senators have entered the chamber since the last election. 

Speaking to the House Finance Committee in March, Sununu said he had set aside $30 million in his proposed budget to fund the administration of the Medicaid direct certification program in New Hampshire. But he again left it to lawmakers to approve the creation of the program in state law.

“You can debate whether you should or shouldn’t do that,” Sununu said. “My budget builds in the opportunity that if you do that, it’s all good.”

Addressing Sununu, Rep. Mary Heath, a Manchester Democrat, showed appreciation for the new stance. “I think that’s a win-win for our state, and I’m certainly hoping that this body will go along with that.” 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Conduent just won another “modular” procurement, with claims and financial as the foundation. Some HCBS and Rx stuff got tacked on, too.

 
 

 
 

Clipped from: https://www.globenewswire.com/news-release/2023/02/14/2607661/0/en/New-Mexico-Awards-Contract-for-New-Medicaid-Management-Information-System-to-Conduent.html

 
 

New Mexico Human Services Department’s current Medicaid Management Information System to be replaced with Conduent’s modular cloud-based technology platform

Conduent’s solution will streamline enterprise Medicaid claims and will provide financial, pharmacy benefit management and data exchange and reporting services

FLORHAM PARK, N.J., Feb. 14, 2023 (GLOBE NEWSWIRE) — Conduent Incorporated (Nasdaq: CNDT), a global technology-led business process solutions company, today announced that it has been selected by the New Mexico Human Services Department (NMHSD) to deliver a new Medicaid Management Information System (MMIS) to replace the agency’s existing system. Conduent’s Medicaid Suite (CMdS), a modular, cloud-based technology platform, will create a seamless experience for providers and improve access for approximately one million state Medicaid members.

Conduent will manage the system implementation, and provide maintenance and enhancements designed to reduce costs while optimizing the state’s Medicaid operations. The CMdS Financial and Claims Modules will form the foundation to transform NMHSD’s MMIS into a future-ready system to support well-coordinated services for providers and members. The all-encompassing replacement project includes the following services:

• Enterprise Claims Processing (including medical claims, pharmacy claims, non-medical claims, and other payment types)
  
• Self-Directed Home and Community Based Services
  
• Pharmacy Benefit Management Services
  
• Drug Rebate Management Services 
  
• Data Exchange and Reporting Services
   
  

“Conduent brings the expertise and solutions that will help position the Human Services Department for the future. By automating manual processes and promoting interoperability between IT systems, operations will become more efficient and effective. We anticipate that the project will also bring significant improvements to help our Medicaid providers by creating a single point of entry for all claims and a streamlined billing process. These and other updates will make it easier for NMHSD and its sister agencies to capture data necessary for measuring and improving health outcomes for our customers,” said Kari Armijo, Acting Secretary, New Mexico Human Services Department.

Conduent provides government agencies with a range of solutions for healthcare, payments and eligibility services, as well as child support and constituent engagement. The company supports approximately 41 million residents annually with various government health programs and processes more than 155 million Medicaid claims every year for 23 states.

“Conduent has proudly served the state of New Mexico for the last 29 years. We are pleased to continue our successful collaboration, now focusing on the transformation of the state’s MMIS technology infrastructure. Our commitment is to bring best-in-class solutions and services that help the Human Services Department meet the mandates to reduce program costs and improve the lives of all New Mexicans,” said Mark King, President of Conduent Government Solutions.

In addition to CMdS and Pharmacy Benefit Management solutions, Conduent’s offerings for the government health sector include its Maven® Disease Surveillance and Outbreak Management Platform and the BenePath® Suite to modernize the eligibility and enrollment process for social services and government aid programs.

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Now specialists can bill for telehealth so we can stop gaming what the PCPs are getting paid to cover the specialists costs.

 
 

Clipped from: https://www.healthleadersmedia.com/technology/cms-improves-medicaid-reimbursement-digital-health-consults

The Centers for Medicare & Medicaid Services has issued guidance changing Medicaid and CHIP coverage for eConsults, or provider-to-provider specialty consults conducted via digital health or telehealth. The  ruling could expand the service, which helps primary care providers keep more of their patients and boosts access to care for underserved patients.

KEY TAKEAWAYS

The Centers for Medicare & Medicaid Services has issued new guidance on Medicaid and CHIP coverage for eConsults, or interprofessional consultations between a primary care provider and a specialist on treatment for a specific patient.

Under the new guidance, specialists are able to bill Medicaid for eConsults rather than primary care providers, who would often have to bill higher rates so that they could reimburse specialists for their services.

The platform is popular with primary care providers who want to keep more of their patients and specialists who want to expand their reach, while it improves access to care for underserved populations who can’t afford or won;t travel to see a specialist.

Federal officials have expanded coverage for specialty consults between care providers via digital health for Medicaid and Children’s Health Insurance Program (CHIP) members.

In guidance issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) announced that interprofessional consultations, or instances when a care provider seeks the advice of a specialist for a patient’s treatment, via eConsults can be covered by state Medicaid or CHIP programs even when the patient is not present, as long as the consult is focused on that patient.

eConsults are clinical consults usually conducted via telemedicine (including the telephone) or digital health. They enable primary care providers to expand care management options for their own patients without having to send those patients off to a specialist. And they improve access to care for patients who might not want to travel to see a specialist due to a variety of reasons, including distance and cost.

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Alongside helping primary care providers retain more of their patients, the platform is popular with federally qualified health centers (FQHCs) and community health centers who treat underserved populations and in rural areas where access to specialists is scarce. It also helps specialists expand their reach and treat more patients in need of their services.

“Timely access to specialty providers can improve the quality of care and treatment outcomes for both physical and behavioral health,” CMS wrote in its guidance. “While access to specialty care has been a challenge across a range of specialties, access to specialty care for mental health and substance use disorders has been a particular challenge.”

The ruling changes the payment model so that the consulting provider, or the specialist, can bill for the treatment. Previously, CMS allowed the treating provider to bill Medicaid, which in many case forced the program to pay higher rates to the treating provider so that he/she could reimburse the specialist for consulting services.

To qualify eConsult coverage, both care providers must be enrolled in the Medicaid program in the state where the patient is located, though the consultant can be located in another state.

“Given the potential for improving access to specialty care, a number of states have obtained authority through state legislation for or expressed interest in covering eConsults,” the Los Angeles-based Manatt, Phelps & Phelps law firm wrote in a recent blog. “States that choose to cover eConsult codes must submit a state plan amendment to CMS to add a payment methodology for the qualifying service, and should consider broadly communicating any related policy changes to their enrolled provider community.”

 
 

 
 

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Andy’s got some ideas on how to make money in Medicaid.

 
 

Clipped from: https://www.statnews.com/2023/01/31/town-hall-ventures-medicaid-slavitt-health-tech/

 
 

SAN FRANCISCO — Part of Andy Slavitt’s core mission at Town Hall Ventures is proving that health tech companies can make a viable business out of reaching low-income people who also face social challenges, like a lack of housing or nutritious food options. It’s a bold assertion that hasn’t been proven out yet, though a handful of Town Hall Ventures’ portfolio companies — including Unite Us and Alphabet spinout Cityblock  — have already achieved valuations over $1 billion.

The stakes are growing steadily higher, especially for the millions who signed up for Medicaid coverage during the public health emergency and who risk losing it as temporary expansions end. And by investing in teams they trust to embed in vulnerable communities, build culturally sensitive products, and develop sophisticated analytics to assess social needs, Slavitt and his team are hoping to set an example for other venture funds who have historically avoided Medicaid.

“The clinical answers are not so hard. I can’t emphasize that enough,” Slavitt said. Though the diagnoses affecting low-income patients are largely the same as the ones affecting those with commercial insurance, the health care system isn’t set up to accommodate homeless people, or medically complex pediatric patients in health care deserts, he said. 

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“What’s different largely speaking is that being poor really sucks and being miles away from anyone who can really care for you really sucks and needing to fill out 10 forms to get housing or child care or any of these other things is a big deterrent to getting care,” he said. “A system that doesn’t welcome you, doesn’t recognize where you live, really doesn’t work.” 

From an investment perspective, he said, there’s potential for a “decent margin — not a huge margin” in helping the country’s roughly 90 million Medicaid patients get better preventive health care, avoiding more expensive treatment in the future. “There’s no bigger market than Medicaid,” he said. 

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STAT spoke with Slavitt in San Francisco, where he and other investors and health care executives descended earlier this month for the J.P. Morgan Health Care Conference. This conversation has been edited for length and clarity. 

What types of companies do you think are best equipped to solve these problems?

The good news is there’s an awakening that the most needed area of investment is also investable space. Not everyone has figured it out.

There’s two types of ways of thinking about investing. One starts with how do I find a market opportunity and make a lot of money? And the other starts with is there a really big problem that I can figure out how to solve? Not every problem in health care will be solved with innovation. But some can, and the ones that can are the ones where you’ve got a clinical, social, behavioral model that addresses the need of a specific population where there’s also some payment model that allows you to meet those needs.

If you look across Medicaid, you can follow the journey from moms to babies, pregnant moms to pediatrics, complex pediatrics, then school-based programs, justice and teen mental health programs, disability, all the way up to [dual Medicare and Medicaid eligibles and eldercare]. We have activities in all those buckets. We have investments in most of those buckets. 

Finding people who really understand these problems at a really operational finite level [is important]. Take a company like Cityblock Health. There are several thousand available housing units in New York that don’t get used for homeless people because they’re only available for people with a psych diagnosis. And in order to get a psych diagnosis, you’ve got to go find a psychiatrist in New York, then make it to the appointment, then it gets rejected. … They’ve got a team of psychiatrists that do that, nothing but that, and they get people into housing. 

How will you know you’ve been successful?

If we’re massively successful, [Town Hall] will invest a few billion dollars over our life into these communities. We need hundreds of billions of dollars invested, and there’s all this capital that sits there trapped [in the health care industry] … or is repatriated to shareholders because these are incredibly profitable companies. And they come into these communities and they take the profits out. Money needs to be reinvested back into these communities. 

Do the communities you’re focused on use technology any differently than wealthier ones?

SMS is less expensive to use than a browser. There are subtleties. I went out to the field with a Cityblock community health partner and I said, “What’s your favorite part of your job?” And she said, “My iPad.” I don’t hear that a lot in health care, but she said, “I bring this into someone’s apartment and I can build access to the whole world for them. I can connect them to the thing they need, I can order something for them on the spot and they can see action. I can communicate with their daughter who is a big user of technology.” 

Amazon has a lot to teach us in coming into health care because they know how to deploy technology in ways that don’t feel like technology. 

How are the metrics you use to evaluate companies different from other markets?

It’s imperfect and it’s a little bit of a moving target. We started in earnest on it probably a year ago. We got more resources on our team to be able to collect the information from our companies. It was always part of the process but if you’d asked me the question for each one how are they doing, I wouldn’t have been able to give you a great answer. 

One easy tell, when I talk to a company, is, “Tell me what it is.” Plume, which is a trans health company, they’re like, “we have to reduce anxiety and depression scores very fast.” So they measure that like crazy. If I look at Eleanor Health, which is focused on addiction and recovery treatment, what they basically want to get to is lower craving levels. They don’t measure urine tests [as much] … they’ve learned that the frequency of touch points with people at various stages of their addiction recovery is really important, so they’ll measure that.

There’s a set of consistent metrics, but you’ve got to respect them to tell their own story. At some level they’re going to know their business better. 

If I don’t hear that they’re measuring Net Promoter Score rabidly in the right way, it tells me, OK there’s some other way you’re getting paid than doing your job. 

There’s questions we ask every company like diversity on your management team, diversity on your board, diversity at each level, diversity of promotions. There’s usually other investors at the table, and I’m pretty sure they’re going to ask the question about “how’s your sales acquisition doing?” But my first questions will always be what I think is important. You have to hire diversity, particularly in the early stages, and then their networks will come in. But you have to force it. 

This story, part of a series on health tech for underserved populations, was supported by USC Annenberg Center for Health Journalism’s national fellowship.