A few weeks ago, I joined fellow industry leaders at the Healthcare IT Connect Summit in Baltimore for a compelling dialogue around the future of health IT. The clear message coming from the Centers for Medicare and Medicaid Services (CMS) at this year’s summit illuminated a renewed focus on data and its role in driving outcomes. As states begin to transform their Medicaid systems in response to the modularity imperative, having a thorough understanding of CMS expectations tied to these interrelated topics will be critical.
CMS has recognized that the current certification process, while comprehensive, may not be clearly leading states to desired outcomes. The current certification process is evolving, and feedback submitted to CMS from various states currently going through the certification lifecycle is continuously being incorporated, and thus the process continues to be refined.
In addition, CMS is exploring an enhanced federal match approval and certification process that is intended to decrease the time and effort spent by states and will place a greater focus on achieving outcomes. The new process is in its early stages – they have piloted the approach with Ohio’s Electronic Visit Verification (EVV) project (all the way through R3, the final certification review). CMS is also open to additional pilots and has communicated that the current certification processes will stay in place until it formalizes the new approach, or if a state and CMS agree to implement a pilot. CMS is also open to input from states to assist in developing and shaping the new approach so it can be as efficient as possible.
Through the dialogue at the summit, several other key insights around the topic of data-enabled outcomes surfaced.
- The outcomes-based approach will apply to the Advance Planning Document (APD), Request for Proposal (RFP), and Certification review and approval processes.
- CMS is adding a new review step after certification – it’s an ongoing performance assessment that will occur on a regular basis during operations – this will be required to maintain the 75 percent enhanced operating funding and will focus on the Key Performance Indicators (KPIs).
- CMS provided some example “Outcomes” for EVV, Pharmacy Benefit Management (PBM) and Eligibility & Enrollment programs. CMS intends to allow states to propose their own outcome measure.
- After a state identifies “Outcomes,” they will then define “Metrics (or KPIs)” and then a set of “Test Objectives.”
- The certification process will include both assessment of KPIs as well as testing the ability of the system to achieve the stated test objectives.
As one key influence in the discussion around outcomes, the role of Independent Verification & Validation (IV&V) vendors is also expected to change under this evolving approach. It appears CMS’ vision for some of the IV&V changes, could be related to testing. While the specific requirements for IV&V are yet to be developed, it’s clear that changes are on the horizon.
In our experience, quality data and an intentional approach to Information Management are imperative for tracking and measuring the outcomes that CMS is striving to achieve. So, it was great to hear that Julie Boughn, Director, Data and Systems Group at CMS declared 2019 as the “Year of Data Quality.” CMS sees great opportunities related to data quality improvement – many of which are needed to support modeling of law or policy changes and determining their impacts. Ms. Boughn also sees the Medicaid data set as a “National Treasure” that can help support policy decisions that can address issues such as opioid use and improvements in long-term care programs.
According to Gartner, “by 2022, 90% of corporate strategies will explicitly mention information as a critical enterprise asset…” Data has never been more critical to organizational performance, and my experiences at the summit brought this to life within the health and human services space. With the renewed focus on outcomes driven by quality data, these are exciting and encouraging times in the Medicaid market.