Public Sector Perspective
Key Takeaways
The situation: To reduce fraud, waste, and abuse, the Centers for Medicare and Medicaid Services (CMS) is mandating the use of Electronic Visit Verification (EVV) technology for Personal and Home Health Care services beginning in 2020.
The analysis: While states have largely been focused on ensuring their EVV programs are delivered on time, within budget, and with the fewest disruptions to providers and members, they may have overlooked one of its greatest opportunities. State HHS agencies can use their existing EVV investments to optimize NEMT with value-added features such as payment via phone app and flexible, on-demand scheduling.
The solution: To unlock the value of EVV and effectively manage the impact it will have on technology, people, and organizations, HHS entities should consider a three-part strategy that incorporates Organizational Change Management (OCM), Organizational Design, and Data & Analytics (D&A).
Uber started in New York in early 2010 with only three cars. The ease and simplicity of ordering a car quickly fueled the app’s popularity. With the tap of a button, a ride could be ordered; GPS identified the location and the cost was automatically charged to the card on the user account; drivers and riders could provide real-time feedback. Despite fierce resistance from the taxi industry and government regulators, Uber now operates in 600 cities across 78 countries, and provided four billion rides in 2017 alone.1
Uber completely transformed how humans move and entirely disrupted the transportation industry with a technological platform that was easy to use and fueled by data. That platform has gone on to enable a diverse portfolio of offerings, including the merchant delivery programs UberEats and UberPool, which allows drivers to pick up multiple riders on one ride, and most recently, an electric scooter rental service where riders can conveniently pick-up and drop-off scooters.
The success of Uber comes down to its technological platform. Enabled by GPS, fueled by user data and input, and exemplified for its ease of use, the technology itself has enabled Uber to be scaled and diversified into a $72 billion enterprise.2
Want to know what’s worth two times more than Uber’s valuation? The cost of missed healthcare appointments in the United States, which is estimated to top $150 billion every year.3 As many as 3.6 million Americans miss these appointments each year because of unreliable transportation, according to JAMA Internal Medicine, triggering a chain reaction of increased emergency room visits, extended hospital readmissions, and lost revenues for practitioners.4
Throughout the public sector, there’s increased focus on how improved mobility can be applied to wellness initiatives that enable better outcomes and mitigate excess costs. For example, the Federal Transit Administration recently announced a new “Rides for Wellness” initiative, allocating over five million dollars in grant funds towards improving public transportation options to enable more seamless access to healthcare—ultimately reducing readmissions and decreasing healthcare expenses.5
As a Health and Human Services (HHS) organization your mandate—and one of your greatest logistical challenges—is to help curb these costs and ensure recipients have access to the services they need by physically connecting your most vulnerable citizens with critical healthcare services through non-emergency medical transportation (NEMT). The cost to fund NEMT has continued to increase dramatically, with some states we’ve worked with reporting a 200 – 250 percent increase over the last four years. Fraud, waste, and abuse have also been on the rise due to inefficiencies and an inability to verify services provided.
A similar technology platform to seamlessly and safely connect riders with transportation, and HHS organizations with verification and efficiencies, would be of great benefit.
Enter Electronic Visit Verification (EVV). While states have been heads-down making sure their EVV programs are delivered on time, within budget, and with the fewest disruptions to providers and members, they may have overlooked one of its greatest opportunities. By leveraging the verification, tracking, and payment capabilities—as well as the Centers for Medicare and Medicaid Services’ (CMS) 90/10 match for EVV implementation—states can establish a platform for NEMT that is efficient, safe, and scalable.
For states, the EVV platform could trigger an Uber-like evolution, one that could be applied to connect and economize not just NEMT services, but also currently disparate services such as aging support services and subsidized child care.
No matter where you are in your EVV implementation process, now is the time to consider how to leverage your investment to optimize NEMT and other services. The following piece makes a case for starting with NEMT, and offers the key considerations for HHS organizations ready to turn EVV compliance into a technological platform with long-term, futureproof efficiencies and value.
From Compliance to Competitive Advantage: A Case for Starting with NEMT
The nation’s best healthcare organizations are useless if patients can’t get there. And with no-show rates as high as 30 percent, transportation issues don’t just threaten public health; they also threaten the fiscal and operational health of providers. Each open, unused time slot costs a physician 60 minutes and $200 on average.6
As is the case in all matters of transportation, time is of the essence. The NEMT market is worth more than three billion dollars, according to the Transit Cooperative Research Program, and private enterprises (including Uber and Lyft) are already working to capture a piece of the pie. And while private entities have the potential to offer (and capture) great value for the general consumer market, public HHS organizations and citizens have much to gain from maintaining the consistency of care and efficient and effective use of funds of a holistic public health system that includes NEMT.
Gains aside, managing an NEMT program is particularly susceptible to fraud, waste, and abuse. In 2013, Massachusetts found that wheelchair van services had requested more than $17 million in reimbursements for questionable rides. Similarly, an ambulance company in Philadelphia provided kickbacks to Medicare beneficiaries who signed forms saying they’d used NEMT transportation when they’d simply drive to the hospital.7 Moreover, maintaining fleets of vehicles often requires large contracts with transportation companies.
In response, some HHS organizations have already successfully tapped into Lyft and Uber’s technological platform. Sisters of Charity of Leavenworth Health System’s Denver metro hospitals have partnered with Lyft to provide NEMT for their patients, and has plans to expand the arrangement to other cities. The partnership provides the hospital system with receipt verification, GPS starting and end points/times, and linked billing information—in other words, greater oversight into a potentially fraudulent system.
In our extensive work with HHS organizations across the country, not only do we deeply understand how critical NEMT programs are now, but we can envision how even incremental improvements in current ways-of-working within these systems could generate massive efficiencies, particularly if executed in conjunction with the deployment of mandated EVV systems. All states are required to establish key EVV functions, many of which could be directly leveraged to facilitate improved NEMT capabilities, including:
- Service delivery verification.
- Flexible, on-demand, direct scheduling.
- Provider/driver matches with members/riders.
- Anticipated start and end times.
In addition to being a “right fit at the right time,” leveraging the EVV platform for NEMT services also delivers the peripheral benefit of positive public perception. Amidst the security and privacy concerns of citizens around EVV requirements, an optimized NEMT user experience, streamlined functionality, and the ability to provide real-time feedback could be a valuable bright spot for citizens.
The EVV platform could potentially be applied to a wide range of services, and long-term, the more connected HHS services are the better data can be applied to deliver efficiencies and improvements. That said, for many states NEMT is an immediate opportunity to leverage the requirements of EVV to trigger positive citizen impact and to discover and establish best practices before scaling to other services.
Where the Rubber Meets the Road: Three Steps Towards Laying the Foundation for EVV
HHS organizations can borrow from best practices established in the private sector to develop a wish-list of NEMT-enabling functions to be incorporated into EVV processes, including the ability to:
- Allow riders to create profiles that indicate if they have a wheelchair, need extra time or assistance getting to/from vehicle to door or office, or their drop-off point.
- Allow drivers to indicate if they are able to accommodate wheelchairs or wheelchair storage, provide assistance loading into the vehicle, and/or escort riders into the destination.
- Accept multiple payment methods, and allow riders to select Medicaid as a payor.
- Add a special “Health” button to the app as a service option.
- Provide prescription delivery to members’ homes.
- Generate claims transactions for rides.
- Generate prior authorization requests.
- Apply to be a Medicaid provider.
- Permit ride-sharing.
- Speed up prior authorization process (e.g. a monthly allowance per rider).
EVV was mandated with the best of intentions, and initial results have been positive in many cases: The state of Oklahoma documented $12 million in program savings in its first two years with EVV, a 10 percent reduction in fraud, and a 500 percent return on investment (ROI).8 Yet the public’s reaction hasn’t been universally positive, and many states are struggling to repair and re-launch poorly received EVV approaches.
We believe a critical failure point of EVV in early adopter states was due to little or ineffective stakeholder engagement and communications, particularly in relation to user privacy and appropriate terms of use. Beyond technological functionality, HHS organizations must thoughtfully plan for and support the change—both internally and externally within all impacted audiences—that will accompany a new and improved NEMT.
To effectively manage the impact EVV will have on technology, people, and organizations, HHS entities should consider a three-part strategy that incorporates Organizational Change Management (OCM), Organizational Design, and Data & Analytics (D&A).
Part 1: Organizational Change Management (OCM)
Make no mistake: An EVV implementation is a transformation. And transformation is hard. Among completed business transformations, 44 percent are deemed unsuccessful after three years, and the majority of organizations place the failure rate of transformations within their industry between 20 and 39 percent.9 Effective Organizational Change Management (OCM) boosts the odds of success with initiatives that inspire change, engage your people, and accelerate ROI.
In one state, North Highland is providing OCM services, in addition to procurement and implementation planning consulting services for the state’s deployment of EVV. In order to avoid the difficulties of previous EVV implementations, North Highland designed and helped administer a robust and flexible OCM strategy based on stakeholder analysis and engagement. The EVV OCM process includes regular and frequent communications with all stakeholders and multiple channels for receiving input and concerns. During the agile procurement process, North Highland has engaged an external stakeholder sponsor network to objectively review and provide input during the demonstrations of potential EVV vendor solutions.
Enabling EVV with Organizational Change Management:
- Define the change. Start with a clear definition of the scope and implications, including challenges, risks, and mitigation options. An effective OCM strategy should overlay the project schedule.
- Know your impact. As states bring new EVV technology online, interoperability with other platforms and systems is a key challenge. Carefully assess all impacted members and service providers, and establish frequent and consistent communications specific to how EVV will affect them. Identify existing perceptions among each audience. Some member stakeholders may be concerned about restricted flexibility, limited mobility freedom, and privacy implications. For example, target communications to provide transparency and insight into those core issues.
- Manage the change. Source feedback channels to understand how perceptions are evolving and refine your messaging and communication platforms to match.
- Develop and deliver training with your solution provider. Define training based on solution and stakeholder capabilities. For instance, many potential users of the new system may require general device usage training, as well as training on the new apps.
- Anchor the change. Based on a careful assessment of EVV adoption and performance, develop and deploy new stakeholder feedback tools, communications, and training programs.
Part 2: Organizational Design
The extension of EVV capabilities to NEMT may seem like an easy plug-and-play opportunity, but implementation should be preceded by a dedicated, careful effort to ensure that the EVV is technologically attuned to the special requirements of NEMT.
Optimizing EVV with Organizational Design
- Entities looking to mature their NEMT program through EVV will need to evaluate and realign business processes for both the Medicaid agency staff and NEMT service brokers. This will likely involve the finetuning of software requirements, Medicaid policies, and business processes through the traditional practice of business analysis, business process re-engineering, and requirements elicitation. We recommend that the NEMT program and policy staff engage in an “art of the possible” learning session to envision what the future can look like with an EVV-like system. This should be followed by a review of the current NEMT process and the roles required.
- Given that EVV will automate much of the data-gathering for validating service delivery, it’s expected that staff will be more efficient, freeing their time to focus on new tasks, such as devising better policy options that help promote self-sufficiency and member independence, or even using the NEMT program to enhance economic independence for those needing employment by broadening the NEMT provider pool.
- With an understanding of the activities that will be automated post-EVV implementation, then focus on redefining the new roles and skills required to succeed in those roles.
Part 3: Data & Analytics (D&A)
When implementing a large-scale EVV program, Data & Analytics (D&A) is critical to tracking and reporting on compliance around the services (visits) scheduled and successfully completed within the allocated time.
Moreover, effective D&A allows HHS organizations to gain insight into successes and identify areas for improvement—both within NEMT and the organization at large. The thoughtful application of D&A in EVV implementation could serve as the starting point for establishing an organization-wide D&A strategy for the future.
Amplifying EVV with D&A
- Before you can begin to generate insight from data, build the foundational capabilities your organization needs to maximize the value of the data you’re collecting with Information Management.
- Engage employees cross-functionally throughout your organization to co-design a vision and roadmap for how data will be used in the context of your EVV implementation.
- Break down functional data silos to shift from a mentality of data ownership to a mentality of data stewardship, in which all employees are focused on applying data to achieve a common goal.
- Develop standards around the collection of data, along with business rules governing usage and movement of data, to ensure that data is accurate and yields meaningful insight towards the success of your EVV program.
- Consider creating dashboards that quantify savings and compliance. Has the number of cancellations decreased since implementation? Has the cost decreased now that EVV is required? These insights are critical to ensuring ROI in a high-cost program.
Revving Up EVV For NEMT and Beyond
An EVV implementation that is optimized for NEMT economizes funding, effort, and capacity for change. Doing it well requires HHS entities to pause and consider implications by audience and to establish a plan that accounts for Organizational Change Management, Organizational Design, and D&A. The Federal government has extended the deadline for EVV deployment to January 1, 2020 for Medicaid-funded Personal Care Services. This provides a great opportunity for states to develop their plan to expand EVV deployment to NEMT and potentially other services. In a time when the only constant is change, the payoff will be exponential in the form of a platform designed for today and built to scale to meet future HHS needs.
1 “Uber powered four billion rides in 2017. It wants to do more – and cheaper – in 2018,” recode, Jan. 5, 2018
2 “Uber’s latest valuation: $72 billion,” recode, Feb. 9, 2018
3 “Uber is driving patients to their doctors in a big grab for the medical transportation market,” The Verge, March 1, 2018
4 “Study Finds Missed Medical Appointments Not Affected by Free Ride Services,” The Hospital + Healthsystem Association of Pennsylvania, Feb. 14, 2018
5 “U.S. Department of Transportation Announces $5.3 Million Funding Opportunity to Improve Mobility Focused on Healthcare,” Federal Transit Administration,” May 21, 2018
6 “Missed appointments cost the U.S. healthcare system $150B each year,” Health Management Technology, April 26, 2017
7 “How a Boston-based startup is changing non-emergency medical transportation,” Statescoop.com, Oct. 9, 2017
8 “How States Can Make the Most of the New EVV Mandate for Home Care,” FirstData, Jan. 31, 2017
9 North Highland survey of 202 VP-level and above executives in US- and UK-based organizations with $1B or more in revenue, February 2017