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Driving Innovation and Sustainable Improvement in Medicaid
The Medicaid population is one of healthcare’s most vulnerable populations requiring unique, frequent and customized delivery of care to provide the resources and services necessary to address health disparities. This leads to significant challenges for care providers in navigating the continuously evolving and regionally unique Medicaid environment. With escalating pressure to contain costs, adapt to fluctuating Medicaid enrollment, address health equity and social risk factors and improve quality performance, the call for effective strategies has never been more pressing.
At ProspHire, our team of Medicaid specialists and project executors offers innovative solutions tailored to the needs of federal and state healthcare agencies, Medicaid health insurers, health systems and pharmacy benefit managers. In this Q&A session, we engage with our Medicaid Practice Leader Julie Evans to dive into various topics spanning delivery, implementation, operations, organization, strategy and technology, offering insights and expertise to address the complexities of the Medicaid landscape.
Can you provide an overview of ProspHire’s approach to how you help clients drive innovation and sustainable improvement in Medicaid?
One of ProspHire’s core values is relationships. As we seek to drive innovation and sustainable improvement in Medicaid, our first step is to understand each health plan’s unique population and regional priorities through relationships with Medicaid beneficiaries, customer facing teams and community-based providers.
State regulations and region-specific needs are the foundation of Medicaid services and pose unique guardrails for our clients. While state regulations are rigid and defined, region-specific needs vary and evolve leaving room for innovation. Through a customer-centered approach, we seek to understand, rather than assume, and drive innovations that are inspired by the customer, leading to desirable and sustainable improvement.
ProspHire partners with our clients to amplify the voice of the customer through the ideation and execution of their innovations by means of strategic initiatives in alignment with organizational priorities.
What are some of the most pressing challenges that healthcare organizations face in navigating Medicaid landscape, particularly considering recent regulatory changes?
As we embark on the journey alongside the second Trump administration, Medicaid is a program being questioned and at risk of considerable change and disruption through regulatory changes. There are several challenges being faced by healthcare organizations:
- Medicaid managed care organizations have experienced the impact of mass redeterminations on their enrollment and therefore their member acuity and financial bottom line. Program eligibility changes that may arise through Medicaid expansion requirements could see similar impacts and call for further operational and financial scrutiny.
- Hospitals and health systems have historically faced challenges with reimbursement rates tied to Medicaid. These challenges are anticipated to continue, or increase, with Medicaid dollars at-risk through federally proposed budgets. Changes to Medicaid eligibility, reimbursement and member acuity, all pose risk. Additionally, NIH funding that has been called into question by the new administration poses threat to academic medical centers.
- Furthermore, providers have historically opted out of serving Medicaid members due to poor margins, in an already short-staffed and limited provider network environment, both health systems and insurers face risk of adequate and accessible network coverage.
- Nationally, equity efforts have also been called into question leading to speculation around existing and pending Section 1115 waivers across states. Any changes to waiver permissions could lead to a rollback of efforts and sunk costs.
Additional challenges independent of any administrative changes to come include:
- State movement toward Special Needs Plan alignment for dual eligibles and exclusive alignment in Medicaid and Medicare enrollment
- Increasingly high costs of pharmaceuticals and coverage, with a particular focus on GLP-1 medication financial and formulary impacts
- Mental Health Parity and Addiction Equity Act (MHPAEA) compliance and enforcement
How does ProspHire stay on top of the evolving Medicaid regulations and policies and how do you ensure your clients remain compliant?
Read, watch, listen and react. Like many of our clients, we stay up to date on industry changes, trends and discussions to prepare ourselves and others to react to our evolving environment. This includes the ever-changing regulatory requirements and discussions at the federal and state level. Our attention to detail and quality assurance practices help us work in partnership with our clients and their legal and compliance teams to drive results and remain agile and, in the case of a new administration, prepare for flexibility and adaptability in response to any sweeping or frequent policy changes.
Can you share a success story or case study where ProspHire’s Medicaid consulting services have significantly benefitted healthcare organizations?
It’s hard to choose just one… so I’ll have to give two. One is tied to a state-wide initiative in Pennsylvania focused on addressing health equity through a collaborative bringing together health systems, managed care organizations, community-based partners and other care providers. Our team facilitated the efforts to address health equity through regional population health assessments and intervention planning across stakeholder groups. This led to regional playbook development that was eventually adopted by the Department of Health for future state implementation. The opportunity to collaborate across healthcare organizations, build meaningful partnerships, and drive patient-centered change was of benefit to those engaged in the collaborative and the communities to be impacted.
The second is an engagement that has been in existence almost as long as ProspHire, where we are partnered with a Medicaid Managed Care Organization’s quality team to provide project management services. By offering project management support, our team can support the planning, design and implementation of Medicaid Quality initiatives year-over-year, continuously collaborating with the client to drive improved health plan performance.
Technology plays a crucial role in modernizing healthcare delivery. How does ProspHire integrate technology solutions into its Medicaid services to improve efficiency and outcomes?
Technology is continuously increasing in significance across healthcare delivery. Most recently our team supported the integration of a new clinical platform to enhance care management, utilization management and reporting capabilities. From requirements gathering to go-live and post go-live risk management and resolutions, our team has been in the weeds, working alongside the client to deliver a multi-state clinical solution. This tool improves efficiency of workflows, decision making and ultimately the delivery of care to the Medicaid population and those who are most vulnerable to adverse health outcomes.
Artificial Intelligence (AI) is another technological advancement that is buzzing as vendors and healthcare organizations find opportunities to integrate AI in the industry. ProspHire focuses on the business and end user when considering AI implementation, supporting health plans through business case development, user stories, vendor or system implementation and readiness and adoption activities. By preparing our clients to utilize the technology effectively, there is a greater return on investment through improved efficiency and outcomes.
Plans have different technological needs depending on the current state of their operations and we partner with our clients to integrate the solutions that are prioritized in alignment with organizational goals to deliver improved member and operational outcomes.
Can you talk about the importance of data analytics in Medicaid projects and how you use data-driven insights to inform decision-making and strategy development?
Social Determinants of Health (SDOH) and health equity efforts have led to a shift in the way specific care needs are identified and delivered. A challenge posed by SDOH, and ultimately health equity, is the variation in need based on environmental factors. Through partnerships with community-based organizations and our clients, mutual goals can be achieved by addressing social needs and downstream health outcomes.
To do so, data analytics is crucial. Who is our population of focus? Where do they live? What impact will our intervention have? These are all questions that data can provide insight to. Knowing this, ProspHire has supported population health assessments and data dashboards focused on marrying publicly available data and internal clinical data to support data-driven decision making. These tools support strategic development and inform the who, what and where of many Medicaid projects, specifically those focused on quality.
With the rise of value-based care models, how do you assist clients in transitioning from fee-for-service to value-based reimbursement structures within the Medicaid space?
Pay for performance models, shared savings programs, patient centered medical homes, Medicaid ACOs… the many value-based care models, continue to evolve and demonstrate their effectiveness. Our focus is to support the readiness and feasibility of transition followed by the monitoring and controlling of care model commitments. The continuous need to reduce costs and deliver improved quality of care poses a challenge to both providers and payors and leads to the continuous need to reevaluate and refine our reimbursement structures.
Looking ahead, what trends do you anticipate shaping the future of Medicaid consulting and how is ProspHire positioned to address these trends proactively?
As we anticipate change to Medicaid during the new Trump administration, it is hard to predict trends, but we can expect change. Medicaid advisory and quick adoption and execution in reaction to said change will be the value of consulting to the industry. As a boutique consultancy with an exclusive focus on healthcare and an emphasis on government programs, ProspHire is well positioned to be adaptive and quickly support our clients in understanding, implementing and monitoring the changes and impacts of regulatory and industry shifts.
One priority in Medicaid that will remain unchanged is the desire to reduce costs and improve quality, an effort that will continue to foundationally drive ProspHire efforts and priorities. As we evaluate the regulatory environment, industry trends and strategies, our goal remains the same – to drive positive change for our clients and the Medicaid population.
