Lack of interoperability opens Medicaid programs to fraud and waste, but registry hubs can be a solution to help streamline IT systems.
One of the largest costs associated with Medicaid is fraud, and the inability to detect fraud is emblematic of a larger Medicaid challenge: non-integrated information systems that date back to the mainframe and early client/server years. In fact, many Medicaid Management Information Systems (MMIS) systems are more than 15 years old and well past their initial expected useful life.
States originally deployed these systems with the goal of managing finance and accounting to ensure timely and accurate payment of provider claims. The systems are often failing to meet even these basic demands, let alone improving the quality of care delivered.
One of the fundamental challenges that typical MMIS environments present is that information remains system-centric, making it impossible to develop a composite view of beneficiaries. Compounding this problem is a lack of system interoperability. Despite these clear challenges, few state Medicaid agencies have the budget to start anew and replace their MMIS environments in entirety.
MITA's principles include interoperability, data sharing and reusability. Its maturity and business process models and national guidelines provide a business-level view of what technical systems should enable at various stages of MMIS evolution. Perhaps the most fundamental change that MITA presents to state Medicaid environments is that in the later stages of MMIS maturity, its suggested emphasis on systems moves beyond finance, accounting and claims processing.
This beneficiary-centric approach is entirely focused on improving care and reducing costs while promoting national interoperability.
At all stages of MITA maturity, state Medicaid systems can benefit from taking a registry-hub approach to matching and linking beneficiary and other Medicaid systems information. Built off of similar architectures to regional healthcare information organizations (RHIOs), registry hubs help states adopt a secure, beneficiary-centric approach to Medicaid services delivery.
Registry hubs link and match all information about an individual beneficiary without the need to replace existing systems. Registries can, in real-time, call information from all existing applications using standard application programming interfaces (APIs), creating instant but complete views of beneficiaries, their providers and other relationships in the Medicaid systems environment.
At the basic level, registry hubs can help transform the eligibility/qualification process, enhance fraud detection and reduce the cost of care through participation in healthcare information exchanges. For more advanced agencies and organizations, the hubs can improve patient outcomes by providing linkages to electronic health records, different providers within a system and regional and national healthcare information systems.
For example, a Beneficiary Registry could improve the eligibility and qualification process by finding, matching and linking all the records about a patient from across multiple agency databases. Through this composite view of a beneficiary, Medicaid administrators can quickly and accurately determine eligibility, see if there has been any status change and ascertain benefits.
A Beneficiary Registry can also help reduce costs. Besides the administrative cost savings that would come from increased efficiency, a program could also cut operational costs by having a complete, accurate view of a patient's records at the point of care. For example, if a patient presents at a clinic, the caregiver would be able to see any tests that had been performed for this patient at any other location in the network. Costs are controlled by preventing redundant testing and duplicate records.
As state Medicaid systems consider the best ways to move up the MITA maturity curve and become compliant, they should consider the following questions in the context of their overall MMIS approach:
1. How can we enhance access to disparate systems, creating a composite view of beneficiaries without compromising data integrity or overspending on costly system replacements?
2. What is the best way to deploy systems that communicate effectively to achieve common Medicaid goals through interoperability and common standards?
3. How can we enable performance measurement for accountability and planning?
4. How can we flexibly respond to rapid changes in programs and technology?
5. How can we best support analysis and decision making for healthcare management and overall program administration with timely and accurate information?
By addressing these questions, Medicaid systems can improve their MITA maturity, reduce administrative and operational costs, make significant progress toward becoming MITA compliant, and drive value across their MMIS initiatives.
Scott Schumacher is the Senior Vice President and Chief Scientist of Initiate Systems.