Systems which Missouri uses to manage its Medicaid program are cumbersome, intertwined, complex, outdated and need to be upgraded, MO HealthNet Director Todd Richardson told a Senate panel Wednesday.
And when hardware and software are eventually replaced, more time and money will need to be spent bringing staff up to speed on their use, he said.
Richardson spoke about issues facing MO HealthNet in a hearing for the Missouri Senate Interim Committee on Medicaid Accountability and Taxpayer Protection.
The committee, which will soon make final recommendations to the entire chamber, was created to develop recommendations concerning MO HealthNet (Missouri's Medicaid program), abortion providers and aligning the way public dollars are spent with the values of Missourians. The committee is to provide recommendations concerning the program for the Senate.
Wednesday's hearing focused on managed care and technology.
Richardson commended the committee for wishing to make improvements to the state's Medicaid Management Information System (MMIS), but advised them that the system does not stand alone as a single entity.
"(It is) a collection of systems that have to work together to provide the type of program we want to deliver," Richardson said. "We're making some significant upgrades to that system as we speak."
MMIS does what it was designed to do, process millions of pieces of information and millions of claims every month, Richardson said. However, being that large, its flexibility is limited.
Replacement of MMIS will be a "significant investment" in money and time that Missouri will have to undertake.
So, MO HealthNet has been preparing for procurement, should the money come available.
Missouri is not unique in having an antiquated Medicaid claims processing system. Upgrading systems is a high priority for every state, Richardson said.
Some states that upgraded have been successful.
"Some have failed spectacularly," Richardson said.
There is a lot of COVID-19-related money coming in from the federal government, Sen. Mike Bernskoetter, R-Jefferson City, said after the meeting.
"This would be a good place to consider a one-time expense," Bernskoetter said. "All the state's departments (could use technology funding). A lot of those things haven't been updated for years."
Some departments may be disqualified from using COVID-19 revenue on technology, depending on the rules, he said.
"I would think that if funds were available, that would be a good place to spend it," he continued.
Other challenges MO HealthNet faces include providing the best service at affordable costs.
Alex Rankin, the Missouri Foundation for Health director of government affairs, said the foundation has identified opportunities to strengthen the MO HealthNet program.
Missouri can improve Medicaid's managed care program using best practices from other states, she said.
In the managed care model, MO HealthNet provider agencies (Home State Health, Healthy Blue and United Healthcare) contract with managed care organizations (MCO) that accept a set payment per member per month for services.
The model improves care, enhances coordination, reduces costs and improves outcomes, she said. The foundation recommends the state managed care contracts for high-need populations and target "super-utilizers."
She pointed out the population that is now signing up for MO HealthNet (under expansion of the program) is expected to have a higher percentage of behavioral health and substance use disorders than the current population.
"MCO contracts should account for members with these needs," she said.
States can require screenings and develop care plans, knowing people go to their primary care offices (if they have primary care providers) as their first effort to seek help for substance use, Rankin said.
Data collection for "upstream" health determinants, those social-structural factors like housing, poverty and household makeup that influence health, can be used as leverage to require agencies to address further needs.
"Some states require more intensive care management for people with difficulties with food and housing and transportation," Rankin said.
The committee wants to do the best it can for the people who are already on MO HealthNet rolls and those who are coming on, Bernskoetter said, while doing what's best for the state.
And, making data about MCOs available in dashboards can be useful for consumers, Bernskoetter said.
He pointed out that senators are behind creating dashboards that show results from Missouri's MCOs.
It's important the dashboards are user-friendly and accurate, he said, and they have enough information to help consumers to make informed decisions about providers.
Sidney Watson, a law professor at St. Louis University, testified that making data available empowers stakeholders, and creates a "race to the top." MCOs don't want to be on the bottom, she explained.
A challenge, she continued, is having in-network services within Medicaid-required proximities.
Medicaid requires certain managed care plan network services to be within a limited distance or time of travel.
Enrollees should be able to find basic hospital services within 30 miles of their homes. Secondary services (like operating rooms and emergency departments) are supposed to be available within 100 miles of patients' homes.
"There is a shortage of in- network hospitals in 34 counties across the state," Watson said. "In 26 counties, managed care companies cannot meet these requirements because of a shortage of hospitals."
Seventeen counties have shortages because hospitals refuse to contract with managed care companies.
Hearings already have led to the committee offering recommendations for the General Assembly.
An early recommendation that came out of the hearings was that regulations be relaxed so departments of Health and Human Services (DHSS) and Social Services (DHS) may share information regarding Medicaid provider investigations. Another early recommendation was that Missouri be able to consider out-of-state behavior of a Medicaid provider, when making determinations about its qualifications in Missouri.
The committee recommends an expedited process allowing DSS to use information provided through DHSS investigations to identify patterns of violations or a provider's lack of qualifications to be certified as a MO HealthNet provider.
The committee wants DHSS and DSS to include violations of state law relating to abortion facilities - including failure to get informed parental consent for an abortion, failure to retain records or failure to cooperate with DHSS during an investigation - as reasons for why a provider could be terminated or rejected from the MO HealthNet program.