More than a third of Vermont’s population is enrolled in Medicaid. Their health care claims every year number in the millions, and those claims add up to well over $1 billion — on par with the size of Vermont’s General Fund, or even bigger.
But, like a lot of the state government’s technology, the IT system the Medicaid program runs on is really old: 30 years old.
It still works, but not very efficiently. Reports on those millions of Medicaid claims are vulnerable to human error, and producing them is time-consuming. So, the Medicaid Management Information System, or MMIS, is inefficient by modern standards.
It also doesn’t allow the state Medicaid office to be as effective as it could be in managing care for the roughly 225,000 adults and children enrolled in the program.
Trinka Kerr, the State Health Care Advocate, said that slicing and dicing claims data in more sophisticated ways could help identify people who might be falling through the cracks — such as someone using the emergency room a lot, or not filling prescriptions, or missing appointments for preventive care.
“Why aren’t you going to your appointments?” she asked rhetorically. “Why aren’t you getting your prescriptions? Because you’re having transportation problems? Why are you having transportation problems? Can the state help?” Kerr said a good case manager will look at a beneficiary’s barriers to care, and try to eliminate them.
She said claims analysis also is important for provider accountability. It lets the state Medicaid office see which practices show great outcomes for patients with a particular condition, for example. Or, on the other hand, they can spot providers who seem to be issuing costly prescriptions without much effect.
This type of care management has been in place for several years for Medicaid beneficiaries with chronic conditions. The idea is to roll it out for everyone.
Ultimately, the new Medicaid information system will be able to link up with this Care Management project, as well as Pharmacy Benefits Management, and investigation of waste, fraud and abuse. Those functions happen now, but in IT systems that operate in silos.
With the new Medication Management Information System, these functions all will be integrated. The new MMIS also may include additional health care effectiveness reporting, special focus on people enrolled in both Medicare and Medicaid, and a comprehensive directory of all health care providers in the state.
But many of these improvements are in limbo because plans for a revamped Medicaid information system have faced years of delays.
Single-payer is a big reason. A Request for Proposals, or RFP, for a new Medicaid system was pulled after the state passed Act 48 in 2011. That was the legislation that aimed for a statewide single-payer health care system by 2017. Bids had already come in when the state’s vision for health care changed, and some federal guidelines for state Medicaid programs also were updated, rendering the original RFP irrelevant.
It took about three years for the Agency of Human Services to issue a new a new RFP, in June 2014. The plan then was to select a vendor last November, who would start work in February 2015. Meanwhile, a parallel project to integrate eligibility determinations for all the state’s 40-plus public assistance programs would already be underway.
None of this has happened, because of the technological train wreck of Vermont Health Connect. To this day, efforts to get back on track with the health care exchange after its faulty rollout are consuming so much of the state’s resources that all other big health-related IT projects are on hold. That’s despite federal pressure to get them done.
Lawrence Miller, Chief of Health Care Reform, said that in addition to ultimately saving money, the new Medicaid and Integrated Eligibility systems will help the state help Vermonters more effectively. But, he thought the Agency of Human Service’s implementation timeline was ambitious to begin with. And that’s putting it mildly.
“Candidly, I thought it was absurd,” Miller said. “There simply is not the capacity at the agency to manage that many different high-stakes projects at once. They have to be phased. Or, the risk of difficulty is much too high.”
On that point, the Legislature agrees. Lawmakers refused to fund either project in the current fiscal year, after Gov. Peter Shumlin’s administration had asked for $8 million this year, and another $8 million the next.
Those budget requests turned out to be a drop in the bucket. Both the Medicaid and Integrated Eligibility projects come with initial price tags well over $100 million dollars.
Sen. Jane Kitchel, who chairs the Senate Appropriations Committee, said legislators weren’t ready to fund the projects because they didn’t feel they had enough information about either one. Learning from the mistakes of Vermont Health Connect, she said, more homework was necessary to ensure the projects’ scope, management and accountability mechanisms were right.
“I think if anything, what the Legislature is saying is, we understand the need to upgrade our technology. We understand that those investments long-term are necessary,” Kitchel said. “But we want to have the confidence and the assurance that we have projects that in fact are going to have a high degree of success.”
And that, she said, means fixing Vermont Health Connect before tackling another big project.
Officials at the Department of Vermont Health Access say they’ll move ahead with contract negotiations for the new Medicaid and Integrated Eligibility systems. Stephanie Beck, who’s overseeing the projects, said they’ll likely choose a vendor for Integrated Eligibility this summer, and for MMIS in the fall.
But both projects’ implementation timelines now hinge on Vermont Health Connect achieving “substantial completion,” which means that everything except the small business operations must be working.
After that, Integrated Eligibility will get underway, and only after that gains traction will the state be ready to start developing the new Medicaid information system.
Until then, whenever “then” may be, many functional improvements are on hold. And the federal government, the state, the case workers, the health care providers, and the beneficiaries, will just have to wait.
Hilary Niles is a freelance investigative journalist based in Vermont.
This post has been updated.