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The annual Medicaid Enterprise Systems Conference (MESC) began day 2 with a deep dive into Machine Learning for Medicaid Payers and Providers, followed by sessions on successful modular MMIS implementations and best practices from state reuse initiatives, including that of New Jersey and Pennsylvania.

If you weren’t able to attend, check out our MESC recap of key takeaways.

Machine Learning for Medicaid Payers and Providers

There is broad agreement in the industry and among research communities that Artificial Intelligence (AI) and Machine Learning (ML) will significantly alter and improve healthcare. The session got off to a great start, engaging the audience with: “What is a machine and how is it learning?” Outlining the basics of analytic excellence and how it leads to better decisions. Digging deeper, the session highlighted the differences between Machine Learning and Classic Analytics (BI). 

The problem:
  • State Medicaid leaders need to be able to predict the medical costs for a member in the coming year 
  • Newer members have limited cost histories 
  • Members are “just” diagnosed with diabetes, go-forward costs not represented in old data
  • Members with both diabetes and congestive heart failure have a combination of cost that cannot be simply trended
The Solution:
  • Classic analytics (existing product dashboards):
    • Gather past data, generate average cost/year, and calculate a trend value to use going forward
  • Machine learning:
    • Utilize “Nearest Neighbor” Machine Learning. 
    • Use the cost patterns of a lookalike member to make projections for new member

Strategic Planning for Successful Modular MMIS Implementation

Another insightful session was Strategic Planning for Successful Modular MMIS Implementation lead by The Commonwealth of Pennsylvania’s Sam MooreDory McGuireDan Sorge, and Phil Tarquino. The Commonwealth of Pennsylvania, who is leading the pack in modularity, is replacing its legacy monolithic MMIS. The new MMIS 2020 Platform will provide a modular enterprise-wide system providing automated support for the Department’s programs, supporting almost three million individuals. Sam Moore describes challenges, improvements, and timelines needed for MMIS. “We started looking at all of these puzzle pieces and formulating how to bring everything together.” Moore also tells us “we knew we needed a system integrator,” as a team, they developed several RFP timelines and strategic plans, which include CMS R1 Review  and the “Road to Certification.”  

‘What’s the Re-Use?

Planning, Considerations for Reuse, and Keys to Success were the three major points of ‘What’s the Re-Use? State and Vendor perspectives on Modularity and the MITA leverage condition. This session was led by Carie Clements of Accenture, Ed Dolly of CMS, and Mary Arcenas of New Jersey. MITA leverage condition offers agencies the ability to reuse proven technology, practices, and methods while reducing redundancy. Two perspectives to consider that maximize cost and effort savings are: Partnering with other states to help agencies with a range of initiatives—from sharing of state-operated MMIS or specific vendor capabilities focused on reusability. Clements broke down her three major points below:  

  • Planning: Spend time upfront and develop a clear vision for enterprise solution. This avoids functionality gaps or redundant solutions, results in better solutions and total cost of ownership, reduces change orders and improves contract management.  
  • Considerations for Re-use: Define capabilities based on what is commercially available, choose commodities that lend themselves to reuse across modules.  
  • Keys to Success: Approach to procurement, approach to contracting, clearly defined APIs/approach for interaction between components and modules, and governance.  

Next, leverage and reuse between states was discussed. Below is a brake down of the four major components of West Virginia/New Jersey’s leverage and reuse project: 

  • Reduce Duplication 
  • Testing 
  • Certification (Processes, templates, artifacts) 
  • Bidirectional Leverage and Reuse 

Mary Arcenas of New Jersey states, “In New Jersey, we are doing a full system replacement.” She explains how West Virginia’s model has strongly influenced training and implementations in New Jersey.  

The session also highlighted West Virginia’s leverage and reuse initiatives:  

  • Partnering with two states to share and enhance West Virginia’s current provider enrollment functionality  
  • Input from other states for Electronic Visit Verification (EVV) systems: 
  • Stakeholder involvement opportunities 
  • Effective requirements 
  • Lessons learned 

Ed Dolly of CMS explored meeting the requirement for reuse, “speed, efficiently and delivering the service to the program.” He ended off with, “Make the alternatives analysis a meaningful conversation.”  

Thank you for everyone that stopped by Softheon Booth #71 Monday night for Demos and Donuts. To learn more about how Softheon is supporting states with Softheon Verify contact   

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Check back tomorrow for our recap of Day 3 at #MESC2018. 

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