Jamey Harvey’s Post

Transcript

So. In addition to being knitted together by money, they're also being knitted together by data and documents and policies. You know, every state Medicaid agency has a state Medicaid plan that is a document that they've showed us CMS and has been approved. They have waivers, they have policies, they have Spas. They have all of these different bureaucratic ways of like talking about making sure that the regulations match up between CMS and the regulation and then to the payers and all that's supposed to flow into the data. They're supposed to match and, you know, give you a little preview. It doesn't all necessarily match, but the, and when it doesn't match, that causes problems downstream. So the state Medicaid agency is responsible for determining who's eligible for Medicaid. And then they, they get the information over to the MCO through a technical form called an 834, which, which is basically like saying, hey, this person is eligible for Medicaid or they're enrolling, they're disenrolling as well as like publishing the, the regulations that do this and. This is a a vastly simplified view of sort of how things work inside the Mcos. Those blue bubbles in the. Are in square are processes that every Medicaid plan is responsible for, for example, claims processing and doing prior authorization and claims, which is sort of the financial management part of it. And those are processes that produce data that need to be passed back and forth between the player and the provider. So now we're getting into sort of how the payers and providers work together. At this point, you need a legend because I want you to be able to tell apart the different things. So essentially the the white bubbles are entities that could be people or organizations. The green bubbles have to do with money. The blue bubbles are essentially functions that would produce data. The grave bubbles are are data are documents. And then the the dark Gray bubbles represent the data exchange infrastructure that I talked about at the beginning. And you know, there's. A whole bunch of things there. There are ones for the regulators, there are ones for the pay visitors. There are some pretty important pieces of the infrastructure here. Some of you have heard about the change healthcare hack that that, you know, shut down whole provider networks and made it really hard for them to to communicate with their players. You know, that's a very important piece of data sharing infrastructure that's actually owned by private companies that turned out to be a single point of failure for for many, many. Organizations inside the HealthEquity ecosystem. So it it it is very important for executives in the HealthEquity ecosystem to understand how these things work and what the risks are associated with them and. You know, this begins to get to give you a picture of like sort of what's the data? How do they relate to each other? How does the money flow? And then at the end, you know, how does IT service the patients and enrollees who are, you know, in, in this picture? They obviously patients and enrollees actually interact with payers and they interact with regulators and they interact with the providers. But you know, I think for the sake of most patient enrollees, they're most concerned about their interactions with the providers, which is why I put them down there at that end. So a very pretty picture of sort of how it all fits together. I don't usually show this picture so much to my customers because honestly, like if you're the CEO of a payer, you know all this stuff already. What the, the, the picture I show is the, is the visualization of, of how it's working altogether. And so we, we talk about agility and the Medicaid technology stranglehold. So essentially each one of these groups has their own naughty. Problems with interoperability with their data not matching with things being out of date, with the rate of change happening faster than they can update their systems to keep up with it. Not just their IT systems, their IT systems, certainly right, but also their, their rules, their regulations, their policies, their procedures, their practices, the way that people, the way that people are accustomed to working has to change to accommodate all of these new things. How do you manage all of that? And then in an. In in an environment where everybody is as interdependent as all of these organizations are with each other, how do you create a situation where your organization is no longer being, you know, destroyed by things that are happening outside of your control? Ouch. You know, change healthcare got hacked and it got it became a ransomware problem. Boom, you're no longer getting your claims. You're providers can no longer get paid. Many of them were in danger of going out of business as a result. Real problem, right? Caused by something outside of your control? During recently. Medicaid payers, MCO have become very concerned about the information that they've been getting about the disenrollment information after the public health emergency. They, they call that in the industry, we call that the Medicaid unwinding. And so essentially for a few years during COVID, they stopped disenrolling people from Medicaid and when they decided to start again. Lots and lots of people got disenrolled. And there were lots of reasons why that more people got just enrolled than probably should have been, right? And some of that's human error, some of that's technical error. Some of that's the problems with these strangleholds, right? So, you know, how how does that show up for people, you know, inside of these organizations? They have trouble answering business questions. They have trouble keeping up with regulation. Their IT department tells them no all the time. You know, they have trouble. Measuring what matters you know they they they have a hard time definitively answering questions about pH disenrollments enroll these are churning and you know and with providers it shows up in the people's user experience and the difficulty getting prior authorization which you know many of us have experienced whether we're in Medicaid or not with private health insurance right like you you want to you your doctor has told you you need something you go to try and get it and. You know, does the insurance company say yes or not, right? How much resistance do you get? And if you wanna really good time about that, you know, check out the latest South Park episode about navigating the American healthcare system. Maybe I'll drop a link to it in the comments of of this video. So. We added, Jillian, take a holistic view to this, right? And and when I say holistic view to the ecosystem, I've tried to give you a holistic view of the ecosystem. You, you can't solve these problems by buying some system and having that. You'll just be adding another system to the, to the cluster systems you have. You have to do some. You have to figure out how to normalize your data. You have to figure out how to update your business processes. You have to figure out how to bring the people along in your organization. So if you're part of the Medicaid ecosystem and you would like some help thinking through that, that is my favorite thing to do ever. It's it's what we do all day here at a Jillian would be delighted to talk to you about that. But regardless, if if you like this content and you would like to hear more about this, please, please like or share the video and feel free to put in the comments which part of this you'd like to hear about next. We're probably going to do deep dives into each of the three major areas. Regulators, the payers, the providers, OHH, the four and then also the data infrastructure and you know, probably try and talk about some real world examples of problems that we've helped solve for our customers. We're very at the end of the day, everybody at a Jillian is is. Is committed to finding ways to have these systems do what they're supposed to do better. And you know, they're, they're challenging problems, but they're not impossible to solve and. Really with with the right attention and and thinking about it holistically. We, we've proven again and again that we can, we can help Medicaid enterprises get better results and, and that that directly impacts the health and well-being of their members and, you know, makes the world a fairer place because the folks on Medicaid and a lot of the folks that we service on some of the plans that we do are, are among some of the most disenfranchised people in the country. And we, it would be a, it would be a privilege and an honor to help you. Think that through if you're interested in doing that. OK, Thank you very much. My name again is Jamie Harvey. I'm the CEO of a Jillian. You can find a set of jillian.com. And thanks for your attention today.