Host: The saying goes, if you don't have your health, you don't have anything. And health insurance is an essential part of that equation. For millions of low-income Americans, the Medicaid insurance program is a lifeline to accessing care. But Medicaid is notoriously difficult to navigate --for healthcare providers and patients. And it’s compromising care.
Dr. Sumit Agarwal: Medicaid tends to have the most administrative complexity when it comes to submitting these claims and getting a reimbursement.
Debora Magalhaes: It still confuses me to this day. It's very, very confusing.
Debarshi Datta: Medicaid is a prime area of where we can leverage a lot of the technologies and provide meaningful gains to the end users.
Swami Chandrasekaran: So how do we create this highly available architecture?
Debarshi Datta: If it was easy, it would have already been built.
Host: This is Speed to Modern Tech, an original podcast from KPMG. I'm Tori Weldon. Each episode, we'll bring you a problem many businesses are facing, and the story of how technology was used to tackle it.
Today, the technological challenge of modernizing Medicaid information systems. And how to build a system that lets doctors spend less time on paperwork, and more time with patients.
Host: Medicaid is the federal and state government program that provides health coverage to low-income Americans. The scale of it is enormous -- nearly one quarter of Americans receive some benefits from Medicaid.
The cost is heavily subsidized by the federal government. But individual states actually administer the program.
Think of a franchised restaurant with 50 locations -- they kind of look and feel the same, have similar food. But each franchise has their own system for paying waiters, managing reservations, scheduling shifts.
The same applies to Medicaid. From state to state, there are different rules around who qualifies for the program, and what services are covered. States also use different information systems to manage Medicaid -- and these systems come with a lot of administrative and technology challenges.
It can make essential business tasks - things like billing and claim processing - pretty difficult for healthcare providers. It's a key reason why some doctors don't treat patients insured by Medicaid.
Dr. Sumit Agarwal: I'm Sumit Agarwal. I am a primary care physician at Brigham and Women's. And I'm also a health policy researcher as a part of Harvard medical school.
I did my medical training at the Mayo Clinic, fantastic place to train, fantastic place for patients to get medical care. And then I went to the University of Virginia for residency, and it's a safety net institution, meaning they see poor patients. They see patients with Medicaid or have absolutely no insurance.
Host: At UVA, Dr. Agarwal saw firsthand how hard it can be for Medicaid patients to access care.
Dr. Sumit Agarwal: Gerald was one of my patients when I was practicing and training in Virginia. And he is elderly. He used to be a school bus driver. He has diabetes for which I would prescribe him insulin. He has osteoarthritis and he would travel an hour to see me each way for a 20, 30 minute appointment, every three or so months.
I find that pretty insane having to drive an hour for primary care, that should be very, very accessible.
Host: The reason Gerald had to drive an hour? He couldn't find a doctor where he lived that accepted Medicaid.
It's a pervasive problem -- Dr. Agarwal says that according to some national estimates, about a third of physicians are not accepting new patients with Medicaid. The stakes get even higher when people with Medicaid need urgent, or specialized, care.
Dr. Sumit Agarwal: I took care of a patient with cirrhosis or liver failure caused by an immune condition, autoimmune hepatitis. And so it was pretty severe in that she had a lot of complications from the liver failure. She had swelling all over the body. She had confusion. She had bleeding.
Host: Dr. Agarwal was treating this patient at a community hospital - but she needed to be transferred to a different hospital, one with specialized care.
Dr. Sumit Agarwal: You make a phone call to that hospital. You talk to another physician and you discuss whether a transfer to a higher level of care is warranted. And so the physician agrees. The next step is you get transferred to what's known as the transfer coordinator and that's where you have to share the patient's demographic information, including their insurance status.
And so at that point, the receiving hospital learns that this patient was on Medicaid.
And so this is not an obvious way that insurance determined needed care, but it's sort of insidious. It just kind of happens. And this patient can't get to a higher level of care because of the insurance she had.
Host: It's a difficult position for patients and doctors - many patients spend months searching for doctors who accept Medicaid. And even if they do manage to find a doctor who will take their case, that doctor needs to spend many extra hours navigating the Medicaid system.
Dr. Sumit Agarwal: As a physician, seeing a patient with Medicaid, is sometimes a losing proposition. It turns out that Medicaid pays one of the lowest reimbursement rates for a variety of services. And then Medicaid tends to have the most administrative complexity when it comes to submitting these claims and getting a reimbursement.
Host: For doctors, it is a double whammy. Medicaid pays less than private insurers for the same services. At the same time, submitting claims to Medicaid is more time consuming and more complex. Dr. Agaral says studies have shown that roughly one-quarter of all Medicaid claims are denied.
Dr. Sumit Agarwal: To put this in numbers, you know, these researchers, they've tried to put a dollar amount on how much it costs to go do this back and forth with insurers and to have denied claims. And the number they put, it was around $16. So what we have is $66 for an office visit, is actually more like $50 for an office visit when you average it across all the office visits and having to have this back and forth with insurers. So that requires hiring billers. That requires time of the physician that could have been spent doing more direct patient care.
So it's the combination of the both. It's both the low reimbursement and the red tape associated with billing Medicaid.
Host: Healthcare providers who do accept Medicaid patients have a lot to say about the red tape they face -- and why it's such a barrier to care.
Debora Magalhaes: My name is Debora Magalhaes and I'm the owner and also the clinic director at Kids In Motion Therapy Center. We provide pediatric occupational therapy and speech therapy services.
Host: Debora's clinic is in Framingham, about 30 minutes west of Boston. Her clients are children and teenagers -- a group that makes up the majority of all Medicaid users. Debora opened her clinic just a few months ago, in January 2022.
Debora Magalhaes: The real reason I started my private practice was to take on Medicaid in our community, Framingham Ashland. This area has a lot of Brazilians, a lot of immigrants, a lot of kids with MassHealth. I speak Portuguese. I was born in Brazil, so I had a very diverse caseload. So that's really what drove me to kind of get my private practice going, was really the Medicaid aspect.
Host: Together with a speech therapist, Debora treats about 35 children who need occupational therapy to learn basic life skills -- things like learning to self-groom, getting dressed in the morning, putting on shoes.
Debora Magalhaes: In pediatrics, a child's occupation is play. So you want to have the correct skills to play, whether it be a social skill or a motor skill such as their balance – is their balance getting in the way of them playing? You know, if you have a weak core, believe it or not, it's really hard to get dressed and put on your shoes. So really focusing on helping a child be as self-sufficient, as independent as possible.
Host: About two thirds of the children at Debora's clinic rely on Medicaid - or what's called MassHealth in the state of Massachusetts.
As a brand new clinic director, Debora says it took hundreds of hours to learn the MassHealth system. Knowing how to file the claims and what is covered meant a lot of trial and error. The portal is also really outdated, especially compared to other insurance platforms she works with.
Debora Magalhaes: It's pretty complicated. I mean, I had never worked on Medicaid before.
They don't give as much information as the other portals will. For example, if I use Blue Cross Blue Shield, and I ask for a child's eligibility, it gives me everything right there. And then it's visually pleasing versus MassHealth – it just tells you whether or not their plan is eligible.
Host: And she's coming across new challenges now.
Debora Magalhaes: If a child has private insurance, but also MassHealth, I bill that private insurance and then I have to bill MassHealth secondary. And so what I have to do is I have to go into the MassHealth portal and re-type everything manually. If you type anything wrong, it comes back as rejected, so it's kind of been like a trial and error. I've been getting a lot of denials.
Host: Despite Debora's frustrations with the Medicaid portal, and layers of red tape, she's committed to working with these children.
Debora Magalhaes: It was actually really discouraging at first. The process wasn't as smooth as a child walking in with private insurance. The only thing that keeps me going with Medicaid is the volume and families call all the time and they ask “Do you take Medicaid?” and I'm like, “Yes!” And they're like, “Oh my goodness. I cannot believe it. I wasn't expecting that answer!”
Host: With so many Medicaid programs across the country, it's a mammoth task to make any national-level changes. That includes changes to the information systems states use to manage their Medicaid program -- what are called MMIS.
Current MMIS systems are pretty outdated, and monolithic -- some of the systems were even built in the 80s and 90s. Basic functions within a single MMIS don't communicate with each other - things like checking a patient's eligibility, and billing. It means doctors have to input data multiple times, in multiple places.
A better interface would make administering Medicaid much easier. So in 2018, the federal agency for Medicaid, CMS, tried to tackle this problem.
Host: They mandated that states modernize their MMIS, and provided funding to get the job done. This modernization mandate encourages states to take a modular approach. This means that states can buy multiple commercially-available softwares for different administrative needs.
For example, a state could use Oracle for finance, a different software for enrolment, and another for customer relationship management. So different vendors serve different functions.
And there's a lot riding on states complying -- if they don't they will lose their federal funding.
Just like that, modernizing Medicaid systems became a priority for state governments across the US. But where others saw obstacles, Debarshi Datta saw opportunity.
Debarshi Datta: My name is Debarshi Datta. I am a director specializing in a large system architecture within KPMG focused mainly on the healthcare and life sciences. I was the chief architect of the KRIS connected platform.
Host: For the past two and half years, Debarshi and his team at KPMG have taken on the challenge of modernizing Medicaid, by building a platform that will help connect all the different software that currently works in silos –– the KPMG Resource Integration Suite Connected Platform.
Debarshi's experience in the commercial healthcare sector, and large architecture, meant he understood the business and technology pain points that needed to be fixed.
Debarshi Datta: There are two sets of pain points – one from the end user point of view that there was no uniformity of service. Each program of Medicaid was built providing solutions in a very different way. And because there was no uniformity in the backend, one service might require 10 or 15 documents to prove your eligibility and the lead time to getting a service, something like physiotherapy might get into a month.
On the other hand, primary care visits require very little upfront documentation. But then the pain point is actually felt by the doctors where they don't get reimbursement for the billing by Medicaid.
And this sort of variation provided a very non-uniform experience.
Host: This non-uniform experience was one of the central challenges Debarshi and his team had to overcome. Since every state was using different types of software, for different services, they needed to design a platform that could thread them altogether, and communicate with CMS. The system needed to allow all the software to connect and communicate seamlessly.
Swami Chandrasekaran: Now, this is like saying I'm going to go buy a microwave from GE, a dishwasher from Samsung, maybe my faucet is from somebody else. But somebody's got to put the kitchen together.
Host: That's Swami Chandrasekaran. He worked with Debarshi at KPMG Lighthouse to build this platform. And he explains connecting these components is like a kitchen renovation.
Swami Chandrasekaran: You’ve got to have these different modules to be able to communicate with each other. So if I'm eligibility, I'm trying to look up Joe Schmoe. If the person is anywhere in the system, I need to go talk to that existing member database, for example. And that's where we come in. We are the ones who are putting the kitchen together. We are the ones who are building a systems integration platform that will help and facilitate these different modules, communicate with each other and automate these business transactions.
Host: A systems integration platform. That's what Swami and Debarshi's team are building to help solve this problem. The SIP allows multiple vendors to connect with each other, and also allows individual states to connect with federal agencies. Plus, the SIP will bridge the gap between older systems and new ones, as states modernize their MMIS. So nothing gets lost or broken -- always a risk with large migrations.
Swami Chandrasekaran: No data can be lost ever. No transaction can be lost. Ever. If you have a failure, you need to be able to restore, at least 15 minutes right off of the failure. So there are these recovery time objectives, recovery point objectives, where you are able to recover from the point you failed, which cannot be too far behind. It is complex. It might look very easy, but this is the engineering challenge that we are taking up to build this and make it work.
Host: Another engineering challenge they faced was constructing a system with close to zero downtime each year. Everyone knows the feeling of logging into an online account, only to see "sorry, we're down for system upgrades.” Most of the time, waiting for the system to come back online is just a minor inconvenience.
But in healthcare, keeping that downtime low is critical -- patients need care at all hours, and doctors - they need to be paid for their services.
Debarshi Datta: Downtime is a very, very, very important factor. If the system is sitting down for two days and saying, “Hey, can't provide you any information” because either something is down or you have to switch to paper – which brings in those inefficiencies – was a no no.
So we had to architect this right from the ground up to have what is called an HA, or a high availability system, spread across multiple regions of the cloud. So there is a geographical disaster in one point that doesn't affect the other, and then also resiliency, that if a piece of the equipment goes down, I have a smooth failover into another piece of the equipment without disturbing the services that are provided.
Host: On top of overcoming these engineering challenges -- the platform, above all, needed to be affordable for state governments to purchase.
Debarshi Datta: Ultimately it's a cost aspect which will drive Medicaid's purchasing of the system. Like as a technologist, given enough time and given enough money, we can solve many problems. And that's where we did not start. So we have to provide fast services, uniformity across multiple modules, conforming to a common vocabulary at the lowest cost point.
Host: Then there was the final challenge: how to deliver this same platform to many different states -- all with different users and different service agreements?
Debarshi Datta: So that's where cloud comes in, where we can scale up and scale down. I will have spikes of usage because enrollment months, October, November, I may have a lot of needs to process a lot of enrollment requests. So you need to go burst up and capacity, come down.We knew that each state has a different preference for their cloud of choice. So we definitely knew there wouldn't be a one size fit. We wanted to put all the services containerized, which is basically, uh, make it into a framework, which then can be ported as is to multiple clouds.
Host: The end result? It's a platform that accounts for doctors' pain points, complies with CMS specs, and works with any state's selection of vendors, and cloud providers. It can be made as unique as each state's version of Medicaid itself.
Swami Chandrasekaran: Step one is laying that foundation for the SIP, the systems integration platform, which is common across everybody. And KPMG is building that as a platform and we want to take it to all the states. Step two is bringing in all the vendor state-specific nuances based on their model timelines. When they're going to get onboarded, we will onboard them into using the platform and start making the tweaks. And step three, continue to operate and maintain.
Host: So far, Swami and Debarshi have helped one state modernize their MMIS by adopting this platform. And by the end of this year, the platform will be live in two more states.
What's most rewarding is the opportunity to improve a key aspect of health coverage for lower-income Americans. For doctors, A better MMIS could mean smoother billing processes, getting paid faster, less time spent behind a desk. And for patients, they could enroll more easily, find providers – or possibly have better access to care if more physicians start accepting Medicaid.
Debarshi Datta: We have an immense opportunity in front of us to help a whole population and see that change manifesting in our daily lives. If this thing works and works in my state, I will see my services improve. And my friends and my children and my family and everyone.
I can see a tangible benefit in something as important as healthcare, where we are improving their quality of their life – that's the biggest gain I get from projects like this.
Host: You've been listening to Speed to Modern Tech, an original podcast from KPMG. I’m Tori Weldon.
Todd Lohr: And I'm Todd Lohr, the head of technology enablement at KPMG. If you want to know more about the technologies and the people you heard about in this episode, click on the link in the show notes.
Host: And don't forget to subscribe and leave a review in your favorite podcasting. We'll be back with a new episode in two weeks.