Medicaid: Healthcare Software Solutions Reduce Operational Costs

Thousands of poor U.S. citizens will have access to the U.S. Medicaid program. This is evident from the outcome of the midterm elections as part of one of the initiatives approved on the ballot in the red states of Idaho, Nebraska and Utah, which added to the 34 that already have that system.


This means that most of the poor adult population and low-income families in those states will have health coverage.


To give an idea of the number of future enrollees in those three states that have joined the expansion, provides a detailed list divided by expanding and non-expanding Enrolled States by August 2018.




Services Available for Medicare and Medicaid

The Centers for Medicare & Medicaid Services (CMS) have an alliance to modernize health care better known as CAMH. This collaboration with the First Federal Funded Research and Development Center (FFRDC) is intended to enable these entities in each State to accelerate progress in modernizing health care. However, the solutions offered are not tailored to each region and may not provide the necessary capabilities, especially when there is no precedent for complex projects.


To foster a smooth transition to a value-based payment structure that enables the delivery of high-quality care at low cost with better health outcomes, Medicare and Medicaid organizations need to consult with experts who have proven tools to achieve those goals.



Economic Benefits of Expansion

Despite this challenge, which involves others associated with it, the study, “The Impact of ACA Medicaid Expansion on the Burden of Unpaid Hospital Care and the Potential Effects of Termination,” highlights positive effects of the former.


Indeed, it asserts that the reduction in the costs of uncompensated health care in expanding states has a major impact on their economies. Between 2013 and 2015, these costs fell from more than 6.2% to just under 3.7% of operating costs in high-burden hospitals. The research concludes that the findings suggest that all hospitals benefited from the expansion and that the hospitals that had the highest levels of uncompensated care prior to 2014 benefited the most.


The research concludes by suggesting that all hospitals benefited from the expansion and that those who did the most were those with the highest levels of unpaid care before 2014. This shows that the trend of expanding Medicaid is likely to continue. Therefore, States that opt for this system must carefully implement state-of-the-art health software solutions for an orderly transition that allows them to maintain their health budgets and provide higher quality care to new enrollees.



Four Lessons Learned from The States That Joined In 2014

To better understand what’s next for each red state that joined last week and those that may expand Medicaid services in the future, I will explain some lessons learned from those that have already chosen to expand and how to address some of those challenges.


The experience of the six States that began expansion (CA, CT, DC, MN, NU and WA) provides a list of potential difficulties that new entrants are likely to face and resolve.



Predicting the number of enrollees during expansion presents a challenge

The uncertainties associated with the calculation of enrollment and costs varied significantly from the estimates. States that are expanding should be cautious because underestimating the enrollee calculation will make current budgets insufficient. If this happens, it will challenge legislators and lead to unwanted measures.



Problems with Coverage After Expansion – Significant Uncertainty in Costs

Enrolling and keeping enrolled, especially the very poor population facing challenges such as mental illness, housing insecurity or substance abuse, or those who have been in prison, has been a challenge, as in the case of Minnesota, according to research



Poor population critical need for behavioral health

This population that adheres to the expansion has high needs for mental health and services, including treatment for substance abuse.



Administrative challenges

The large volume of new obligations will require an adequate administrative workflow with streamlined processes.



Ways to Reduce Costs in Medicaid Organizations

Conexia has extensive experience in the field of information technology solutions, with highly trained professionals who ensure the quality of our services globally, including the United States. Through the consultation with our healthcare experts’, assessment and recommendations we support the adoption and maintenance of standard electronic transactions while helping to reduce costs.





Avoiding Costs Uncertainty and Eliminating Administrative Difficulties

The way to reduce uncertainty of costs is by acquiring a system that can be overlaid with existing software with a customized Real-Time Adjudication (RTA) model. This way, major disruption to the current system is avoided


The ability to have RTA enhanced by the Point-of Care feature, will redefine and simplify the administrative workflow. Easier administrative management means accelerating communication between payers and providers which helps them to be in control of costs, in turn, patients become a high priority and receive better quality of care.



Prior Authorization Re-definition

To reform manual, burdensome procedures, such as prior authorization, processes need to be re-designed expediting flow of information and responses to help reduce administrative expenses in health care spending. This will increment efficiency in physician practices and grant timely service for patients.



Help with substance abuse prevention

Implementing alerts in the platform information systems used that aim at detecting aspects related to: poly medication in prescribed patients (when there are 5 or more medications per prescription), medication interactions, quantities, costs and suppliers, will help identify patients at risk. These alerts are managed by the client’s medical audit team facilitating actions towards the providers allowing to decrease exposure and help in the prevention of new addiction.



Fraud detection and prevention

The implementation of platforms that help to detect and prevent certain types of fraud, saving money for our clients as detailed in a previous article.


Implementation of a new alert system results in measures that improve the safe use of drugs and improve cost control. Reducing the likelihood of adverse drug effects while at the same time improving patient safety.


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