Medicaid and CHIP federal quality measures

Dustin Haisler (00:00):

All right. You know what time it is, it's TGIF. Time for In Case You Missed It, GovTech's Weekly News Roundup. Now, today we're talking health equity for state government. There's upcoming changes in quality measures for Medicaid and CHIP, and this is going to have an impact on all state government agencies. So today we're going to be looking at those new rules, data, and approaches specifically around the technology components and those foundational elements that need to be in place to support these new reporting requirements.

Dustin Haisler (00:56):

We'll also be looking at what the future holds for states that have the right foundation to implement these new rules correctly. And Joe and I are back at it, but we've brought two experts from Optum in to help us make sense of what's happening. We have Mylynn Tufte, Practice Lead, Population Health for Optum Advisory Services, and Meta Kreiner, the Practice Lead for Population Health for Optum Advisory Services as well.

Dustin Haisler (01:20):

Mylynn and Meta, thank you so much for carving some time out to break down this really complex topic for us and help make state governments understand what to do with it.

Mylynn Tufte (01:29):

Great. Thanks for having us.

Dustin Haisler (01:32):

So maybe to start, I'd love to get to know a little bit about both of you and your backgrounds and kind of how you got to where you're at today. And Meta, let's start with you for this one, tell us a little bit about yourself.

Meta Kreiner (01:43):

Sure. I have a Master's in community health and I am the Population Health Specialist in Optum State Government Solutions. And prior to that I worked for the state of Michigan in their Medicaid bureau.

Dustin Haisler (01:56):

Fantastic. And Mylynn, how about you?

Mylynn Tufte (01:59):

Sure. Thank you. Mylynn Tufte. I am a nurse as well as I also have a business degree in information systems management. I've been in population health consulting a long time, but prior to returning to Optum, I ran the Department of Health for the state of North Dakota for three and a half years, and live in North Dakota.

Joe Morris (02:23):

That's awesome. My wife's a registered nurse, so I know I'm in good company today.

Mylynn Tufte (02:27):

That's right.

Joe Morris (02:29):

Mylynn, maybe you could kick us off and by helping us dig into what is health equity and health equity measurement.

Mylynn Tufte (02:36):

Well, it's really good for us to ground on what that definition is around health equity. And we believe it's having the resources and access to care wherever you need it at the time that you need it. And it's that equality, the equity around that.

Mylynn Tufte (02:57):

When we talk about equity, we also hear people talking about social determinants of health and the importance of those social determinants in their overall health and wellbeing.

Dustin Haisler (03:12):

Yeah, I think that's super important for us to kind of ground ourselves in the right definition. But as I mentioned at the beginning, we've got some changes that are coming, especially around quality and health equity measures themselves. And so Meta, I'd like to go to you for this. Tell us a little bit about how this is going to impact state government.

Meta Kreiner (03:29):

Sure. So I think one of the drivers of quality and health equity metrics for state Medicaid programs are what are called the CMS Core Sets. And these are metrics that have been carefully selected and provided by CMS, by the federal government, for all state Medicaid programs. And they're kind of divided into three lists. One of them is the child Core Set, so those are metrics for children and their health needs. Another one for adults. And both of those have a subset that's kind of focused on behavioral health. And then there's a third one, which is the Health Homes Core Set, and that's for states. And I think the last time I looked is about 19 states that have a health home program within their Medicaid.

Meta Kreiner (04:20):

So these Core Sets and these metrics, they've all been around for about 10 years now, but reporting has been voluntary. And what's changing, and it's kind of been known as coming for a couple of years, is that they're going to be mandatory. And that is set for federal fiscal year 2024. It is going to be based on a proposed rule that came out this summer, starting to give us a sense of what that mandatory reporting is going to look like. It's going to be the full child Core Set the behavioral health portion of the adult Core Set, and the health homes Core Set for states that have health homes.

Meta Kreiner (05:01):

So that's coming for federal fiscal year '24, which might sound like it's far away, but that means 2023 data. So that means services and care that's being provided right now, starting this month. So it's actually a little bit sooner than it might seem. And-

Joe Morris (05:23):

Go ahead. Sorry.

Meta Kreiner (05:24):

Go ahead.

Joe Morris (05:25):

I was going to say it does seem soon, especially for a bunch of new administrations that have taken off as well at the state level.

Meta Kreiner (05:31):

Right. Yeah, with quality metrics, you're always kind of going back in time a little bit. So you really have to be prepared.

Meta Kreiner (05:39):

And this proposed rule kind of helps to see what's coming in terms of the mandatory requirements. And one of them, clearly, it's a focus on national consistency in reporting. While it's been voluntary, states have had a little leeway to use some different methodologies, maybe include different portions of their Medicaid populations because Medicaid's really a lot of different programs that can look a little different. And so that consistency, that's going to be a new element, I think.

Meta Kreiner (06:12):

And the other piece is that it's not just for the national focus, it's really also to be a resource. And you can see that in the proposed rule for state governments and state Medicaid programs, and give them some Medicaid-focused metrics for monitoring and quality improvement within their own programs, which is going to mean partnering with providers and managed care organizations to do that work.

Meta Kreiner (06:40):

And the last piece I think comes back around to what Mylynn was saying, which is health equity is really at the forefront of this too. So it's not just looking like one rate for each state, but there's also a real focus on stratifying those rates so that you can see if there are any disparities or differences for different populations.

Meta Kreiner (07:03):

And while it's been voluntary, that focus has been on age, sex, race, ethnicity, geography, urban, rural. But looks like in that proposed rule that those stratifications are going to get expanded, and that whole focus on health equity is just going to keep growing.

Joe Morris (07:22):

You're right, in terms of A, providing a phenomenal breakdown of what's coming, but that it's a relatively quick turnaround. So Mylynn, who's ultimately responsible for implementing these standards at the state level?

Mylynn Tufte (07:38):

There are so many different stakeholders that are responsible for this collection of data standards and quality measures. And it's important to have one person that's accountable to do this, but it really takes leadership; leadership from the top to understand the importance of these measures, and the input from all those stakeholders that Meta talked about; our provider community, our payer community, our community benefit organizations that really feed into those measures.

Mylynn Tufte (08:17):

So while it may be, if it was Meta in Michigan at the time, it may be Meta, but there are such a team of people that really bring this together in order for states to be successful in reporting.

Dustin Haisler (08:34):

Absolutely. So as we take a couple steps back, I'd love to maybe frame for our audience, what are some of those common challenges that state government agencies are dealing with surrounding health equity and reporting requirements today in the context of everything else that they've got? Meta, I'd love to hear from you on this one.

Meta Kreiner (08:51):

Sure. Yeah. So one of those challenges is really specific to these Core Sets, is that these metrics are complex. This is not just counts of services. And I think the last report I saw is the average state is reporting about two thirds of the metrics right now while they're voluntary.

Meta Kreiner (09:10):

And part of that is the challenge of getting the data together for this. Some of the metrics are administrative, so they're a little bit more straightforward in terms of you're pulling together your Medicaid eligibility claims and encounters. If your physical health and your behavioral health are in two different systems bringing those together, pharmacy.

Meta Kreiner (09:33):

But there's more and more of a focus on health outcomes, metrics that go to that next level. And that means really data integration. And one of the resources or one of the benefits for state governments is that Medicaid is just one piece of it.

Meta Kreiner (09:53):

And there's also public health, and public health has other data sets that can really be a great asset for these kinds of metrics, like vital records, childhood immunization registries. But that means data integration, because just because they're all in state government doesn't mean that they aren't housed in different places. Then you've got to get to data sharing agreements and actually bringing this data together, person matching and all of those challenges. So data security, lots of complex pieces. But really rewarding when you're able to link together the services and the health outcomes.

Meta Kreiner (10:39):

I think another challenge with that is even with that resource of your public health outcomes data, a lot of these metrics are still looking for clinical data, and that can be really challenging for Medicaid programs. It used to mean medical record review, actually pulling down paper files. Now that means the technology to integrate with electronic health records, health information exchange. So that can be another challenge.

Meta Kreiner (11:14):

And I think these stratifications also often mean another data set. Medicaid can sometimes have incomplete demographics when you're talking about data integration. The different systems could collect and store this data in different ways, and so you've got all of those data elements as well.

Dustin Haisler (11:38):

So a lot of data that has to be kind of wrangled right now as a part of that. So yeah, I love that breakdown.

Dustin Haisler (11:45):

And Mylynn, I'd love to shift to you because you were in this seat before. So as you think about wrestling that data that Meta was talking about, what are the technology components that really need to be in place to support that and all the new requirements that are coming? And anything else states should be doing to kind of operationalize the data?

Mylynn Tufte (12:03):

Yeah, thanks, Dustin. Even before we talk about technology and technology systems, I always try to remind people, let's step back and look at our overall strategy and what we're trying to achieve. And having that good strategy that you can communicate to those stakeholders is so important.

Mylynn Tufte (12:22):

When you have the strategy, then you can do the assessment around your technology and technology components, and understand where the gaps might be. Meta talked a lot about data interoperability. Data governance is so important. So that individuals that we're serving have trust in providing us with the data, and then us to be able to share that within the regulatory constraints or environment that we live in. Those are all considerations for us to be good stewards and be able to deliver on what we have to do and want to do to improve health equity and health outcomes in the state.

Mylynn Tufte (13:11):

The other thing that I would say is states that do this right are really making heavy investments in analytics, and looking for technologies that can advance the work that they do through automation and use of AI or machine learning. But I'd step back and really say that that level of technology and analytics that's required to do identification and stratification is so important so that the resources that you do have within the state are going to the best and highest use.

Joe Morris (13:47):

I want to kind of piggyback on that a little bit. I'm thinking in terms of the audience that's tuning in today, what actions should they be taking if they're a technologist, if they're a program manager, if they're coming from that data angle that you just kind of uncovered? Meta, maybe you could share with us, whether it's the people, the process, the technology, what should states be considering now to handle that, their data, their health equity measurement?

Meta Kreiner (14:13):

Yeah, I think that you can think about these reports as this once a year, one time thing, but it really builds on everything you're doing every day across all the different positions that you were just listing there. It's really about your day-to-day operations and the technologies you have in terms of collecting this data, storing it, and then your analytics teams. But also the people providing the services; the providers, the hospitals, clinics, your managed care plan organizations, if it's a managed care state, because they're the ones who are going to be playing a role with the data collection.

Meta Kreiner (14:57):

And then it's really important, I think, as Mylynn was saying, to share those results, get everyone sort of on the same page about the importance of that, seeing those disparities, because they're also going to be your partners when you're doing quality improvement and working to address those disparities and improve care. And then those are multi-year initiatives and brings you right back to data collection again.

Meta Kreiner (15:24):

So I think the key here is that really good metrics and good health equity analytics build on everything you do every day for strong operations.

Dustin Haisler (15:37):

That's such a good point. So now, let's shift and talk a little bit about the future. And Mylynn I'd love to get your take on this as we kind of look to the future. What is the future for states that have the right foundation, that implement these new procedures and the foundational elements correctly? What does the future look like for them?

Mylynn Tufte (15:56):

Well, the future that I'm dreaming about is really a future where we don't have these disparities in healthcare, and that people do achieve that optimal health and they have those resources at their fingertips. So that's the future that I'm dreaming about. The states that are doing it well, truthfully, they've been funded and they have the people, the process and technology, and they've been able to bring it together.

Mylynn Tufte (16:27):

But I want to make sure that everyone's working towards this and there's that awareness that everyone has a part to play in driving good health equity and health outcomes for their state constituents, whether you're sitting in technology, whether you're a nurse in the public health department or you're running a Medicaid department. That's the future. When we all work together inside government and outside government with our key stakeholders, that's when we're going to really make a difference.

Joe Morris (17:04):

I love that. I think that aligns to the mission I know that we have as an organization in terms of making government better, and I think that the health equity, health equity measurement in improving healthcare outcomes is a massive part of that.

Joe Morris (17:17):

So Mylynn I want to stay with you for a second. This is probably the easiest question that you've got all afternoon here, but where can our audience go to learn more about Optum State Government solutions and how you're working with states to prepare them for these new requirements?

Mylynn Tufte (17:31):

Yeah. We'd love to talk to you. We'd love to hear from you. You could reach out to me, you could reach out to Meta. You can see our email contacts that are running across the screen. In addition, you can find out more information, things that we've published around thought leadership, other capabilities and resources that we have at optum.com/stategov. That's another great resource to access some of the things that we've been talking about today, as well as other things that you might need at your state.

Joe Morris (18:06):

Awesome. Well, Meta, Mylynn, thank you so much for taking time out of your day to join us and to share a little bit of insight into these new requirements and what they mean to states. So thank you both.

Mylynn Tufte (18:18):

Thank you.

Meta Kreiner (18:18):

Thank you.

Joe Morris (18:19):

Have a wonderful-