By Tom Still
MADISON – If you meet someone who claims to know how health care reform is going to play out over the next year, hold on to your wallet. You’re probably talking to a con artist.
The advent of the Affordable Care Act means many states are scrambling to set up insurance exchanges, which are online marketplaces to shop for private insurance, while other states will rely on a federal exchange. This shuffle is taking place just as rules covering Medicaid eligibility are changing for millions of families, including about 92,000 in Wisconsin.
Meanwhile, most private health providers are falling into one of two categories – predator or prey – and the entire U.S. system is figuring out how to absorb tens of millions of uninsured people just as legions of doctors are retiring.
Confused? Don’t worry. You have plenty of company, from the architects of “Obamacare” on down to the medical professionals at your hometown clinic.
In Wisconsin, the transition may go smoother than in most states thanks to cutting-edge technology embedded in the state’s Medicaid Management Information System. It’s a network that should give providers and consumers alike the kind of flexibility needed in changing times.
The “interChange” system in Wisconsin is one of 13 certified nationwide by the federal Centers for Medicare and Medicaid Services. Designed over time by the former Electronic Data Systems and its successor company, HP Enterprise Systems, interChange is the platform through which Wisconsin manages BadgerCare and Medicaid. It processes 41 million claims per year for doctors and hospitals, enrolls and communicates with 70,000 providers, verifies patient eligibility for about 1.3 million people, authorizes a range of services and generates reports essential to system accountability.
It replaced a legacy system that had been in operation for more than 30 years, and it has provided much-needed speed and flexibility just when health care needs precisely that. Change orders related to rules that once took months to carry out are now done in a matter of days or less.
“interChange will be a system that can bridge the gaps and be flexible enough to manage the changes that are coming, whether they are changes in existing policies or programs, or adding additional programs and transitions that take place in Wisconsin or nationally,” said Rich Johnson, HP’s account executive in Wisconsin.
Most states hire companies to crunch health-care data and process claims because they lack the technology and expertise. Wisconsin is no exception. Tech companies such as HP, Xerox and Computer Science Corp. are usually invisible to Medicaid recipients and even most providers, but they’re the platform through which the state-federal partnership on Medicaid works.
Such systems cost tens if not hundreds of millions of dollars, but the federal government believes the savings more than cover the cost over time in faster, more efficient delivery of health care while minimizing fraud and abuse. That’s why the feds reimburse states for much of the costs of replacing or modernizing out-of-date systems.
That doesn’t mean such transitions always go smoothly. In Wisconsin, once the decision was made to quit tinkering with the old mainframe system, it took a while to get interChange on track. During the build-out phase, it fell behind schedule and costs ran higher than expected, in part because of a series of change orders related to Medicaid and in part because of mission creep. The state stuck with the project, however, and in 2008 implemented the system. Today, the state boasts a “multi-payer” system that can adapt to whatever rules state and federal policymakers throw at it.
While it’s too early to know for sure, data collected by the system may also lead to improved quality of care through analytics. Data collected about vaccines and immunizations, Type 2 diabetes and other diseases and conditions may help epidemiologists predict and treat outbreaks faster, for example.
It will take time to sort through all the coming changes in health care, no matter what. In Wisconsin, however, it’s fortunate the state stuck with its plans and built a data system that can roll with the digital punches.