General Introduction

The presentations of the 2022 Medicaid Managed Care Conference in New Orleans moderated by Virginia Burchett gave an insightful snapshot of the challenges faced by Medicaid programs and vendors. These challenges are diverse, and all are impacted by program design and IT support systems.

Medicaid Introduction

The Medicaid ecosystem is a multilevel, hierarchical framework, which includes the largest population of any state. Managing the monumental tasks of this diverse population with complex medical and social needs is a testament to the dedication, competence, quality and care for the public good shown by Medicaid personnel.

Themes: Each of the Medicaid presentations included the role of technology support in specific programs. Though diverse, each program and initiative from the standpoint of flexibility of technology systems, expose common themes. The following is a list of program or Medicaid policy level themes. Enumerating the themes serves as a starting point for adapting information technologies to serve a flexible approach to program and policy innovation. As is apparent these themes reflect actual issues from Medicaid leaders, which are not limited to value-based purchasing programs.

• Program integration, specifically behavioral and medical programs:
  • Provider engagement.
  • Patient centered care and engagement by trust.
  • Inclusion of nontraditional programs in IT systems.
  • Collaboration among providers.
• Network development by engagement with plans, and among providers.
• Compliance with CMS regulations facilitated by adaptable IT systems.
• Program integrity, reliable IT systems and algorithms for fraud detection.
• Member eligibility, adaptable to enable non-traditional tracking of eligible members.
• Overcoming fragmentation of the entire health care ecosystem that effects Medicaid programs by implementing interoperability.
• Whole person care, rethinking patient care as an organic activity.
• Sustainable systems with actuarial soundness, using care pathways as measure of costs.

This smorgasbord of issues has common themes that simplify tech solutions. A new requirement, which will fall on Medicaid behavioral health programs, comes from the gun reform law with its emphasis on mental health.

Government Medicaid Managed Care Proposals

New and emerging programs at the Federal and State levels address trajectory to transformation in a multilevel hierarchical ecosystem. In the current rules from CMS, FHIR (Fast Healthcare Interoperability Resources), speaks to integration of data within the entire healthcare ecosystem. This is the first and essential step in health care transformation. From the perspective of the entire healthcare ecosystem, a new organization created by the National Academy of Medicine, the Committee on Emerging Science, Technology, and Innovation (CESTI), will set the North Star for emergent policies, technology and Innovation in all health care sectors. The Medicaid space for reasons mentioned above is the ideal program to promulgate and test emergent technology.

“The path to innovation is never smooth and never ending” (Dena Stoner, Director, Innovation Strategy, Texas Health and Human Services Commission). Framing innovation in concrete, measurable terms sets a platform for interoperability for Medicaid and its context in the broader ecosystem. Convergent thinking brings diverse programs, in and outside the Medicaid space, together for behavioral health, medical health, social determinants of health and all other features of the ecosystem. Developing and refining practice, at the level of the patient, in the ecosystem hierarchy is a continual process of discovery, for both patient care and program development.

The path to transformative innovation requires knowledge to be created and shared. The FHIR requirement for interoperability can be the catalyst. What follows is the first, in a short series of blogs, describing how interoperability can be realized using Model Based Logic. We’ll wrap up this blog introducing how counterfactual analysis, exercised in the Moment, enables outcomes that make health plans and provider networks as efficient as possible.

Value of Model Based Logic

The common themes enumerated above are relevant for Medicaid programs, provider networks and patients. Plan and program level themes include, for example:

• Program integration
• Provider engagement and network adequacy.
• Inclusion of nontraditional programs in IT systems.
• Collaboration
• Compliance with CMS regulations.
• Program integrity
• Sustainable systems with actuarial soundness.

Each of these general categories has a solution narrowly imbedded in single programs, contracts, and business processes, but some themes are aspirational, not yet realized. For a variety of reasons the ad hoc nature of solutions has resulted in a fragmented ecosystem, based on data analysis alone, with minimal interoperability and little ability for innovative transformation.

Why? these data driven approaches, require BIG data, linking population metrics as averages to the patient, which does not rise to the abstract levels required for patient centering. The most common themes for Medicaid refer to patient centering, as in personalized care, patient engagement, fragmentation of care, trust, and whole person care.

How can model-based technology help themes benefit from interoperability?

Model-based technology serves to break apart the siloed nature of these programs. Patient centering will show the benefits of using models that integrate both the patient data with the remainder of the relevant ecosystem.

The path to innovation requires models that reflect themes, placed in a hierarchical framework. Topology and logical processes apply to all levels of the hierarchy. Topology reflects scale, location and relations of entities of the ecosystem. Logic reflects paths of information through these entities. More to the point, interoperability has two facets, the first is the transparency of information between entities of the ecosystem, and the second is the logical framing of this information. For example, whole person care exists at a place in a timeframe. This care flows among entities on a pathway as diagnoses, treatments and responses. The Moments in place and time as a topology are sequential, which is what makes a pathway. Both the Moments of the topology and why the pathway leads to whole person care requires selection of management decisions that follows a logical path. This logic is encapsulated in the Model and consists of matching what is known about the patient’s history and their risk profile, to the possible effect of decisions on the future. The point is, what makes the pathways patient centered is that they are necessarily whole person care. Care cannot be centered on only part of the patient. This complex set of relations drawing on patient centered topology, and logical qualities of information is actually a description of these two facets of interoperability in action. To reiterate, the two facets are entity and logical transparency. Clearly establishing whole person care is quite complex. Fundamentally, interoperability among the topology of ecosystem entities, and relationships with logical links, frames the path to innovations. Topology alone with systems and organizations fixed in place are unchanging, but adding logic to the flow of information among the entities allows entity-based IT systems to support change and innovation.

This is where a model-based approach is essential. Models originate from domain experts. These experts come from all levels of the multilevel, hierarchical healthcare ecosystem. IT systems in use at present do not lend to problem solving in this multilevel ecosystem. Without requisite interoperability among entities, actuated by logic there can be no innovation. From the population to the patient as the scale changes, models can reflect relationships and links among patients, networks and populations. In fact, together the topology and logic of interoperability defines relationships. Once defined as a participant in many relationships of the ecosystem, an entity has the potential to inculcate information. The organic scale in the ecosystem starts with the patient. A data driven approach can be organic. However, logic will point the patient centered Moment to more than what is obvious in the data.

What will this model-based technology look like, and how will it simplify technology design?

Topology and logic can integrate as pathways of many kinds that spans scales of the ecosystem. For the coordination of the ecosystem, entity-based models are complemented by coordination-based models. Causal paths (Causality, Judea Pearl) provide this coordination where each interval in the path has a context in the ecosystem. These intervals span the scales of the ecosystem. Here is where interoperability arises from the models, allowing translation of information among the scales, the plan, network and the patient in a quantitative way. For the patient to have an organic context, multiple inputs are required, including patient specific data, best practice, and accountability. Most importantly, the counterfactual dimension makes patient centeredness organic. Though there are many domain experts with control of inputs into the whole patient, interoperability of information, not just the medical record, ties the multiple hierarchical levels together into an organic whole.

Achieving organic, interoperable whole person centering begins with the Moment. In the sense of transactional datasets, the Moment is a single time and place of an encounter. This Moment becomes organic when features of the ecosystem relevant in the Moment are accessible with interoperability. Generalizing the Moment into pathways of sequential patient centered Moments frames patient centeredness as the driver of pathways. Pathways then become the link of the entire ecosystem whereby information of all entities frame not just the patient as the unique entity, but the impact and transfer of information of all entities onto the unique patient. This is the organic whole, arising as a process of the interaction of all relevant entities, organizations and networks. The organic whole implies more than collecting known information as the context of the Moment. As stated above, counterfactuals drive the pathways as well as information from the patient’s past and from the context of the Moment. In fact, counterfactuals define the uniqueness of the patient in any context. This leads to the forward-looking aspect of pathways in the causal sense. A Moment in a pathway moves forward in one of many possible ways. These possibilities narrow to one when selected as the option or choice. The causal potential of pathways is exercised in the Moment. More than collecting relevant past and ecosystem data, the Moment is the opportunity to act on potential outcomes from a set of potential actions. This distinguishes patient centered actions from actions prescribed only by large population (BIG) data. In so doing, actions are always “customized” even when there may be little difference between the chosen action and what population guidelines indicate.

We have used the word “counterfactual” throughout this blog, but what are counterfactuals?

In the simplest way it can be described as “Expressing what has not happened but could, would, or might under differing conditions.” So why must counterfactuals be part of the organic moment? Answer: The environment, conditions, state, etc… of the whole patient (or any entity of the ecosystem), changes – and is also necessarily different from other entities that would be considered the same. For example… Is a patient with mobility challenges more likely, to break a hip if they live in a structure requiring them to climb stairs? Obviously yes, but could there be other environmental, social, or fiscal factors that are unknown? Correlative analysis alone will fail to prove a factor as causal in “small” data, or maybe fail to identify it at all. Even worse is the flip side, correlative relations that appear causal, but in fact are impossibly so. Remember, from its definition, a counterfactual has to be possible (could, would, or might) even if it has never happened before.

In this first blog, with themes forging a path to a transformative and innovative future, we have laid the foundation for how interoperability can be realized using Model Based Logic. In the next installment we will take a deeper dive into the power of counterfactual analysis, exercised in the organic Moment; enabling outcomes of health plans and provider networks to be as efficient as possible without micromanaging patient care.