Hacking for good: A Medicare administrative contractor tale

hacking_Medicare

In this piece:

Have you ever listened to TED Radio Hour? It’s a podcast that cleverly weaves together wisdom from different TED talks in relation to a specific topic.

A 2013 episode titled “Hacking our way to a better world” really struck me.

Although we often focus on the negative aspects of hacking, in this episode, all the highlighted speakers hack for good. What we learn by challenging our expectations is that “hacking for good” can change how we think about solving difficult problems.

As a listener, I immediately started relating the concept to healthcare and how hacking could provide answers to some of our industry’s most complex problems.

Each morning I wake up thinking about this question:

How can we drive down the cost of healthcare by improving the underlying processes?

Our system wastes billions of dollars each year on inefficient sharing of healthcare data and documents, and I really hate waste. Plus, we could be using that wasted money for noble things: Wellness initiatives, senior care, research and more.

Why “hack” Medicare?

I want to start a grassroots movement to hack Medicare processes.

Before you call the FBI, here’s what I mean.

The Centers for Medicare & Medicaid Services (CMS), while often maligned in its history, has done an admirable job of efficiently and effectively delivering healthcare to seniors. In fact, it’s earned relatively popular support for expansion, with 55% of Americans in 2021 saying they would support Medicare for all.

In most cases, its processes are vastly more efficient (and less expensive) than those in the commercial sector.

Medicare processes millions of transactions per day between payers and providers. Some of these transactions are data, yet much is still unstructured data (content in the form of paper, fax, voice and so forth).

While much of the data flows smoothly, some of the more difficult to manage content can flow more like molasses on a cold day, clogging processes and costing billions.

This is a problem tailor-made for hacking.

> Learn more | Why payers are moving from legacy ECM to content services

The Cheetah Project: A tale of hacking for good

Let’s see how a hacker mindset helped a Medicare administrative contractor (MAC) modernize its processes and keep its business operating at full tilt.

The key is to ask, “What can be done — quickly, efficiently and with the greatest impact — right now?” Let’s dig in.

Challenge presented; challenge accepted

Picture me, your friendly health insurance/tech professional, walking the building of a MAC with one of that organization’s executives in 2005. He led me to the center of a vast cube farm at his organization. Just like rows and rows of Illinois corn, the cubes seemed to go on forever.

He turned to me and said, “Look at all these cubes. If Medicare, and for that matter, this company, is to survive, we need to figure out a way to do this work faster, better and with fewer resources. For right now, I need you to introduce automation into every operational process in every cube in six months. Get to work.”

Then he walked off.

There was no road map, no case study, no time for new hires or new tools, and the date could not move.

We had to be done in 20 weeks. There wasn’t time for a traditional IT waterfall approach; that would simply take too long.

We named the project “Cheetah” and got to work.

> Read more | IT implementation best practices that go beyond on-time and on-budget

The Cheetah Project’s first step

The Cheetah Project would expand workflow and business process management (BPM) into every operational team, a feat that would require:

  • 20 workflows in 13 departments
  • Usability for over 350 users in five locations
  • Speed (just 20 weeks to do it all)

We needed a hack.

The stakes were high

The organization we were applying the Cheetah Project to served Medicare users and providers. Although it may surprise some (many think of Medicare as a slow-moving behemoth that wastes billions of dollars and delivers subpar services), the truth is 94% of adults 65 and older with Medicare coverage report being very satisfied or satisfied with the quality of their medical care and the availability of specialists, according to the Kaiser Family Foundation.

At the time of my project, there were about 42 million Americans in the Medicare program (in 2022, there are about 58 million). The Cheetah Project could immediately impact as many as 6.3 million beneficiaries and 130,000 providers — it had to go well.

Helping a MAC protect its business

CMS administers Medicare by hiring private MACs to manage the administration of its programs in various regions. CMS ruthlessly bids on MAC contracts every five years. At the time, the Darwinian contracting process had pared the number of contractors to a hyperefficient team of contenders.

The Cheetah Project was needed to help the MAC effectively compete for its existing contract. If it lost, 6.3 million beneficiaries and 130,000 providers would be calling another contractor, and a significant number of the MAC’s employees would get pink slips.

The Cheetah Project needed to be a home run. No pressure.

> Read more | RPA: End-to-end automation for content management

Putting the Cheetah Project in motion

My team needed to do some metathinking — in other words, we needed to think about how to think about automating processes.

After all, how do you automate the process for creating automated processes?

I started to think about Henry Ford. He was a metathinker. He created an optimized factory to build cars.

Why not build one for Medicare processes?

> Read more | An intelligent automation roadmap

Start building the process, like Legos

Fortunately, the MAC was already using a platform that was well-suited to act as Lego bricks for our process exploration. We conceived, designed and constructed a process factory in about four weeks.

The process factory churned out processes like widgets coming off Ford’s assembly line. We assembled a team of employees, contractors and vendors to make the approach work. We had the tool, the factory and the team.

Then a bit of brilliance struck.

A key Cheetah Project hack that Ford would have loved was the strict division of tasks.

Each programmer focused on building a “machine” in the assembly line that could build subprocesses.

We made steady progress, fueled by constant communication.

We completed the project four days early, under budget and with few bugs to correct.

6 keys to the Cheetah Project’s successes

Here are some of my learnings from this project that hold true today:

1. Fortune favors the bold

When faced with a massive undertaking, we didn’t think small — we thought BIG. We eliminated the incremental, small ideas to wholeheartedly pursue the one big idea we knew could accomplish our goals.

2. Trust

Everyone had 100% buy-in and 100% trust. This was the absolute key ingredient.

3. Agility

It’s not about how fast you can go down the straight-away; it’s about how much control you have in the turns. Things change. Agile processes enable you to adapt quickly and painlessly.

4. Metathinking

Thinking about how to think — about what you are doing and really trying to accomplish — is a very valuable asset in any significant effort worth doing.

5. Build a process factory

Organizations should be working on factories, not processes. Projects are not the right vehicles for driving process improvement; it is about continuously innovating for the best solutions today and into the future.

6. Obtain the right tools

Our automation tool made all the difference. A less-flexible tool would have doomed the project from the start.

> Read more | 70% of IT implementations are not successful; yours can be

The Cheetah Project’s legacy: Millions of dollars saved

The Cheetah Project saved Medicare between $50 million and $100 million in the first years.

Now that’s a health insurance solution.

Additionally, the Cheetah Project produced nonmonetary benefits, including:

  • Quality improvements
  • Ability to audit processes
  • Disaster recovery abilities
  • Internal controls
  • Help with compliance
  • Risk reduction

I am pleased to say the MAC in this story went on to win multiple CMS contracts due in no small part to the Cheetah Project’s process factory and its legacy of boldness, agility and — of course — hacking.

In a good way.


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Mike Hurley is a veteran health insurance expert and contributor to the Hyland Blog.
Mike Hurley

Mike Hurley

Mike Hurley is a veteran health insurance expert and contributor to the Hyland Blog.

... read more about: Mike Hurley