Strong Medicine

Massive integration project in Georgia will put four state health care programs under one roof.

by / September 5, 2002
Gary B. Redding has been on the job for less than a year and already he's tackling the biggest assignment he'll probably face working for the Georgia Department of Community Health, and possibly of his career.

As the new DCH commissioner, Redding faces the daunting task of guiding the agency as it consolidates claims and administration of four state health-care plans into one program, which will be operated by outsourcing giant Affiliated Computer Services (ACS).

It's by far the largest state health-care integration project involving information technology, according to several sources. Certainly, it's one of the most unique. Never before has a state put the claims administration of its Medicaid, children's health care and state employees and teachers' health care under one IT roof.

"I've told the staff that this is probably the most important project they will work on for quite a while," said Redding. "It's priority number one for us."

Leaving a Legacy
The five-year, $351 million contract with ACS will vault DCH into the 21st century, replacing green-screen terminals and legacy mainframes with client-server technology, Web portals, electronic commerce and much more.

More importantly, the new system will standardize how state-financed health care is administered, creating the potential for tremendous economies of scale and cost savings.

The contract, announced in July 2001, replaces one held by EDS, the largest Medicaid claims processor in the country. Under the new terms of agreement, ACS will design and implement a new system that will provide claims processing, customer service and administrative support for all of Georgia's public health benefit programs. ACS, a $2 billion IT outsourcing firm which handles Medicaid claims processing in 25 states, will also operate the system for DCH.

The new system will be built using technology and services from a number of vendors, including IBM, Inktel, Computer Sciences Corp., GovConnect, ABSS, Hypercom and PrimeWire. Current plans call for deploying the Medicaid and PeachCare for Kids modules by Dec. 1, 2002; the state health benefit plan by July 1, 2003; and the teachers' health plan by Jan. 1, 2004.

Redding and Chief Information Officer Wade Miller realize they are blazing a new trail. With no other project like it in the public sector, they have little to model it after. But they clearly understand the goal.

"We've brought all [the plans] together to gain some measure of administrative efficiency and to simplify the process as much as possible, not only to save money, but also to ease the burden on the providers," explained Redding.

For the first time, providers will be able to review up-to-the-minute information about the status of members, claims and payments through the system's Web portal. They will be able to look at payment histories, check a member's eligibility, even enroll online as a provider.

The state's 2 million members will have access to similar features over the Internet. Everyone will be able to check the status of a referral, a claim or prior authorization. The same goes for inquiries about eligibility and current benefits. State employees will be able to enroll and change or drop coverage online. Teachers will be able to submit change of address information. And all members will have access to a database of available medical and agency services in their community.

The system is HIPAA-compliant and will be ready to handle all claims filed under the new standards by the October 2003 deadline. ACS has also agreed to construct a mail processing facility in one of Georgia's "tier one" counties, where poverty and unemployment is higher than the state average. The facility will eventually employ about 70 workers who will open mail, scan documents and convert them into computer-readable text using optical character recognition software.

Contract Clauses
Perhaps what's most intriguing about this project are the unique clauses in the contract with ACS. They practically guarantee the system won't remain static in terms of technology. "We did not want to get stuck with the system we bought today and in 2010 find ourselves woefully unprepared, running software that's not supported anymore," explained Miller.

To avoid that problem, DCH stipulated that ACS and its subcontractors provide the agency with a yearly technology refresh of new upgrades for all existing software in the system. ACS must also provide the agency with a yearly report on what's new and improved in the health-care administration software marketplace, so DCH can choose to use the new technology.

Since DCH owns the license rights to the software program that will run the health-care system, the agency has required that ACS provide it with any upgrade that occurs, if and when the vendor implements another version for a different state.

All of the proposed system features and contract clauses are expected to provide DCH with the means to revamp health-care administration and deliver a number of benefits to members, providers, staff and the state. First and foremost, DCH will gain administrative efficiency by having all health-care programs under one roof. Second, the state will save money by purchasing just one system, not four separate ones, Redding pointed out.

The new system will bring powerful forces of automation to bear on what has been a labor-intensive process for handling the health-care claims of two million Georgians. It also will give DCH a mother lode of data on the billing practices of providers, as well as other actions that have been difficult, if not impossible to track in the past.

"With all the providers under one platform, we can analyze things and take a look at patterns of practice from the standpoint of what we get billed for," said Redding. "If we see some irregularities, we can have our utilization review people take a look at them."

But providers will benefit too, Redding added. The largest ones will see a vast reduction in the amount of paperwork they must process in order to get paid. And Redding promised that response time for inquiries will be much quicker. Costs that once varied from program to program will now be standardized, making it easier for providers to anticipate payment for different services they give members.

Challenges Ahead
But all those benefits have yet to be realized, and Redding knows implementing the massive system won't be a cakewalk. Making sure the contractor is staffed in a timely fashion, as well as dealing with the cultural changes agency staff face, are just a few of the challenges he must overcome.

"We're blazing a new trail; it's a new day here," he pointed out.

Redding went on to describe the retooling, retraining and rethinking that occurs when the agency converts a system that is currently entrenched in paper and manual processes into one that is Web-based.

"It's going to take people time to adjust and get used to the change," he added.

At the same time, Redding and his staff must contend with many small providers who still don't have access to the Internet and aren't excited about spending the effort, or money, to change over to the new system.

"That's going to be a huge push for us," he said. "We've got to get them to see the benefits of moving into the 21st century with this technology."

Like other government officials who have tackled large IT projects, Redding and Miller have to walk a fine line between expectations and reality while continuing to meet the needs of members and providers.

"The goal is to serve those two million folks who depend on us for their health-care coverage," said Redding. "It's hard to think about that when you are in the trenches sometimes. But we need to keep our eyes on the prize."
Tod Newcombe Features Editor