Governor of Ohio John Kasich took office in 2011, determined to resolve the state's alarming budget shortfall using a fiscally conservative approach while simultaneously improving the government safety net. To propel this agenda, he formed the Office of Health Transformation (OHT), a small leadership team possessing the skills and experience to formulate a successful transformation plan, which the Governor empowered them to implement.
The OHT transformation strategy is vast in scope, and presently includes over twenty initiatives grouped under three, interrelated threads: modernizing Medicaid, streamlining health and human services, and paying for value. (For a comprehensive view of the OHT plan and details on individual initiatives, please refer to the OHT website or visit the URL at the end of this case).
In this session Rex Plouck, who manages several strategic initiatives within OHT, outlined the convergence dynamics impacting the human services landscape in Ohio, and then described steps they have taken to leverage these dynamics. Although he touched on several OHT initiatives, Plouck focused primarily on their new integrated eligibility system, illustrating how various aspects of the OHT transformation strategy have enabled implementation of large-scale projects.
Governor John Kasich made transforming healthcare in the state a top priority. At the time he was elected, Ohio citizens were spending just over $7,000 per person on healthcare annually, more than 33 other states, and yet Ohio ranked 37 in health outcomes.
Kasich created the OHT, responsible for setting broad policy, managing high level budgets and driving technology projects across all health and human services departments (Aging, Health, Mental Health & Addiction Services, Developmental Disabilities, and Jobs & Family Services), along with Administrative Services and Budget & Management. Plouck described this small team, comprised of just five people, as a "brain trust" that leverages all agencies and their resources. The Governor recruited each health and human service cabinet member, with the understanding that they would all be cooperating on a plan for transformation.
From the outset, OHT noted several areas of convergence that would factor into their transformation strategy. First and foremost concerned Ohio's budget. The recession had left the state with a budget shortfall of $8 billion, and Governor Kasich was determined to minimize the tax burden on citizens. OHT would also have to seek new opportunities for leveraging federal funds.
OHT also had to meet several ongoing demands. Political leaders continued to push for a more streamlined government, initiatives that supported job growth, and increased innovation and responsiveness. Meanwhile, clients wanted services they could access remotely and with mobile technology, around the clock, and they wanted them seamless.
The OHT plan would most certainly include major technology initiatives, and technology was changing faster than ever. "My iPhone 6," Plouck said, "has more processing power than a desktop computer had five or six years ago."
Finally, OHT would have to grapple with several antiquated and inconsistent laws that made service-delivery divisive and inefficient.
In order to move Ohio's healthcare system toward a Generative model, per the Human Services Value Curve, OHT reasoned they would need a transformation plan that included organizational interaction, process improvements, and new technology platforms.
Also guiding OHT strategy was the ultimate goal of making families self-sufficient, a goal which embodied the principles of both fiscal responsibility and better outcomes for citizens. Governor Kasich, a true fiscal conservative, placed the highest value on government providing a hand up and out of poverty for any Ohioan who takes personal responsibility to improve their situation.
Finally, OHT created the "Operating Protocol," which was incorporated into state law. Even though agency policy leaders were eager to work together and share resources, the legal process involved has historically slowed or stalled such collaboration. The new Protocol stipulated that agencies could work together and share resources (data, human or financial) with only simple, not legalistic, agreements between them, provided the activities were part of an OHT initiative.
Summit participants expressed curiosity, even surprise, when Plouck explained how simple the solution to outdated legal barriers turned out to be. Incorporating the Protocol, he said, did not change any existing legal language, but rather added two paragraphs, which basically stated the Protocol would conditionally supersede existing regulations, including stipulations with regard to HIPAA law. "I'm blown away," one participant uttered. "It's literally two paragraphs," Plouck repeated.
Governor Kasich stressed the importance of collaboration with the counties, particularly since county workers are the ones who deliver services in Ohio. "They are our customers," Plouck said, adding, "but our 88 counties were 88 silos." Consequently, OHT recruited several county representatives who now spend three days per week in Columbus, Ohio, working on various OHT initiatives.
An early example of such collaboration involved development of Ohio's new eligibility system, which county workers would ultimately use. County workers helped to compose the Request For Proposals (RFP), evaluate submitted proposals, and inform the design process. Plouck urged counties to offer up only their most talented and dedicated people to participate. "We’re going to replace a 30-year-old legacy system," he reminded them, "and you may have to live with this new one for the next 30 years."
To further facilitate collaboration, and integration, OHT would also seek opportunities to employ a shared-services model that one agency (Job & Family Services) had successfully piloted a few years prior. The pilot program gave seven counties a new technology platform that would enable them to share work across counties and essentially function as one agency. Although the agency provided the new platform, it fell to the pilot group (which consisted of both union and nonunion counties) to work out the collaboration specifics, which they did successfully. The pilot demonstrated that a group of motivated counties could join together around a new platform, develop their own framework for integration, and function together as a unified, service-delivery agency. The potential application of this shared-services model to OHT initiatives held great promise.
One of the first OHT initiatives would be Ohio's new eligibility system. This integrated system would ensure that a case did not "exist" in any one place. "It’s a case," Plouck said, "It doesn’t matter who you are, where you live and where you started it." The system would be an expensive venture, but virtually everyone, including the Governor, believed it would result in far superior service for end-users.
A key feature of the new system would be a self-service portal. The older system had gradually turned case managers into paper pushers, Plouck said. The self-service portal would expedite simpler cases and free up valuable time, allowing frontline workers to focus their efforts on cases that were more complicated.
As mentioned previously, an elite group of county workers participated in writing the RFP and evaluating proposals from private vendors. As soon as the selected proposal was finalized, system design commenced, and the project team put in 24-hour days developing code, testing it, identifying bugs, and so on.
Seven months after the design process started, the eligibility system launched. Plouck noted that he had spent many years working in the private-sector, managing various, large-scale initiatives, including many IT projects. "I've see some of the best there is," he told Summit participants, "but I don't think I've ever seen anything like this."
For its initial launch, the system focused on a few core services, such as Medicaid, SNAP and TANF, allowing OHT to incorporate additional services piece by piece. One of the first was Medicaid expansion. Despite strong political resistance to expansion, Plouck said, Governor Kasich had managed to garner support from his own party. Two months after gaining legislative authority, Ohio finished incorporating Medicaid expansion into the eligibility system. The state now processes 1.5 million applications, 60% of which are initiated by citizens using the self-service portal. Plouck said their next objectives for the system include the addition of WIC and child care, and planning is underway.
To implement this system at the county level, Ohio began applying the shared-services model they had successfully piloted. The state now possessed an invaluable infrastructure they could offer to counties, a toolkit that includes document management, telecommunication capabilities, and of course the new eligibility system. Counties that wished to implement this infrastructure would be responsible for strategically organizing themselves into clusters that could operate effectively as a single agency. "We're not going to tell you how to do it," Plouck said, "because Ohio has three major cities, some metropolitan areas, a bunch of rural areas, and obviously what works in one area won't work in another."
Plouck said they now have a group of 23 counties that are planning to operate as one using the new system. The group will begin by launching a pilot implementation that includes 9 counties, eventually building out to the full 23. There are also 7 counties in Appalachia who wish to adopt the system.
The integrated eligibility system and expansion of county shared services represent only a small portion of Ohio's transformation plan. But the combination of these two initiatives alone has already produced several favorable outcomes. As mentioned previously, Ohio now processes 1.5 million Medicaid applications, and 60% of those come through the self-service portal. Additionally, the state has integrated Medicaid and Medicare benefits, and lowered the growth curve of Medicaid without drastic service reduction. Ohio also qualifies for enhanced federal funding, the result of moving enough clients from institutional to community care to achieve a 50/50 spending ratio, a target they achieved one year before the federal deadline.
The ultimate goal, however, remains moving families toward self-sufficiency. Over the next few years, as the OHT transformation plan continues unfolding, Ohio will build the capacity to track economic and health outcomes.
The early signs are certainly encouraging. Plouck described one particularly uplifting success involving veteran services. "We were trying to get veterans out of nursing homes and into VA care," he said. "Better care, better services, and cheaper for the state." So OHT began incorporating veteran services into the eligibility system, including the addition of five simple questions to the self-service portal for citizens who identified as veterans.
Once the system launched, it soon became clear that many eligible veterans didn’t even know they qualified for care. "So we turned this system on," Plouck said. "Within 20 minutes we found our first veteran. And within 10 hours, he had services that he didn’t have before. Pretty amazing, right?" Thanks largely to the Operating Protocol, the entire incorporation process, from concept to launch, took less than two months.
The new eligibility system now identifies 500 veterans a month, 74% of whom are eligible for services they were not previously receiving. By getting so many veterans out of nursing homes and into VA institutions, Plouck said, Ohio generated millions of dollars in savings annualized for Medicaid. But most importantly: "We can get nearly 4,000 veterans free healthcare."