Medicaid Needs Saving, But Who Can Do It?

Brian Urban:                                           
Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban. And today, we have on our show the Senior Vice President of Product from Gainwell Technologies joining us, Jeff Reid. Thank you so much, Jeff for joining our show today.

Jeff Reid:                                             
Brian, it's a pleasure to be here.

Brian Urban:                                           
This is going to be a lot of fun, Jeff. We've gotten to know each other a little bit here and there before the episode here. But we're going to get deeper into who Jeff is. We love to have our audience get familiar with our guests right off the top.
                                                       
So, you have a very interesting title. You had a really cool technology firm. But let's go back a bit, who is Jeff Reid before the corporate life, before the health tech experience? How did you get into this space? And why did you get into the healthcare technology ecosystem?

Jeff Reid:                                             
Wow, that is taking me back a few days. I appreciate the question. My career, I got started in South Carolina. I'm a South Carolina native. I went to school at University of South Carolina, met my wife there. I was a marketing degree major. And I decided that I was going to change the world related to advertising. That was back in the day of what I was most interested in.
                                                       
And I said my path. Actually, I'm working at UPS out of all places, and I was the first letter center coordinator at UPS. My job was to take those drop boxes that you see on the corner, and put them in place. And then, cold call business buildings to let people know that next day your letter center was right at the corner.
                                                       
So, that's what got me started in my career, and I quickly moved into this area of eCommerce like, what in the world was that back in the day, right? Back in the late '90s, UPS was at the forefront of driving digital eCommerce and was privileged to be part of the team and led many of the teams around bring tracking to the internet, how we're going to track these packages to make sure that they are delivered and integrate that into the supply chain that took on assignments to figure out how do you print a shipping label on a dot matrix printer? Can you remember those days back in the matrix printer days?

Brian Urban:                                           
Man, this was cutting edge back then though. This was the beginning...

Jeff Reid:                                             
It was. It was, it was. And so, we spent a fair amount of my early career figuring out how at that time dotcom companies were going to ship online and how we were going to engage consumers to be able to ship in returns from their homes. So, that got me started into this crazy digital pathway and I was there for, gosh, about 16 years and decided that the next frontier in digital was going to be in financial services.
                                                       
And so, I left transportation and went into financial services for about seven years, helped companies figure out how to sell auto insurance online, how to set up banking online, how to define retirement plans online. And ultimately, sell annuities. So, I worked at a couple of companies leading their digital innovation. And then, Humana gave me a call and was wanting to drive innovation and be known as the best provider of Medicaid and Medicare plans related to experience. They wanted to change the experience and change the game. They wanted to integrate data and their pharmacy benefits into a full ecosystem.
                                                       
And so, I jumped at the opportunity to move into healthcare and spent about seven years helping define their vision. And today, Humana's doing pretty well related to experience. So, we're pretty proud of that work. I left Humana actually to come to Gainwell. One of the things or one of the bugs I got is taking my talents that it generated throughout my whole career to focus on those that need them the most.
                                                       
And so, if you think about Medicaid and who it serves. It's pretty admirable place to get up every day and be able to serve those that are less fortunate and that need the most help. And with the skillset that I have, if you look at Medicaid program of recent, it's not very automated and it's not very user-friendly, and we're not taking advantage of best practices to drive the best medicine. And so, over the last couple of years, that's what I've been focused on and that's what brought you and I together today.

Brian Urban:                                           
Jeff, I'll tell you what, I did not know the early beginnings of your career. So, that's eye-opening on the edge of eCommerce. And then, you go into FinTech, if I could use that phrasing. And then, you transition into healthcare seems like touching the worlds of innovation and experience at that time at the individual level. And wow, what a journey. And now, at Gainwell.
                                                       
So, what an accumulation of experiences that you've brought. It's all seeming really in the consumer side and that's where a lot of healthcare services and services that a lot of health plans are providing today is more that consumer, consumerism type of perspective.
                                                       
So, Medicaid, what a mess the last four years here in terms of enrollment, data sharing down to miscues for federal government, state county. And, of course, it's a challenging population, challenging public insurance space to be in because of the continual change. Medicaid eligibility changes per household individual on a monthly basis. It's very difficult to keep up with and stay engaged with that population.
                                                       
So, it's a big topic to kick us off, but let's talk about it. What stood out to you, looking back maybe pre-pandemic to forward here that you can start to really put a collective effort towards Gainwell and maybe some other partners, and trying to solve some of these gaps we've seen here, whether it's related to health plans or others. I'm curious of what stood out with all the different challenges that Medicaid itself has experienced and what you're hoping to make some progress with.

Jeff Reid:                                             
Brian, your first question can take us through the whole podcast. There's a lot in there to unpack for sure. And when you look at government social programs, it is easy to be able to point and say, "Hey, this looks bad, this is wrong. And this is not driving efficiency," because pretty much any social government program you can pick apart in any way.
                                                       
When Medicaid over the last couple of years, wow, what a transformation we have seen and its importance in our society in driving outcomes for American citizens. The pandemic certainly drove more of our citizens into the Medicaid program. And one of that sobering facts that I remember when I first started working in Medicaid is that majority of the membership are children. Most people think of it being adults or older citizens. But any given number, it's around 50%, 50% of this program is covering children.
                                                       
And just the complexity of that alone, you think of unpacking that about, who is driving the benefit administrators, the administration for that child. You've got parents and caregivers and having to manufacture the IDs and how all of that works. And ultimately, how you make sure that they get to the right services. You have those that are not well connected digitally when it comes to consistent access to a computer.
                                                       
Now, the big fallacy is that Medicaid participants aren't connected electronically at all, and that is so untrue. Majority of them have mobile devices. Yet, to apply for a Medicaid program, most of the time you can't do it on a mobile device. It's typically, you have to log in on your computer or go in person to accomplish. All of that drives complexity when you cannot get the beneficiary, the member, to be able to apply effectively and get notice whether or not they qualify. Chaos ensues, right? And that's part of what we have seen a recent.
                                                       
But the other side of the fence is the provider. You can enroll as many people you want in Medicaid, but if you don't have providers there to serve them, then the efficiency is not going to be there. And that's been one of the big problems of late is how do we make sure that the providers taking care of both in Medicaid program. And then, also how they're able to get paid correctly and how to manage change with locations and hours of the practice. And ultimately, driving the right communication between the provider and the Medicaid program.
                                                       
So, in our conversation today, I think we'll impact those a little bit more. But if you look at the surface, what's crazy about this system is that the efficiency is something that we are working hard to improve, making sure that providers get paid accurately and efficiently. And then, making sure that the states have a partnership. And in this case, with Gainwell, so that we are driving the right outcome for them, that we're not just focusing on technology for technology's sake, that we're really truly partnering with them to solve some of their meanest problems. And I know we'll get into that conversation later in our podcast here.

Brian Urban:                                           
And Jeff, you bring up so many good points. The volume of children, those that we would see under the age of 18, living in a household, having a legal guardian, a parent being dependent on them, it is staggering. We often forget that. We do think of the adults. We think of gross median income. We think of employment, driving eligibility, but we do forget about children. And I think that's the biggest challenge we have across a lot of the ecosystem is just general awareness of what makes up a Medicaid population.
                                                       
So, very thoughtful in how you broke that down. And the other side of it is providers, how provider is a part of the conversation and health plans, they don't dive into Medicaid to make a lot of money. They do it to be able to serve the lives that need to be served in whatever geographical region they happen to be anchored in as well.
                                                       
So, it's a big, big opportunity to dive deeper into. I'd be remiss getting all into the deeper side of our conversation with social healthcare technologies and addressing vulnerable population needs. If I didn't ask about Gainwell, so can you break down who Gainwell is today a little bit more, and then we'll dive back into the other side of our conversation.

Jeff Reid:                                             
Yeah, for sure. When I took the role at Gainwell to lead the product team and then ask, "Well, what do I do for a living?" My job is to problem solve for Medicaid directors. And that's what Gainwell does is, we work with states and the federal government to unpack some of the hairiest problems that are driving in efficiencies and our ability to do our best role or best job with our Medicaid program and fix it.
                                                       
And so, there are many different components to that. There is the technology or the systems that you need to have in place in order to run the program. There are how do you enroll and administer claims with providers as we were just discussing in the systems and the processes to do that. Who's going to be on the other phone, the other line of the phone when someone calls in and has a question or problem? And then, ultimately, who rethinks experience across all of those stakeholders to drive the most effective plan? That's what Gainwell does, and we create the software. We drive the processes and/or the brains behind. A lot of the creative ways that we ultimately engineer Medicaid programs.
                                                       
One of the interesting things that my conversations with state Medicaid directors is focused on is the fact that many of the systems and processes that Medicaid programs have used are years old, 20, 30 years old, and the people that run them have been in those jobs for 20 and 30 years long, and they're all leading in the next two to three years through retirement.
                                                       
And so, if you think about more complexity, you're thinking about more need, and then you have a majority of your thought leadership and know-how leaving the workforce, how do you solve for that. And ultimately, drive the efficiency that we're all being asked to increase. And so, that's what Gainwell does every day is help states decide and define how they're going to make the best decisions in order to take care of the citizens that depend on this important program.

Brian Urban:                                           
Jeff, that is so insightful, obviously speaks to your expertise. And obviously, the crowd that you are in front of quite often in terms of partnerships with what Gainwell Technologies delivers, what you said actually made me think of Pennsylvania, my home state, Commonwealth. We have a lot of great department of health services, DHS at the county level and our state office of Medicaid as well.
                                                       
And I think about a lot of those folks that I've gotten to meet over the years, and you're right, they're very tenured. They've been around for a long time, done some good things, and they're getting out the door. They have maybe one foot or half a foot out the door and rightfully so, what's the next generation going to be bringing to the table to solve a lot of the existing problems, whether inherited or just naturally there.
                                                       
And CEO of Highmark Wholecare, Ellen Duffield echoed a few things that you shared is their challenge with technology gaps, but also basic things like keeping up with correct contact information, home physical addresses, phone numbers, that's one of the most basic things to keep folks engaged. And when you think about re-enrollment as well.
                                                       
But aside from that, I'm curious of really, what are you seeing as being the biggest challenges or the drivers that fix these challenges for Medicaid managed care organizations, Medicaid, state agencies? Is it technology? Behavioral health services? More programs being adopted, policy change, social awareness? What's some of the biggest drivers that are going to impact the next generation of these Medicaid leaders that you're working with today and tomorrow?

Jeff Reid:                                             
It's all the above and the impact is going to be felt most when you're able to get the technology people processes all right in the same order. You brought up data as an important component of driving effectiveness of a program. One of my early days at Humana, I was in charge of figuring out how we keep provider data correct in the provider finder.
                                                       
So, I'm looking to get a provider and I need to make sure they're covered in my network and that they speak Spanish because that's my primary language. You would think that would be so easy. There are providers... They've got their websites and they have everything listed and... But you would find that in the morning, we would call a provider just to get the basic information about what time do they open? Are they accepting new patients? Are they bilingual? All the basics.
                                                       
You can call 10 providers at 8:00 AM and get the answers, and you would call the same 10 providers at 3:00 PM and get totally different answers depending on who answered the phone at the office. So, you manifest that across the whole population that is underserved and under connected in many ways, and you get the data chaos that we're dealing with.
                                                       
So, how you solve some of those problems? There are no one easy answer. But peeling that onion back, can start in a couple of different directions. First, if you think about your team and the agencies that are having to answer these questions, the first thing that is important for them to understand is the full client or customer journey that they take in order to use and enroll and engage in these programs.
                                                       
You will find often people in the agency, they know pieces and parts of it, but they don't understand what happens before or after someone finishes the process that they're in charge of. And so, using journey mapping is a big tool that we've used often at Gainwell to teach and help our clients figure out what is full ecosystem in which things need to work against in order to solve some of these hairy problems such as getting the data right.
                                                       
Another interesting conversation that we've had is around how do you re-enroll providers to make sure that you can do that efficiently and effectively? One of the things we learned through journey mapping is that a provider typically has to go through 150 different fields in order to enroll to a Medicaid program. It takes up to two hours to do so in most states. And if you think about all the other things providers offices need to do, should they be spending two hours enrolling in a Medicaid program for that long and having to do it over and over again?
                                                       
We also found that about 50% of the data that they enter can be automated very easily. Meaning, that we already know that about them and we can pre-fill that information. And so, part of the journey that we've gone on around the provider is automating and making sure that the journey is understood, so that we can provide an experience that gets them to enroll within 10 to 15 minutes versus two hours. Auto enrolls them in the right places and fills in data when we already know it.
                                                       
And you look at that across all of the different enrollments from a beneficiary to even a state employee applying and getting engaged in their role, automation is a big part of what we are focused on. And a big way that will drive some of these inefficiencies that you brought up in your question.

Brian Urban:                                           
I love how you answered that, Jeff. Automation is probably a leading guide through the data chaos that exists. To sum it up, that was really beautiful because that's a problem across the ecosystem. I think it's the biggest challenge for a lot of Medicaid oriented programs, leaders and everything downstream that's touching an individual that is being served in a Medicaid plan.
                                                       
So, I love that you said it like that and very great examples as well. So, when we think about Gainwell investing into making an impact into Medicaid and Medicare space, it seems like you have a really sharp toolbox journey mapping and walking through your partners and how you can clean up inefficiencies. What is Gainwell thinking about in terms of investing into the next leap here in solving problems for Medicaid and crossing over into Medicare, maybe the dual space as well? What's the next big leap here for Gainwell in terms of where you're investing in putting your technology and your people?

Jeff Reid:                                             
That's a great question. If I simply answer it, when you think about Gainwell the future, the best answer is, if you go talk to a Medicaid director and you ask, "Who is partnering with you the strongest to drive outcomes? And ultimately, deliver real results?" And I want Gainwell to be at the top of that list when they talk about partnership.
                                                       
And so, the future and what we're working on today to drive tomorrow's outcomes is really around driving more of an ecosystem of tools and technology, and people that learn more efficiently that automates how decisions are made, make sure that we're at the point of where decisions need to be made, that we've got the data available for that decision maker, making sure that the experience is efficient, whether it's the beneficiary or the provider example that we were speaking of earlier.
                                                       
Our focus is down those pipelines. And when you get all of these things right, you get to the ultimate outcome, which is making sure that our citizens get the best healthcare and the best outcomes that they deserve and that is achieved through making sure all of these piece parts upstream work efficiently and effectively.
                                                       
If I was to talk to a provider and they say that, "One thing I like about Gainwell is that, they enable my practice to be so efficient that I can practice at the top of my license. I don't have to deal with the minutiae of administration in order to do well. I can really focus on delivering good medicine." And that are some of the outcomes that you would think about in the future of where Gainwell is headed.
                                                       
So, having a platform that connects all of these pieces and parts, having the experience through products that we call like Gainwell go, making sure that data is integrated in the right way and is available for the decision maker to have decision support. All of those are key components of our value proposition that we're focused on.

Brian Urban:                                           
And that's very helpful to see all the whole components put together under the Gainwell Technology house there. So, Jeff, I'm interested in your perspective of the landscape here. What do you see in 2024 maybe beyond that... Or the biggest challenges for Medicaid or Medicare advantage-oriented plans that have a lot of lives under those lines of business? What are their biggest challenges? Or what are their biggest cries for help or investments? What's going on out in that specific world or beyond? Take us into healthcare if you want as well. But I'm curious of where that landscape is looking right now, and what they're challenged with.

Jeff Reid:                                             
2023 provided a lot of challenges for everyone in Medicaid and Medicare. If you look at the earning statements of a couple of our peer companies, you have found that it's harder to be profitable in these spaces because the government regulations are changing on how reimbursements occur. More utilization of benefits are being experienced post-COVID.
                                                       
And I think that's going to continue for or the foreseeable future. And all under the umbrella of a political landscape that's evolving and who knows where things were going to be in the next year related to that because there are a lot of ideologies that go into ultimately influencing how these programs work. But at the end of the day, being able to drive efficiency and effectiveness to take cost out, so that you can provide more capabilities and benefits to our citizens, that's still going to be an important component of what success looks like in '24 and beyond.
                                                       
And I think we have a better opportunity to think more broadly about how we serve our citizens. I think companies like Gainwell Technologies should have more conversation with other people in the healthcare ecosystem to drive solutions. I know you've got planned or you'll have conversations with other service providers in your podcast. How should we partner with them differently in order to integrate them more efficiently into the system?
                                                       
If you think about a majority of the states today, when you think about how their Medicaid program runs, it runs on Gainwell Technology. And we are the platform that drives how things get paid, how providers enroll. And so, we have a big voice in the ability to drive change and to incent some of the new ideas that may come from different spaces.
                                                       
I mentioned earlier in the podcast, I work for UPS tracking, how could we use tracking technology in order to drive efficiency when you call in to say, "Are my benefits being paid? Or where's my enrollment in the process? Ultimately, that's a tracking question. Where am I in the supply chain? If you'll. How can we use some of those ideas to drive efficiency?
                                                       
So, in 2024 and beyond, you're going to see more creativity, the use of AI and other disciplines to think differently about how we solve some of these problems that are still nagging at us.

Brian Urban:                                           
I think that's so interesting. And tracking technologies probably could apply over to medication adherence, medication delivery. There's a lot of injectables that are now being delivered at home that once were being injected at a healthcare center or with a primary care for patients.
                                                       
So, all that, your experience is so vast. It's interesting, Jeff, because you are at UPS for a long time. You are at Humana for a long time, and you got to see the evolution unfold before you. I'm curious, if you could be futuristic with me here, Gainwell, you've been with them for a little while now. You're starting to see the evolution unfold again in this iteration of your experience and technology in your career. What's the next three plus years going to be for Gainwell? What is Gainwell going to maybe evolve into?

Jeff Reid:                                             
If you think about serving healthcare across the whole member, we spoke a lot about how you deliver core healthcare benefits more efficiently and effectively. We just brought up the fact that the pharmacy element of care is an important component of whether healthcare is going to be successful for you or not. Can you get your prescriptions and access to them?
                                                       
But the social determinants of care is another part of what drives outcomes. You've had many guests on your podcast and have listened to them over the years. And in time and time again, they talk about no matter what you do and spending around healthcare benefits, at the end of the day, if you don't solve the ecosystem that surrounds the individual, then you're not going to drive the clear outcomes that they're looking for.
                                                       
So, the future of Gainwell is going to be taking this platform that we have developed and expanding it and providing flexibility, so that these other programs and other touchpoint that drive outcomes for our members or our citizens, that it's connected in a way that we can make decisions not only about do we pay a claim or it's this provider approved to be enrolled, but it's through our data we've determined that this person has transportation issues or they're an alcoholic. In order to get to their doctor, they have to pass three liquor stores.
                                                       
And so, can we reroute their journey, so they don't have to do that? Can we help a child that is living in five different homes over a three-month period because their social environment has changed and they may be out of network now? Or how can we realize that early and predetermine how we help that individual? Those are the things that Gainwell in the future we'll be able to make more efficient and effective through our integrated platform, so that as Medicaid directors are driving how they do more with less. They'll be able to depend on companies like Gainwell to drive efficiency that helps each of those components work as best as they can.

Brian Urban:                                           
I love how you said that, Jeff, looking at the ecosystem around the individual, not necessarily the system or the process that's at the plan level or the healthcare center healthcare system level. So, it's so amazing that you're building in more of an intuitive technology to address social health for the individuals being served.
                                                       
I am so excited to see what Gainwell continues to evolve into. I feel a follow-up conversation coming on, Jeff. I'm just so excited to have had you and your voice and your experience on our little show here today. Thank you so much for joining us.

Jeff Reid:                                             
Pleasure to be here. And Brian, I can't wait to come back.

Brian Urban:                                           
Thank you, Jeff, Senior Vice President of Product Gainwell Technologies, beautiful conversation today. And for more exciting excerpts and insights, please visit us at finthrive.com.