/ Economics / Customer Relation Management (CRM) in Government Based Medicaid Services

Customer Relation Management (CRM) in Government Based Medicaid Services

healthcare on January 12, 2015 - 12:48 pm in Economics

Case management in government based Medicaid services has always been a challenging aspect post ACA. While a robust, economical and a complete case management solution is need of the hour, selection of the right customer relation management (CRM) and right service provider vendor is the key.

Case management programs are designed to:

  • Improve or stabilize a member’s overall health status by preventing complications and the deterioration of existing medical conditions
  • Optimize the use of healthcare and other resources
  • Improve member compliance with provider recommendations for care
  • Improve coordination and continuity of care
  • Utilize community resources to enhance and support the member’s health

The ultimate goal is to achieve the optimal healthcare outcome in an efficient and cost-effective manner. The case management process includes five basic steps: case identification, assessment, planning, implementation/monitoring, and evaluation.

Application Areas of Case Management

Health plans commonly use case management for high-risk, high-cost, and/or chronic cases. Some of the medical conditions for which case management may be appropriate include aids, stroke, burns, chronic respiratory conditions, kidney failure, amputation, cancer, neonatal complications, brain injuries, certain cardiovascular conditions, congenital defects, and spinal cord injuries.

The graphic below represents a typical case management system deployed at a U.S. government agency –

Challenges faced by Government in Implementing Case Management

In the wake of ACA, State Governments are facing stiff challenges in implementing an integrated case management and comprehensive assessment system using modern technologies. This is based on a service oriented architecture as a foundation to deliver innovative, flexible and interoperable solution components that are adaptive to changing policies, business rules and interoperable with external systems.

The U.S. Government is looking to replace the existing case management system to support the assessment operations of nursing homes and community based Medicaid waiver programs across multiple populations and agencies. In this regard, they are working with multiple stakeholders, advocates, medical professionals and fellow state agencies. There are issues with such multiple agencies as they follow disparate business operations leading to localized, uncoordinated, duplicated and redundant data making it difficult for enrolled folks’ to avail end to end seamless services.

The current systems used to administer the Case Management and Assessment systems program are a combination of disconnected, single-purpose applications, without modern identity, access, workflow-capabilities or data normalization across systems. These systems grew out of program conditions in the past and they do not reflect current operational needs.

To improve the overall case management system, Government agencies are seeking to take advantage of current technology opportunities such as cloud, Software as a Service (SaaS) and Service Oriented Architecture (SOA) to lower infrastructure burden, streamline reporting, analytics and dashboards, as well as expand data sharing goals. Current operational need includes the ability for data to be managed according to an individual’s needs and not according to disparate agency structure

The Government is implementing program changes that comprise the reform effort which includes increasing care coordination for individuals who are dually eligible for Medicare and Medicaid, beginning the process of harmonizing Home and Community-Based Services Waivers (HCBS) serving individuals with a Nursing facility level of care, modernizing Medicaid eligibility, and implementing health homes for individuals with severe and persistent mental illness

Attributes that Cater to Immediate Needs

Selection of a right CRM product and service-providing vendor becomes one of the key factors in meeting the case management need of an organization. 

CRM for government is composed of the systems, software, and approaches for managing, measuring, investigating, automating and otherwise facilitating an agency’s interactions with related interacting elements. The CRM suite should enable the agency to use data better to meet the “more for less” mantra by providing the ability to create more personalized service at lower cost.

It should also meet government compliance and regulatory requirements; be configurable based on the employee’s role, with as much out of the box as possible along with the possibility for additional customization; incorporate sophisticated analytics and reporting tools to measure aspects of interactions; integrate well with other applications, including legacy systems; and facilitate self-service using social and multi-channel approaches.

Critical Factors of Assessment 

Market Impact

A vendor may have the greatest overall revenue by a large margin, but the proposed CRM may not yet be as large as a revenue driver for the company as other vendors’ CRM offerings are for them. Salesforce recently overtook SAP to claim the most CRM-specific revenue for a company, but government is not yet as large a percentage of revenue for the firm compared to Oracle Service Cloud (Right Now), which is tied for collecting the greatest percentage of their revenue from the public sector. A number of players show substantial public sector revenue growth, led by Oracle Service Cloud and Salesforce. Geographic expansion beyond the “usual suspects” of North America and Western Europe will be another growth strategy that vendors need to explore in near future.

Solution Assessment

A few categories are worth highlighting here as particularly important. One such area is workflow and automation, a make-or-break part of the government CRM experience characterized by a trend towards embracing visualization-wizard-style approaches to editing and designing rules. Workflow and automation is so important because it is really the core of the user’s experience, bringing functionality to the fore and making common employee actions more efficient and accurate. This is key in government as regulations and standards must be met and process is often more complex and unwieldy compared to the private sector.

Deployment and scalability seem to be the top priority for government agencies which are increasingly turning toward cloud for faster deployment, simpler contracts, and automatic upgrades. Nonetheless, on-premise remains a necessary option for many agencies, and solutions offering strong cloud and on-premise options place them at the top in terms of flexibility.

Latest Trends in Government CRM

  • Commercial off-the-shelf (COTS) solutions as a preferred route are gaining popularity in government, given their cost benefits and time to value. This is increasingly true not only for simpler projects but also for those addressing more complex business needs
  • Government agencies’ increasing comfort in SaaS and platform-as-a-service (PaaS) based solutions
  • Agencies looking for flexibility with on-premise, partner-hosted, and cloud deployment options – as well as its excellent usability, workflow, and integration with the Office suite (a mainstay in most government agencies), and the consistent experience across web and mobile devices
  • Solutions which are well tailored to meet the requirements of local and regional governments and which provide high degree of penetration of and verticalization for the government market.
  • Solutions which are well suited for next-generation customer service and case management functions – government customers can better participate in and learn from social media. These solutions have capabilities of Integration with Social Media components.

Winner in CRM Proposals

There are factors affecting the selection of final vendors by the State Agencies –

  • Local players – Benefit of their reach and focus on “deliverables” than on processes.
  • Inhibitions to go for overseas to offshore vendors; ignorance / lack of knowledge.
  • Inhibitions to go for a pure “Cloud” based solution than an on premise version.
  • Advantages of easy availability of Contractors and contractor based references.
  • Presence of Strong Product Vendor – opportunity for Governments to save money on licenses buy out. They are price sensitive.
  • Vendors with huge experiences in HHS, Public Sector, in managing the complex health and human service programs that promote the health, safety and wellbeing of its citizens. Vendors who are proven partners in integrated eligibility and service delivery; and bring technology, business and project management experience to the clients’ challenges.
  • Relationship with offshore service providing organizations that have strong domain expertise’s in health care and who are looking to collaborate with the government using their collaborative partnership with product vendors.

Authors Bio:

Vandana Singh:

Vandana Singh, a PGDM from SIBM Bangalore, works as a Healthcare Product Specialist with a leading consulting and IT services firm in Healthcare IT domain.

Vandana has 7 Years of experience in Healthcare IT. Her areas of interest include healthcare administration management product (Facets), Healthcare Insurance processes, Claim Adjudication work flow and business process related to health plans.

She is certified Professional, Academy for Healthcare Management (PAHM) and Fellow, Academy of Healthcare Management (FAHM)

Vivek Singh:

Vivek Singh, a PGP from IIM Bangalore, works as Business Development Manager with a leading consulting and IT services firm in Healthcare CRM IT domain.

Vivek has around 8 years of experience in Healthcare IT. His areas of interest include US healthcare industry, Patient Protection and Affordable Care Act (PPACA), Medicare and Medicaid services. He has worked extensively on several CRM products used in healthcare Payer, Provider and Pharmacy Benefit Management industry. He was instrumental in conceptualizing a PRM (Patient Relationship Management) product in his current organization.

He is certified Professional, Academy for Healthcare Management (PAHM) and a certified Salesforce Cloud Consultant


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  • January 17, 2015

    Nice article. Conveying many things. Expecting more on individual component.