Special Report | Channel leaders: Relationships are the Rx for healthy systems

In times of tight budgets and financial constraints, states often are forced to get creative when looking for ways to cut costs. New Jersey is no exception.The state was looking for ways to run its Medicaid program more efficiently, and Kevin Lee, vice president and senior program director with cost-recovery company Health Management Systems Inc., believed he had the answer.Lee led a team that worked with the New Jersey Human Services Department to come up with a way to submit Medicaid claims over the same network that pharmacies use to submit insurance claims, and make the process faster and more efficient. On Lee's watch, the state has recovered $500 million, according to the department."In virtually all Medicaid programs, pharmacy is probably the No. 2 cost center behind skilled nursing-facility care," Lee said. One of his career goals, he said, is to have a positive impact on health care delivery by improving funding and financial aspects of the system, specifically in the government sector."Focusing on where the money is spent in pharmacy is certainly a topic that continues to demand attention and creative thinking," Lee said.The program that Health Management Systems developed for the state, COBManager, can increase pharmacy-cost recovery by 4 percent or more, amounting to millions of dollars a year. Other states are looking at doing something similar, according to Lee."Kevin's had excellent relationships" with everyone involved in the project, said Chuck Anderson, vice president of eligibility services with Health Management Systems. Lee was instrumental in getting the pharmacy community's approval of the company's plan, he said."We attacked the program strategically," Lee said. "What we endeavored to do was put Medicaid on more of an equal footing with more of the dominant practices for pharmacy management for adjudication and process." Putting Medicaid in this "real-time setting" ensures that the government pays no more than it owes, he said.Because transactions occur in real time, the possibility of overpaying as a result of less than timely coordination with insurance carriers or other systems is reduced.At Health Management Systems, Lee works with states that want to set up new databases and systems, and helps them determine which processes or technologies likely would work best. Getting large-scale systems under control can be challenging, he said. "The systems are unique," he said. "One state Medicaid program may look very different from another state's Medicaid program."Some across-the-board industry standards have been developed, but "we're still on the leading edge of that," he said. "As we move toward more open standards, some of that will, I think, be easier, but in some ways, it's incredibly challenging, because [as technology improves,] the rate of change continues to increase," Lee said.Even after 16 years with the company, the job remains exciting, said Lee, who works in Trenton with the New Jersey team. "Every day is different," he said.Health care information management is a dynamic industry, he said. "Technology's changing. Software's changing. You've got standards that are evolving and converging. Every day's an opportunity to try to do better."