Don’t Start from Scratch: SOA in Medicaid

1. Don’t Start from Scratch: SOA in Medicaid Human Services 2.0Implementing InterOptimability: From Theory to Practice MITA Rick Friedman, Director Division of State Systems, CMS U.S. Dept Health & Human Services Richard.Friedman@cms.hhs.gov Tel: 410 786-4451

2. Medicaid Background • Part of the Great Society programs in 1965, together with Medicare and others • Unlike Medicare, Medicaid state-administered • Federal role is to provide funding support to the states with strings attached • The more money, the more strings

3. Millions Medicaid Enrollment 1990-2008 • Medicaid enrollment has more than doubled over the past 20 years • In 2008, 1 out of 5 Americans are enrolled in Medicaid • Nearly half (47%) of Medicaid’s enrollees (24 million) are children • Nationally, 2 out of every 5 births covered by Medicaid • In 9 states, 1 out of every 2 births paid for by Medicaid Millions of Enrolled Medicaid Beneficiaries

4. Aged and Disabled Account for 2/3’s of Medicaid’s Costs Percent of Total

5. Although the Number of Medicaid Enrollees Has Doubled Over the Last 20 Years, Medicaid Spending Has More Than Quadrupled

6. Medicaid Systems

7. Medicaid IT = Burger King Model: ”Have It Your Way” • The focus was on paying claims • Each state designed its own MMIS “from the ground up” Result = 51 highly customized claims processing engines that couldn’t talk to each other (or any other program) within or across states very easily

8. What Did the Medicaid Systems World Look Like?

9. Unfortunately,Medicaid Is Not Alone • Incompatible systems, data, cultures • Change requires time, money, leadership and institutional knowledge…all of which is in very short supply • Paradigm shift will require an accountability horizon longer than the next quarter, this fiscal year, or, even, the life span of the current administration • Legal safeguards re data exchanges

10. MITA to the Rescue!

11. Clients are the problem Cut costs To achieve program savings: Cut services Cap enrollment Reduce fraud + abuse Technology is part of the problem; it drives us apart We are the problem Improve outcomes To achieve program savings: Re-define enterprise Empower managers, service providers, clients Technology is part of the solution; it brings us together Medicaid Business Yesterday Tomorrow

12. Medicaid Systems MITA MMIS • Program-oriented • Claims-driven • Enhancements bolted-on based on need and/or technological advances • Limited competition--difficult to bid parts of a solution--all or nothing • Community-oriented • Business-driven • Enhancements evolve relative to maturing business requirements and desire for increased data sharing with others • Encourages best-of-breed

13. What Is MITA? • MITA is a FRAMEWORK • MITA is a TOOL KIT • MITA is a ROAD MAP NOTE: MITA is NOT a one-size-fits-all approach Each State builds its own IT solution based on standards, models and processes contained within the MITA Framework that have been developed with the help of all States and the IT industry

14. Key Principles--MITA • Support State program requirements as well as Federal • Provide Medicaid stakeholders at alllevels with robust data sets thatsignificantly enhance their ability to focus on outcomes • Commonalties and differencesco-exist peacefully • Standards first • Built-in Security and Privacy • Business-driven enterprise architecture

15. Defining the Enterprise is Easy??

16. 5 4 Enroll Member Member Management 3 Provider Management Enroll Provider 2 Contractor Management Manage Contract Information 1 Operations Management Edit/Claim Encounter Maintain Benefit / Reference Info Program Management Establish Case Care Management Program Integrity Identify Case Relationship Management Manage Business Relationship State Self Assessment Business Process Business Area “As Is” “To Be”

17. Applying MITA to Behavioral Health; i.e., Mental Health and Substance Abuse

18. BH-MITA Project • Joint CMS and SAMHSA project to extend Medicaid Information Technology Architecture (MITA) model to behavioral health (mental health and substance abuse) agencies • Reworks and develops equivalent foundation documents for BH to establish a common framework • Tool for state BH Agencies to help build the bridge to state Medicaid

19. BH Landscape Analysis • In October 2007, SAMHSA/CMS reviewed the Medicaid business processes to determine what to change • Many administrative processes were virtually identical, particularly MH • Key distinctions in: • Care management • Provider/contractor management • Program integrity/accountability • The bulk of the MITA model appeared applicable to BH agencies, with some minor adjustments

20. MITA Components Used in BH • A Landscape document, describing current business and technical capabilities • A Concept of Operations, describing a vision of future business operations and technology • A Maturity Model, describing steps in a high-level roadmap that project how business and technology will change along the • A Business Process Model,describing current operational processes, and • A State Self-Assessment, which uses the BPM to help States assess their current business capability levels for each business process

21. Lessons Learned? • The real problems are carbon,not silicon, based; i.e., people not technology • Definition of Enterprise is important • Get the vision right first, then think about how to get there • It takestime -- 5-10 years • Cross boundary leadership is difficult • Work toward incremental success, not Big Bangs