IME Att 3 MITA

MITA Case Studies: Which came first – the enterprise or the architecture?

Presented to: MMIS Conference 2005: Big Sky, MTAugust 14 - 18, 2005

Mary Tavegia – IME Project Director, State of Iowa DHSErin Harris – IME MITA Coordinator, Software Engineering Services

MITA Case Study - Iowa Medicaid Enterprise 2

The Iowa Medicaid Enterprise Iowa Facts and Figures IME Vision

Similar to MITA Goals Implementing the Vision

RFPs, Contracts, and Performance Measures DDI – Building the IME

The Enterprise is Live! Initial Results What’s Next

“MITA-sizing” the IME


Medicaid in Iowa

Iowa Population – 2.9 million Currently 10% of population Medicaid eligible Medicaid impacts one out of every three Iowans

Dramatic Medicaid Cost Increases Average Monthly Eligibility (> 39% in 5 years) Average Monthly Total Payments (> 69% in 5 years)

Results-based Accountability in Iowa Performance measurement Cost-effective healthcare


MMIS in Iowa Last procurement in 1995

Fiscal agent customized MMIS Pharmacy Point of Sale (POS) Decision Support System (DSS) Medically Needy Managed Care Operated on Contractor hardware in Pennsylvania

and Georgia Professional Services and operational support by

Fiscal Agent Interfaces with state-operated Medicaid eligibility

systems (Title XIX, ISIS) Ability to adapt to change constrained


Iowa Medicaid Enterprise (IME)

The Vision Improve service to Iowa Medicaid members, providers, and

partners Shift control from Contractor to the State

Increase accountability throughout Medicaid operations Enhance decision making ability

Implement “Best practices” in key Medicaid business functions State management with “Best of Breed” Contractors Improve health outcomes for members

Enhanced primary care case management Initiate disease management program Collect and analyze cost and outcome information

Collaboration rather than competition Increase flexibility and adaptability Leverage state IT infrastructure


IME Similar to MITA Goals RFP for IME released in 2003 MITA Framework 1.0 published in January 2004

MITA Goals1. Integration and interoperability2. Flexibility to respond rapidly to

change3. Enterprise view to align technology

and business needs4. Data that supports analysis and

decision making5. Performance measurement for

accountability and planning6. Coordination with partners to improve

overall health

IME Strategy• Co-location state, contractors• Integrate contractor systems • Modular business units• Begin technology migration• Collaborative business model• Workflow integration• Collect clinical data• Improve DSS capabilities• Performance-based contracts• Enhanced monitoring and

reporting of trends, costs• Enhanced case and disease

management• PDL, pharmacy/clinical

coordination


Implementing the IME Vision Single RFP, multiple components

Systems Professional Services

Contract with “Best of Breed” service providers 8 Systems and Professional Services Contractors Operational support from the State

Department’s Division of Data Management (DDM) Network Support Data Warehouse Other Medicaid State Systems

Department of Administrative Services Iowa Technology Enterprise (ITE) Printing and Mailing Services

Separate Responses MMIS administration, Workflow, Imaging Pharmacy POS Medical Services Pharmacy Medical Services Member Services Provider Services SURS Provider Cost Audits and Rate Setting Revenue Collection


DDI – Building the IME One-year timeframe

IV&V and PMO contract services Early transfer MMIS to state hardware Build and transfer Medicaid Data Warehouse

Shared Data and Tools Co-location Common data sources for all IME staff

MMIS Medicaid Data Warehouse Workflow Process Management System

Integrate on- and off-site contractor systems with MMIS

Performance based contracts and Report Cards


The Enterprise is Live!

Initial Results Preferred Drug List 1-15-05 Pharmacy Point Of Sale 6-25-05 MMIS, Workflow & Contractor systems 6-30-05 Began Paying claims with Payment Cycle 7-11-05 Phasing in Medicaid Reform: IowaCare Phase 1

Next Steps Medicaid Reform: Next phases IowaCare Better integration, expand SOA capabilities Monitor performance and fine tune collaboration Continue MITA-sizing and enterprise architecture

development


Enterprise Architecture: MITA-sizing the IME

MITA activities for the IME Opportunities for Enterprise Architecture (EA)

MITA Tools for the IME EA Business Process Model Capabilities and the Traceability Matrix

EA and IME Strategic Planning MITA self-assessment Business–focused IT planning


MITA for the IME

MITA Activities in Parallel to DDI at the IME Track and assess MITA framework

Contribute to MITA definition Apply MITA principles to the IME

Current DDI recommendations Problematic in timeframe

MITA continuing to evolve Plans and contracts for the IME already underway

Assess MITA impact for future planning Validate/pilot MITA and enterprise architecture

Business process modeling Collect architectural elements, artifacts


IME’s Opportunities for Enterprise Architecture

Redesign of business operations Document business processes

Workflow Operational procedures Cross-functional integration

Planning for quality by measuring performance Extract and document business rules from transferred

MMIS Technical environment adapted to business needs

Configured for operational efficiency Flexible, adaptable modularity


MITA LifecycleCollaboration

Phase 4 – Transition Plan Executionand Iterative Updates

MITA Capability

Matrix

Combined Target

Capabilities

State (CIO) Enterprise

Architecture

State Medicaid EA

MITA Medicaid EA Guidelines

Self Assessment

State/ Medicaid Strategic Planning

MedicaidEA

Development Process

NASCIO Enterprise Architecture Tool Kit

Phase 3 - Transition PlanDevelopment

Phase 1- Self Assessment

Phase 2 - State Medicaid

EA Development

(Recommended)

MITA ArchitectureFramework

State Transition Plan

Transition PlanDevelopment

Legend

State ProcessSub-step

MITAProcessStep or

Sub-step

MITA Product

State MedicaidProduct

State (CIO)

Product


IT View: Enterprise Information Architecture

Where is the Business?

Richard Watson, Lawrence Livermore National Laboratorycsdl2.computer.org/comp/proceedings/hicss/2000/0493/07/04937059.pdf


Business-centric Focus

Multiple dimensions of MITA EABusiness Process

CapabilityData

ApplicationTechnical

TimeMITA Maturity

Business Drivers


EA Modeling Questions What? – the process

Verb + Object (Process Claims) How? – the capability/competency

Qualities: Timeliness Accuracy Efficiency Quality Cost-effectiveness Value

Who? – stakeholders, actors, customers What information? – the data With what? – the application(s) With who, when, where? – the technical infrastructure


IME Business Process Model

Functional framework in IME RFP Business units Requirements capabilities

IME operational procedures manuals Decompose and recombine chronological events Develop outline of business processes (table) Create graphical representation (model) Review/Assess/Modify – visual aid to refine model

Functional hierarchy, redundancy, trigger events


IME BPM Models


MITA - IME BPM Crosswalk

Revealed Gaps in IME BPM Differences in granularity of BPMs

Multiple IME BPs map to a MITA BP BPs that cross IME business areas Highlights areas for BP and/or system integration

Provides roadmap for self-assessment Keeps IME BPM relevant to IME business model

No “forcing the framework” onto the enterprise


Crosswalk SampleMITA Business

Model v21b IME Business

Model

Business Area Intermed 1 Intermed 2 Business Process Business Process Intermed 2 Intermed 1 Business Area

Member Management

Eligibility Determination

Determine EligibilityDetermine Medicaid

Eligibility DHS Eligibility Administration

Enrollment

Enroll Member

Enrollment Brokerfor ManagedHealth Care Member Services

Enroll Member for Waiver, Mental Health

DHS Eligibility Administration

Enroll Selected Members and Providers for EPCCM

Enhanced Primary Care Case Management (EPCCM) Medical Services

Enroll Selected Members and Providers for DiseaseManagement Program

Disease Management Medical Services

Lock-in Enrollment Lock-in Medical Services


Initial Traceability Matrix ExampleIME Business

Area/Key Process"As is" Current

Capability"To be" IME Capability

"As is" -> "To be“ Gap Description

Stakeholders Business Value Goal Alignment

Medical Services

Medical Support

Claim Review Review claims foradministrative andJudicial appeals.Request additional information from providers as needed.

Provide well-qualifiedMedical Director(MD/OD) and professional staff or consultants formedical review functions.

Dispersed clinical review services with Limited staffing.Increasing Program focus on health outcomes.

Medical DirectorMed Srv Unit MgrMed Srv Ops MgrClaim Rev SuprvsrPolicy RepElig RepAtty Gen, Rep

Partner w/local medical communityto ensure fair review using established standards of care.

#1 Improve service – H (3)#3 Best Practices - H (3)

Total Goal Alignment = 6

Pre-procedure/Pre-admission Review

Process paper or fax PAs and requests for exception to policy.

Accept electronicPAs. Provide medical consultingservices to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically.

Limited legacy system EDI capabilities.Dispersed clinicalreview services with limited staffing. No automated CRM or Documentmanagement systems.

Medical DirectorMed Srv Unit MgrMed Srv Ops MgrPA SupervisorsPolicy RepProvider Srv RepMember Srv Rep

Improved response time and accuracy of prior authoriza-tions improves provider and patient relations,and increases accuracy of billing.

#1 Improve service – H (3)#2 State control - L (1)#3 Best Practices - H (3)#4 Flexibility/Adapt - M (2)#5 Leverage state IT–L (1)


Retrospective Inpatient and Outpatient Review

Perform medical review of 10% of all claims. Initiate revenue adjustments as needed.

Dispersed clinical review services with limited staffing.Increasing programfocus on claims quality.

Medical DirectorMed Srv Unit MgrMed Srv Ops MgrPolicy RepRetro Review

Sprvsr

Improved payment accuracy and monitoring of utilization.

#1 Improve service – L (1)#2 State control - M (2)#3 Best Practices - H (3)


Capabilities/Goals/Business Value


Traceability Matrix – EA Example

IME BusinessArea/Key Processl de

"To be" IME Capability

Related IME

Requirements Documents

Related IME

Design Documents

Technical Solutions Notes

Data ArchitectureNotes

Medical Services

Medical Support

Claim Review Provide well-qualifiedMedical Director(MD/OD) and professional staff or consultants formedical review functions.

> Requirements Confirmation Workbook – FINAL

> SRS061.000 Medical Support

> MQUIDS DSD 3-3-05 MQUIDS

> VB.NET using Visual Studio 2003

> 2-tier environment

> Crystal reports

> ADO.NET object model

> SQL Server 2000

> MMIS Claims History

Pre-procedure/Pre-admission Review

Accept electronicPAs. Provide medical consultingservices to DHS regarding policy changes, and to providers regarding policy for PAs and billing. Track all communications with providers regarding policy electronically.



> MQUIDS DSD 3-3-05

> WDS915.2_Prior Authorization

> WDS913_Workview

> WDS907.2_Medical Services

MQUIDS



> Crystal reports


OnBase Tech Env.

ELVIS Tech Env

MMIS Tech Env

> SQL Server 2000

> MMIS Prior Auth Master

Retrospective Inpatient and Outpatient Review

Perform medical review of 10% of all claims. Initiate revenue adjustments as needed.



> MQUIDS DSD 3-3-05 MQUIDS



> SQL Server 2000

> Crystal reports


> SQL Server 2000

> MMIS Claims History

EA Dimensions


More EA/MITA Details in Extended Traceability Matrix

IME BusinessArea/Key Process

"To be" IME Capability

Timeliness Accuracy Efficiency Quality Cost-Effective-

ness

Value Performance Measures

Medical Services

Medical Support

Claim Review Provide well-qualifiedMedical Director (MD/OD) and professional staff or consultants for medicalreview functions.

Extend details captured in matrix for each EA dimension: Capability/competency definition (MMM qualities, performance

measures, etc.) Application architecture (COTS, legacy systems, subsystems, etc.) Data architecture (files, locations, formats, . . ., metadata repository) Technical architecture (hardware, telecomm, operating systems,

integration, services, etc.) EA details collected in matrices provide information to perform MITA

self-assessment

MITA Maturity Model (MMM) Qualities/Performance Measures


EA and IME Strategic Planning MITA self-assessment

BPM extended traceability matrix + crosswalk self-assessment

Business–focused IT planning Traceability matrix collects EA artifacts Provides process change roadmap

Gaps, goals, stakeholders, data, applications, technical infrastructure

Scope and impact of change Incremental

Iterative process Granularity Focus: business process, functional area, business area,

enterprise


Questions

Mary Tavegia, [email protected], (515) 725-1110Erin Harris, [email protected], (615) 293-2993

IME Att 3 MITA

Business

initiate revenue

qualified

medical review

crystal reports

tier environment

ime mita activities

2 state control

professional