MEDICAID MANAGEMENT How we got here; learn from our success and failure.
Dec 21, 2015
MEDICAID MANAGEMENTHow we got here; learn from our success and failure.
CA-MMIS System Replacement ProjectObjective:• To replace existing CA-MMIS Legacy Systems with new technology &
processes that provide business value and improvements to customers (end-users, providers, members), while enabling new levels of Medicaid Information Technology Architecture (MITA) business maturity.
Goals:• Enhance the quality of the project output while providing business value
earlier in the schedule • Improve Program Operations by providing opportunities for Business
Process Re-Engineering. This will be in parallel with the systems and business process implementations.
Medi-Cal Fiscal Intermediary Statistics2014 Average Daily Statistics
• 760,000 Claims processed per day*
• 40,000 paper claims
• 590,000 Medical claims
• 170,000 Point of Service (POS) claims
• 2,200 Live Provider calls per day
• 2,100 Live Beneficiary calls per day
• 12,000 Interactive Voice Response (IVR) calls
• 1,500 Paper Treatment Authorization Requests (TARs) processed
• 15,000 Beneficiary Identification Cards (BIC) produced
• $382 Million in claims paid, weekly
2014 Total Statistics• 197,629,924 Claims processed
• 10,465,798 paper claims
• 153,039,726 Medical claims
• 44,590,198 Point of Service (POS) claims
• 574,279 Live Provider calls taken
• 565,227 Live Beneficiary calls taken
• 3,049,664 Interactive Voice Response (IVR) calls
• 390,448 Paper Treatment Authorization Requests (TARs) processed
• 3,938,513 Beneficiary Identification Cards (BIC) produced
• $19,843,395,096 in total claims paid
$73,557,429,177.53 paid since Assumption of Operations on 10/03/2011
2014 v. 2013 Statistics• + 5,406,130 Claims processed (+2.8%)
• - 1,297,265 paper claims (-11.0%)
• + 3,115,281 Medical claims (+2.1%)
• + 2,290,849 Point of Service (POS) claims (+5.4%)
• + 38,437 Live Provider calls taken (+7.2%)
• + 194,163 Live Beneficiary calls taken (+ 52.3%)
• + 515,128 IVR calls (+ 20.3%)
• - 111,039 Paper TARs processed (- 22.1%)
• + 1,400,137 BICs produced (+ 55.2 %)
• + $2,905,185,719 in total claims paid (+ 17.2%)
• + $56 Million weekly claims paid (+ 17.2%)
Medi-Cal FI Responsibilities• Claims adjudication for Medi-Cal
95% Electronic claims, 5% paper 130,000+ Medi-Cal Providers and 11.5+
Million Beneficiaries
• Call Center for beneficiaries and providers; supports 11 languages
• Medi-Cal Eligibility Verification• Provider Relations Organization
Provider Outreach, Education, and Training: 1,800+ visits per year
Financial Cash Control Print Center
• Infrastructure (System Hosting and Maintenance) and Application Support 220+ Million web transactions 1,500+ Annual System Edits and Audits
• Other Services Fraud/Abuse Detection & Prevention Cost Containment
SR Release Roadmap Vision
Release 1
Release 2
Release 3
Release 4
Release 5
Release 2:Initial Claims ProcessingCHDP ClaimsCHDP Plan ManagementCHDP Financial ManagementEstablish FQHC Plan Mgmt.IHO Case Management
Release 3:Pharmacy, Medical Supplies, PADs, and LTC Claims and Drug RebatePharmacy, Medical Supplies, PADs, and LTC AuthorizationsPharmacy, Medical Supplies, PADs, and LTC ClaimsPharmacy , Medical Supplies, PADs, and LTC Financial MgmtDrug Rebate
Go-liveQ2 2016
Release 4:Medical Authorizations and ClaimsCCS/GHPP/OHP Claims Initial Supporting ProcessesFinancial Management
Release 5:Claims and Supporting ProcessesAll Other ClaimsAll Other AuthorizationsAll Other Supporting ProcessesAll Other Financial Management
Go-liveQ4 2016
Go-liveQ4 2015
Go-liveQ2 2015
Go-live Q4 2014
2014 2015 2016
StartApr 2014
StartJuly 2014
StartJan 2014
StartNov 2014
StartJan 2015
Release 1:Health Enterprise FrameworkInfrastructureSecurity/Single Sign-On (SSO)Member Eligibility ServiceProvider EnrollmentInitial Plan Management
Agile is a time boxed, iterative approach to software delivery that builds software incrementally from the start of the project, instead of trying to deliver it all at once near the end.
Individuals and interactionsover
Processes and tools
Working softwareover
Comprehensive documentation
Customer collaborationover
Contract negotiation
Responding to changeover
Following a plan
CA-MMIS Paradigm Shift to Agile• Our highest priority will be to meet our business objectives through early and
continuous delivery of the most valuable software.
• DHCS business people and Xerox developers must work together daily throughout the project.
• The most efficient and effective method of conveying information to and within a development team is face-to-face conversation.
• Working software, rather than documentation, will be our primary measure of progress.
• Agile processes promote sustainable development. DHCS sponsors, DHCS business owners and Xerox developers should be able to maintain a constant pace for the duration of the project.
• At regular intervals, the project team will reflect on how to become more effective. It will then tune and adjust its behavior accordingly.
Continuous Process Improvement
Requirements Design Coding Testing Release
In a traditional software development approach, projects analyze “lessons-learned” at the end of the project (or phase) in order to share their mistakes with other projects in the future.
In an agile project we constantly repeat the same iterative development process every month. Mistakes become process improvements on a regular basis.
Requirements
Design
CodingTesting
Release
Requirements
Design
CodingTesting
Release
Requirements
Design
CodingTesting
Release. . .
Delivering Value Instead of StatusRequirements Resources Time
Resources Time Features
Estimation Driven
Priority Driven
WATERFALL AGILEOpposing Approaches
Agile Projects at DHCS
Short Doyle Medi-Cal Maintenance and Operations Project
DMH-ADP to ITSD Migration Project (Medi-Cal systems)
DMH-ADP to ITSD Migration Project (Non-Medi-Cal systems)
CalHEERS (California Health Benefit Exchange)
THE DECK IS STACKEDSome days it feels like…
Change is HardIt requires a change in:• Organizational culture• Personnel with the right skills• Management support• Communication• Values• Decision Making
What are the Obstacles?• Government wants Legal Protection• Government Decision Making• Public Oversight• Government is Risk Adverse• Contracts• Budgeting
IS THERE HOPE?If the system is designed for waterfall
“Firm fixed price development tends to create situations where neither the government nor the contractor has the flexibility needed to make adjustments as they learn more about what is feasible and affordable as well as what needs to be done to achieve a design that meets requirements during a product’s design and testing phases.”- Frank Kendall, Under Secretary of Defense for Acquisition, Technology and Logistics
A False Sense of Security• Everything about our current waterfall process is
intended to eliminate uncertainty.• While this may be successful on small projects, it
creates a false sense of security on large projects.• How many projects’ definition of success remains
constant from inception?• Agile processes are designed to create transparency
and expose risk.
The Case for Agile• Agile provides a direct pathway to transform
government solutions through the development of value-driven solutions that focus on the public’s priorities.
• However, government is inhospitable to outsiders, agile included. From decision making, to budgeting and procurement, the public sector has been designed for waterfall.
Agile Myths• Agile teams don’t plan
• Agile is not predictable
• Chaos with no ownership
• It’s a silver bullet
• No documentation
• Agile is easy
• Agile only works for web projects
• Agile implementations are more expensive
• Agile is not scalable
• Cowboy coding with no best practices
PLAYING TO WIN
Being prepared for the obstaclesto adopting agile in state government.
People
TechnologyProcess
People• Start small and create a culture that embraces
change• Choose your team carefully, choose change agents• Educate your team before you begin• Coach your team as you go• Engagement with your customer is just as
important as with your development team
Process• Choose a non-reportable (delegated authority)
IT project• Establish your agile processes before you
execute them – then improve them as you go• Agile processes are intentionally
light weight, so adhere to theprocesses that you value
Technology• Local development
environment• Source code control –
daily code merge• Build and test systems –
automationRegression
Test
Build/ Deploy
Commit
Most Common Agile Techniques1. Daily Standup2. Iteration Planning3. Unit Testing4. Retrospectives5. Release Planning6. Burndown/ Team-
based Estimation
7. Velocity8. Coding Standards9. Continuous Integration10. Automated Builds11. Dedicated Product
Owner
VersionOne, State of Agile Survey 2013
QUESTIONS?
Contact informationPeter KellyCA-MMIS [email protected](916) 373-7722
Nilay PatelXerox Govt. [email protected](770) 866-0628