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Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
Ohio Medicaid Information Technology System (MITS)Business ...
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Ohio Medicaid Information Technology System (MITS)Business ...


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  • Increasing Costs: Rising medical costs in the face of shrinking budgets Increasing Needs: Increases in the number of needy persons - Beneficiaries living longer, chronic health care needs Obsolete systems expensive to maintain and operate Emphasis on Business Benefit: Balanced budget amendment and accountability – business case justification Rate of Change is Increasing: Benefits from various programs affect Medicaid liability Medicaid program policies change frequently in response to beneficiary needs and economic conditions New Public Health Focus: Integration with public health networks National Initiatives: Presidential initiatives to promote integrated health (eHealth), Focus on Beneficiary: Focus shifting to the beneficiaries and away from funding sources Focus on Data Exchange; CHI, Multiple organizations interested in data exchange -- Need to support bio-terrorism detection, prevention, and response Stakeholders expectations for access and data sharing Need for ongoing standardization of health care data
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    • 1. Ohio Medicaid Information Technology System (MITS) Business Transformation Business-Driven Architecture Ohio Health Plans
    • 2. Ohio’s Medicaid Info Tech System
      • Ohio Health Plans
        • Business & Drivers
        • Business Driven Architecture - MITA
      • MITS I - Business Case
        • Findings & Recommendations
      • MITS II - Business Requirements
        • Project Plan & Deliverables
        • Change Leadership
        • Risks & Realities
          • M – Medicaid
          • I – Information
          • T – Technology
          • S – System
          • Y – Yes, we can!
      We are due for a break! MITS(Y)
    • 3.
      • Ohio Health Plans
      • Business & Drivers
      • Enterprise Architecture
      • MITA Early Adopter
    • 4. Ohio Health Plans …& the need for change…
      • OHP is…
      • 6 th largest public health care purchaser nationally
        • 33% state expenditures
        • 76% ODJFS expenditures
        • $12 billion in SFY 2004
      • Value Purchaser – covering
        • 1 in 3 births & children
        • 1 in 4 seniors over the age of 85 years
        • 75% of long term care costs
      • 3 rd oldest legacy system in the country
        • Build by SME’s & served OHP well in the past…
        • MIS’s largest customer…
      CRIS-e 1.8M members 94% CRIS-e cases `96 Delink MMIS 65M claims 30 Rx, 25 Tape, 10 Paper 42% OHP - Operations Financial $12B OHP
    • 5. Business Drivers
      • People
      • OHP functional silos
      • IT Medicaid IS legacy system staffing, lack customer service focus
      • Reactive–crisis oriented
      • Task, not analysis, oriented
      • Limited skill sets-COBOL
      • Process
      • Manual, work-arounds, re-work
      • Policy without implementation
      • Paper, Paper, Paper
      • Limited business case, impact analysis, prioritization, governance
      • Technology
      • Antiqued technology
      • Multiple core systems
      • Numerous stand-alone, non-integrated systems
      • Lack of management data, data integrity, privacy/security protections
      • Business Pressures
      • Regulatory Demands
      • Rapid Change
      • Demand Growth
      • Cost Containment
      • Legislative & Commissions Recommendations
      • Audits & Oversight
      • Workforce Changes
      • Change Realities
      • Legacy system, hard code
      • Slow, inflexible & costly
      • Control-D Reporting
      • “ Work-around” mindset
      • Limited automation projects
      • Project Results
      • HIPAA – 3 yrs & $30M
      • TPL – 6 yrs, “pay & chase”
      • Buy-In – 13 yrs, huge county problems
      • CRISe De-link – 8 yrs
      • Request backlog - 350+
      “ PAC man of State budget.” - Governor
    • 6. As Medicaid agencies move from a regulator to value purchaser of quality services for health plan enrollees, they must fundamentally shift their design, management, & technology Strategic Change  requires Technology Change OHP Strategic Plan Value Purchasing Ohio Access- Disabilities Services & Choice Business Project & Performance Management Cost Management Workforce Excellence
    • 7. Enterprise Architecture E-Gov Federal CIO Council Business Architecture Business Reference Model “ The value of IT is best measured by the contribution IT makes towards achieving agency business goals and business objectives .” - ODAS ITP-D.4 Business Governance - roles, decision making process Data Architecture Applications Architecture Conceptual Process Model Interoperability Model Technical Architecture Technical Models Technical Reference Models Standards
    • 8. CMS Medicaid IT Architecture Enterprise Business Needs = Enterprise Architecture
      • Increasing Costs
      • Increasing Needs
      • Obsolete Systems
      • Emphasis on Business Benefit
      • Rate of Change Increasing
      • New Public Health Focus
      • National Initiatives
      • Focus on Beneficiaries
      • Focus on Data Exchange
      • Ongoing Standardization Supports Data Exchange
      M edicaid I nformation T echnology A rchitecture
    • 9. MITS Goals CMS selected Ohio as early adopter of MITA* Rate of Change Complexity & Growth Workforce Changes Increasing Demand Tech Rigidity Oversight, Audit Motivation, Skills *Adopter MOU – (1) Ohio Business Model, (2) MITA Self-Assessment, (3) APD Process, & (4) Hub Architecture To improve Ohio’s return on investment through federal enhanced reimbursement for MITS planning, design, development & implementation To implement value purchasing tools to improve performance results, health outcomes & quality & cost management To streamline systems development building on the MITA business model To implement “business drive architecture” – technology that supports the business needs of the Medicaid enterprise
    • 10. MITS Path Project Production (3.08) Procurement (7.05-11.05) MITS Development & Implementation (1.06-12.06) RFP & Implementation APD (1.04 -5.05) Phased Implementation (1.07-3.08) Detailed Requirements Strategic Projects (9.04-1.04) Budget Approval (1.05-6.05) We are here * Date estimates, subject to change . MITS Project Business Case, Budget & MITA APD (3.04-6.04)
    • 11. MITS Business Model *Integrate LTC functions across business processes To Be Model I. Member Management II. Provider & Contract Management III. Payment Management IV. Utilization & Quality Management V. Information Management VI. External Data Sharing & Exchange CMS MITA 6 core processes, 27 sub-processes
      • Member Services - Elig & Enroll
      • Benefits & Service Adm
      • Customer Rel’s Mgt ( Provider Srvs)
      • Contract Management
      • Financial Management
      • Claims & Encounters
      • Program Integrity?
      • Quality Management?
      • Management Information
      • Privacy & Security?
      • Project Management
      ODJFS MITS 11 core processes, 60 sub-processes
    • 12. MITS Business Model MITS Project Management Customer Relations Mgt (Provider Srvs) Member Services (E & E) Benefit & Service Adm HIPAA E-Claims & Encounters Privacy & Security Management Information Contract Management Financial Management Quality Management Program Integrity
    • 13. Findings – Technical Gap Assessment
      • Business improvements primarily focused on claims processing only
      • No transparency into claims adjudication process
      1 Applications to improve Medicaid business processes Business Area Improvement
      • Focused primarily on claims processing measurements
      • Data warehouse solution not optimally targeted
      1 Standard policy & performance measurement capabilities Performance Measurement
      • Adaptability and extensibility limited to look-up tables maintained for individual systems
      • Changes to code are ‘hard coded’ and performed manually
      1 Utilities that can be tailored (adapted) & added (extended) to meet state needs Adaptability & Extensibility
      • Most systems have their own security and privacy design
      • Access to each system managed and administered separately
      1 Secure & private mechanisms to facilitate exchange of information among multiple organizations Security & Privacy
      • Limited to point-to-point interfaces that are necessary for claims processing
      • No data sharing being performed outside of the organization for health outcome purposes
      1 Collaborative agreements & standards to enable data sharing in/outside Medicaid enterprise Data Sharing Coordination
      • Data modeling performed on a system by system basis
      • No enterprise standardization of data affects reporting capability
      1 Medicaid enterprise-specific data Data Management
      • Systems developed and maintained separately
      • Point-to-point interfaces limit commonality
      • Integration achieved through individually developed interfaces
      1 System-to-systems communications Interoperability Key MITA Scoring Rationale ODJFS Score Description MITA Portfolio
    • 14. Recommendations
      • Transfer MMIS +
        • Significant, additional capabilities
        • Incorporate Info Delivery & Internal Adm requirements
      • Assess CRIS-e to Modify or Replace
        • Do not delay MITS to complete assessment
      • Determine Sourcing Strategy
        • In-house vs. fiscal agent new system operations
      • Implement Infrastructure Changes – now to enable systems change
        • People  Process  Technology
      Very favorable business case – 3.8:1