Ohio Medicaid Information Technology System (MITS) Business Transformation Business-Driven Architecture Ohio Health Plans
Ohio’s Medicaid Info Tech System <ul><li>Ohio Health Plans   </li></ul><ul><ul><li>Business & Drivers </li></ul></ul><ul><...
<ul><li>Ohio Health Plans </li></ul><ul><li>Business & Drivers </li></ul><ul><li>Enterprise Architecture  </li></ul><ul><l...
Ohio Health Plans …& the need for change… <ul><li>OHP is… </li></ul><ul><li>6 th  largest public health care purchaser nat...
Business Drivers <ul><li>People </li></ul><ul><li>OHP functional silos </li></ul><ul><li>IT Medicaid IS legacy system staf...
As Medicaid agencies move from a regulator to  value purchaser  of quality services for health plan enrollees, they must f...
Enterprise Architecture E-Gov Federal CIO Council Business  Architecture Business Reference Model “ The value of IT is bes...
CMS Medicaid IT Architecture  Enterprise Business Needs = Enterprise Architecture <ul><li>Increasing Costs </li></ul><ul><...
MITS Goals CMS selected Ohio as  early adopter  of MITA* Rate of Change Complexity & Growth Workforce Changes Increasing D...
MITS Path Project Production (3.08) Procurement  (7.05-11.05) MITS Development & Implementation (1.06-12.06)  RFP & Implem...
MITS Business Model *Integrate  LTC  functions across business processes To Be Model I. Member Management II. Provider & C...
MITS Business Model MITS Project  Management Customer Relations Mgt (Provider Srvs) Member Services (E & E) Benefit &  Ser...
Findings  –  Technical Gap Assessment <ul><li>Business improvements primarily focused on claims processing only </li></ul>...
Recommendations <ul><li>Transfer MMIS  +   </li></ul><ul><ul><li>Significant, additional capabilities </li></ul></ul><ul><...
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Ohio Medicaid Information Technology System (MITS)Business ...

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

  1. 1. Ohio Medicaid Information Technology System (MITS) Business Transformation Business-Driven Architecture Ohio Health Plans
  2. 2. Ohio’s Medicaid Info Tech System <ul><li>Ohio Health Plans </li></ul><ul><ul><li>Business & Drivers </li></ul></ul><ul><ul><li>Business Driven Architecture - MITA </li></ul></ul><ul><li>MITS I - Business Case </li></ul><ul><ul><li>Findings & Recommendations </li></ul></ul><ul><li>MITS II - Business Requirements </li></ul><ul><ul><li>Project Plan & Deliverables </li></ul></ul><ul><ul><li>Change Leadership </li></ul></ul><ul><ul><li>Risks & Realities </li></ul></ul><ul><ul><ul><li>M – Medicaid </li></ul></ul></ul><ul><ul><ul><li>I – Information </li></ul></ul></ul><ul><ul><ul><li>T – Technology </li></ul></ul></ul><ul><ul><ul><li>S – System </li></ul></ul></ul><ul><ul><ul><li>Y – Yes, we can! </li></ul></ul></ul>We are due for a break! MITS(Y)
  3. 3. <ul><li>Ohio Health Plans </li></ul><ul><li>Business & Drivers </li></ul><ul><li>Enterprise Architecture </li></ul><ul><li>MITA Early Adopter </li></ul>
  4. 4. Ohio Health Plans …& the need for change… <ul><li>OHP is… </li></ul><ul><li>6 th largest public health care purchaser nationally </li></ul><ul><ul><li>33% state expenditures </li></ul></ul><ul><ul><li>76% ODJFS expenditures </li></ul></ul><ul><ul><li>$12 billion in SFY 2004 </li></ul></ul><ul><li>Value Purchaser – covering </li></ul><ul><ul><li>1 in 3 births & children </li></ul></ul><ul><ul><li>1 in 4 seniors over the age of 85 years </li></ul></ul><ul><ul><li>75% of long term care costs </li></ul></ul><ul><li>3 rd oldest legacy system in the country </li></ul><ul><ul><li>Build by SME’s & served OHP well in the past… </li></ul></ul><ul><ul><li>MIS’s largest customer… </li></ul></ul>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. 5. Business Drivers <ul><li>People </li></ul><ul><li>OHP functional silos </li></ul><ul><li>IT Medicaid IS legacy system staffing, lack customer service focus </li></ul><ul><li>Reactive–crisis oriented </li></ul><ul><li>Task, not analysis, oriented </li></ul><ul><li>Limited skill sets-COBOL </li></ul><ul><li>Process </li></ul><ul><li>Manual, work-arounds, re-work </li></ul><ul><li>Policy without implementation </li></ul><ul><li>Paper, Paper, Paper </li></ul><ul><li>Limited business case, impact analysis, prioritization, governance </li></ul><ul><li>Technology </li></ul><ul><li>Antiqued technology </li></ul><ul><li>Multiple core systems </li></ul><ul><li>Numerous stand-alone, non-integrated systems </li></ul><ul><li>Lack of management data, data integrity, privacy/security protections </li></ul><ul><li>Business Pressures </li></ul><ul><li>Regulatory Demands </li></ul><ul><li>Rapid Change </li></ul><ul><li>Demand Growth </li></ul><ul><li>Cost Containment </li></ul><ul><li>Legislative & Commissions Recommendations </li></ul><ul><li>Audits & Oversight </li></ul><ul><li>Workforce Changes </li></ul><ul><li>Change Realities </li></ul><ul><li>Legacy system, hard code </li></ul><ul><li>Slow, inflexible & costly </li></ul><ul><li>Control-D Reporting </li></ul><ul><li>“ Work-around” mindset </li></ul><ul><li>Limited automation projects </li></ul><ul><li>Project Results </li></ul><ul><li>HIPAA – 3 yrs & $30M </li></ul><ul><li>TPL – 6 yrs, “pay & chase” </li></ul><ul><li>Buy-In – 13 yrs, huge county problems </li></ul><ul><li>CRISe De-link – 8 yrs </li></ul><ul><li>Request backlog - 350+ </li></ul>“ PAC man of State budget.” - Governor
  6. 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. 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. 8. CMS Medicaid IT Architecture Enterprise Business Needs = Enterprise Architecture <ul><li>Increasing Costs </li></ul><ul><li>Increasing Needs </li></ul><ul><li>Obsolete Systems </li></ul><ul><li>Emphasis on Business Benefit </li></ul><ul><li>Rate of Change Increasing </li></ul><ul><li>New Public Health Focus </li></ul><ul><li>National Initiatives </li></ul><ul><li>Focus on Beneficiaries </li></ul><ul><li>Focus on Data Exchange </li></ul><ul><li>Ongoing Standardization Supports Data Exchange </li></ul>M edicaid I nformation T echnology A rchitecture
  9. 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. 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. 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 <ul><li>Member Services - Elig & Enroll </li></ul><ul><li>Benefits & Service Adm </li></ul><ul><li>Customer Rel’s Mgt ( Provider Srvs) </li></ul><ul><li>Contract Management </li></ul><ul><li>Financial Management </li></ul><ul><li>Claims & Encounters </li></ul><ul><li>Program Integrity? </li></ul><ul><li>Quality Management? </li></ul><ul><li>Management Information </li></ul><ul><li>Privacy & Security? </li></ul><ul><li>Project Management </li></ul>ODJFS MITS 11 core processes, 60 sub-processes
  12. 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. 13. Findings – Technical Gap Assessment <ul><li>Business improvements primarily focused on claims processing only </li></ul><ul><li>No transparency into claims adjudication process </li></ul>1 Applications to improve Medicaid business processes Business Area Improvement <ul><li>Focused primarily on claims processing measurements </li></ul><ul><li>Data warehouse solution not optimally targeted </li></ul>1 Standard policy & performance measurement capabilities Performance Measurement <ul><li>Adaptability and extensibility limited to look-up tables maintained for individual systems </li></ul><ul><li>Changes to code are ‘hard coded’ and performed manually </li></ul>1 Utilities that can be tailored (adapted) & added (extended) to meet state needs Adaptability & Extensibility <ul><li>Most systems have their own security and privacy design </li></ul><ul><li>Access to each system managed and administered separately </li></ul>1 Secure & private mechanisms to facilitate exchange of information among multiple organizations Security & Privacy <ul><li>Limited to point-to-point interfaces that are necessary for claims processing </li></ul><ul><li>No data sharing being performed outside of the organization for health outcome purposes </li></ul>1 Collaborative agreements & standards to enable data sharing in/outside Medicaid enterprise Data Sharing Coordination <ul><li>Data modeling performed on a system by system basis </li></ul><ul><li>No enterprise standardization of data affects reporting capability </li></ul>1 Medicaid enterprise-specific data Data Management <ul><li>Systems developed and maintained separately </li></ul><ul><li>Point-to-point interfaces limit commonality </li></ul><ul><li>Integration achieved through individually developed interfaces </li></ul>1 System-to-systems communications Interoperability Key MITA Scoring Rationale ODJFS Score Description MITA Portfolio
  14. 14. Recommendations <ul><li>Transfer MMIS + </li></ul><ul><ul><li>Significant, additional capabilities </li></ul></ul><ul><ul><li>Incorporate Info Delivery & Internal Adm requirements </li></ul></ul><ul><li>Assess CRIS-e to Modify or Replace </li></ul><ul><ul><li>Do not delay MITS to complete assessment </li></ul></ul><ul><li>Determine Sourcing Strategy </li></ul><ul><ul><li>In-house vs. fiscal agent new system operations </li></ul></ul><ul><li>Implement Infrastructure Changes – now to enable systems change </li></ul><ul><ul><li>People  Process  Technology </li></ul></ul>Very favorable business case – 3.8:1

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