the role of it in running an effective medicaid program
DESCRIPTION
The Role of IT in Running an Effective Medicaid Program. William D. Hayes, Ph.D., President [email protected] Health Policy Institute of Ohio http://www.healthpolicyohio.org 37 W Broad Street, Suite 350 Columbus, OH 43235 614-224-4950 September 8, 2005. 1. - PowerPoint PPT PresentationTRANSCRIPT
The Role of IT in Running an Effective Medicaid Program
William D. Hayes, Ph.D., President
Health Policy Institute of Ohio
http://www.healthpolicyohio.org
37 W Broad Street, Suite 350
Columbus, OH 43235
614-224-4950
September 8, 20051
Medicaid Functions in a Highly Flawed U.S. Health Care Delivery System
• Per the Leapfrog Group, the quality of the U.S. health system is equal to how well the airline industry handles baggage– versus the safety record for flying planes
• Per researchers at Rand Corporation, providers follow best practices on average 54% of the time
• Per Midwest Business Group on Health, 30% of U.S. health spending adds no value or creates negative value (overuse, not enough use, or misuse)
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Medicaid as Four Different Types of Health Insurance Plans
• Medicaid consists of 4 types of health insurance plans, with differing eligibility requirements, provider systems, and delivery approaches:– High risk pool (even for higher income
families) – Regular health insurance plan, especially for
children and some of their parents– Long term care plan (even for middle income
families)– Largest Medicare Supplemental plan
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Medicaid Delivery System Realities in Ohio• Two delivery systems for acute care services:
fee-for-service and full risk managed care• Over 35,000 fee-for-service providers• Currently 5 full risk managed care plans• Pharmacy runs through a point-of-service system• Long term care costs account for almost 40% of
spending, occurring either through a set of institutional or various community-based long term care providers
• Consumers get a medical care monthly showing that they are enrolled in the Medicaid FFS or managed care delivery system
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Medicaid and Private Health Plan Comparison
• Medicaid is an entitlement plan; must take all who meet eligibility standards
• Almost 50 different mandatory or optional eligibility categories with different standards
• Eligibility based on some or all of the following criteria: age, income level, asset level, disability status, residency, pregnancy
• Limited cost sharing options• Typically, administratively set provider
payments• Part of Medicaid population more expensive &
sicker to cover than the general population5
Medicaid and Private Health Plan Comparison
• In Ohio, Medicaid administration involves management relationship with federal government, single state agency, other state agencies, and local government agency
• Medicaid programs spend, on average, around 4-5% for all administrative functions
• Medicaid program often seen as liability, cost center versus a profit center
• Administrative appeals process typically favors the consumer, especially on clinically-based actions
• Public rule making process for all program changes• Population-based orientation
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Critical Operational Processes for the Medicaid Health Plans
• Medicaid’s operational needs similar to private plans. These needs include:– Eligibility determination and notification– Provider enrollment and relations– Consumer education and relations– Claims payment– Fraud detection and investigation– Outcomes monitoring and evaluation– Contract procurement and management– Coordination of benefits (Medicaid to be payor of
last resort)
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Critical Operational Processes, continued– Account reconciliation with federal government– Budget forecasting– Value purchasing, including support for move to
pay for performance– Consumer cost sharing– Public health system surveillance and tracking– Health outcomes improvement– Information system maintenance, development,
and integration– Health system research– Ability to answer program questions in timely
fashion– Audits from federal and state oversight bodies
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How Medicaid Match Works with IT
• Medicaid program runs on state funds combined with federal matching funds
• IT efforts currently get an attractive match, often at 90% or 75% for development. (The match is usually 50% for regular operations)
• Current federal government proposals, especially setting a block grant on administrative expenditures, could hurt IT investment
• Often Medicaid can support IT efforts of other state agencies, if effort has an effect on the administration of the Medicaid program (e.g., immunization tracking system development)10
Medicaid Administration Challenges & IT
• How to keep slow the rate of ongoing cost growth, preferably to at or below average cost of state revenue growth (4% a year)
• How to coordinate eligibility, services, and information sharing across mixture of federal, state and local agencies, each with aspects of management responsibility and power
• How to foster effective emphasis on IT enhancement within existing state government structures and processes
• How to make sure that policy makers consider realities of implementation when making decisions11
Total ODJFS Medicaid Spending 1992 - 2005
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3
4
5
6
7
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10
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1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 est 2005 est
State Fiscal Years
Spe
ndin
g in
Bill
ions
6.73%9.91%
1.81%7.76% -.88% 4.0%
% Change from Previous Year
5.75%
8.16%
14.9%
12.66%
12.29%
11.6%
6.71%
Reduced growth in SFY'04-05 (the lowest since SFY '98-99) is the result of $863 million in cost containment strategies enacted in HB 95, Biennial
Budget
20.42%
Federal welfare reform caused eligible people to
leave Medicaid rolls & masked ongoing PM/PM
growth Recession of the early '90s is reflected in large % growth. NF prospective payment system developed and put into place in
response to double digit growth.
Recession of the 2000 decade is
reflected once again in large % growth, in part due to return of Medical inflation
growth.
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Office of Ohio Health Plans…& the need for change…
OHP runs Ohio’s Medicaid program and is…• 6th largest public health care purchaser nationally
– 33% state expenditures
– 76% Ohio Department of Job and Family Services 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
• 3rd oldest legacy system in the country– Build by SMEs & served OHP well in the past…
– MIS’s largest customer…
CRIS-e1.8M members
94% CRIS-e cases`96 Delink
MMIS
65M claims30 Rx, 25 Tape, 10
Paper42% OHP - Operations
Financial$12B OHP
13 from 10/29/2004 OHHIT Summit presentation by Ailene MacKay,
Ohio Medicaid Information Technology System (MITS)Business Transformation
Technology
• Antiqued technology
• Multiple core systems
• Numerous stand-alone, non-integrated systems
• Lack of management data, data integrity, privacy/security protections
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
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 projectsProject 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+
“PACMAN ofState budget.” - Governor
14 from 10/29/2004 OHHIT Summit presentation by Ailene MacKay,
Ohio Medicaid Information Technology System (MITS)Business Transformation
OHP Strategic Plan
ValuePurchasing
Ohio Access-Disabilities
Services & Choice
BusinessProject &
PerformanceManagement
Cost Management
WorkforceExcellence
As Medicaid agencies move from a regulator to valuepurchaser of quality services for health plan enrollees, they mustfundamentally shift their design, management, & technology
Strategic Changerequires TechnologyTechnology Change
15 from 10/29/2004 OHHIT Summit presentation by Ailene MacKay,
Ohio Medicaid Information Technology System (MITS)Business Transformation
Enterprise ArchitectureE-Gov Federal CIO Council
Data Architecture
Applications Architecture
Conceptual Process ModelInteroperability Model
Technical ArchitectureTechnical Models
Technical Reference ModelsStandards
Business Business ArchitectureArchitecture
Business Reference Model
“The value of IT is best measuredby the contribution IT makes towards achieving agency business goals and business objectives.”
- ODAS ITP-D.4
Business Governance – roles, decision making
process
16 from 10/29/2004 OHHIT Summit presentation by Ailene MacKay,
Ohio Medicaid Information Technology System (MITS)Business Transformation
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
MMedicaidIInformationTTechnologyAArchitecture
17 from 10/29/2004 OHHIT Summit presentation by Ailene MacKay,
Ohio Medicaid Information Technology System (MITS)Business Transformation
MITS GoalsCMS selected Ohio as early adopterearly adopter of MITA*
To implement “business drive architecture”– technology that supports the businessneeds of the Medicaid enterprise
To streamline systems development building on the MITA business model
To implement value purchasing tools to improve performance results, health outcomes & quality & cost management
To improve Ohio’s return on investment through federal enhanced reimbursement for MITS planning, design, development & implementation
Rate of ChangeComplexity & GrowthWorkforce ChangesIncreasing DemandTech RigidityOversight, AuditMotivation, Skills
*Adopter MOU – (1) Ohio Business Model, (2) MITA Self-Assessment, (3) APD Process, & (4) Hub Architecture
18 from 10/29/2004 OHHIT Summit presentation by Ailene MacKay,
Ohio Medicaid Information Technology System (MITS)Business Transformation
MITS Business Model
CMS MITA6 core processes, 27 sub-processes
I. Member Management
II. Provider & Contract Management
III. Payment Management
IV. Utilization & Quality Management
V. Information ManagementVI. External Data Sharing & Exchange
ODJFS MITS11 core processes, 60 sub-processes
1. Project Management
2. Member Services - Eligibility & Enrollment
3. Benefits & Service Administration
4. Customer Relationship Mgmt (Provider Services)
5. Contract Management
6. Financial Management7. Claims & Encounters
8. Program Integrity?9. Quality Management?
10. Management Information11. Privacy & Security?
*Integrate LTC functions acrossbusiness processes
To Be Model
19 from 10/29/2004 OHHIT Summit presentation by Ailene MacKay,
Ohio Medicaid Information Technology System (MITS)Business Transformation
MITS Business Model
MITSMITS
Project Management
CustomerRelations Mgmt (Provider Svcs)
Member Services(E & E)
Benefit & Service Admin
HIPAAE-Claims &Encounters
Privacy & Security
Management Information
ContractManagement
FinancialManagement
Quality Management
Program Integrity
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Findings – Technical Gap AssessmentTechnical Gap Assessment
MITA Portfolio Description ODJFS Score Key MITA Scoring Rationale
Interoperability System-to-systems communications 1
Systems developed and maintained separately Point-to-point interfaces limit commonality Integration achieved through individually developed interfaces
Data Management
Medicaid enterprise-specific data
1 Data modeling performed on a system by system basis No enterprise standardization of data affects reporting
capability
Data SharingCoordination
Collaborative agreements & standards to enable data sharing in/outside Medicaid enterprise 1
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
Security & Privacy
Secure & private mechanisms to facilitate exchange of information among multiple organizations
1 Most systems have their own security and privacy design Access to each system managed and administered separately
Adaptability & Extensibility
Utilities that can be tailored (adapted) & added (extended) to meet state needs 1
Adaptability and extensibility limited to look-up tables maintained for individual systems
Changes to code are ‘hard coded’ and performed manually
Performance Measurement
Standard policy & performance measurement capabilities 1
Focused primarily on claims processing measurements Data warehouse solution not optimally targeted
Business Area Improvement
Applications to improve Medicaid business processes 1
Business improvements primarily focused on claims processing only
No transparency into claims adjudication process
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Recommendations1. Transfer MMIS +
– Significant, additional capabilities– Incorporate Info Delivery & Internal Admin
requirements
2. Assess CRIS-e to Modify or Replace – Do not delay MITS to complete assessment
3. Determine Sourcing Strategy – In-house vs. fiscal agent new system operations
4. Implement Infrastructure Changes – nownow to enable systems change– People Process Technology
Very favorable business case – 3.8:1
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What Information Needs Do People Want to be Solved?
• To enhance effectiveness of Medicaid program for consumers, providers, and program staff could use:– Online enrollment for consumers and providers– Online eligibility status check– Access to electronic health information, especially
diagnoses and prescription medication data– Easier linking between eligibility and administrative
data systems within and among agencies– Improved value purchasing and fraud detection tools– Better communication on practice patterns with
providers and consumers
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The U.S. Health System is in Crisis
(Don Berwick, M.D., 2002 Escape Fire speech)
http://www.cmwf.org/usr_doc/Berwick_escapefire_563.pdf
“We have tens of millions of uninsured Americans, significant medication errors in 7 out of every 100 inpatients, tenfold or more variation in population based rates of important surgical procedures, 30% overuse of advanced antibiotics, excessive waits through our system of care, 50% or more underuse of effective and inexpensive medications for heart attacks and immunizations for the elderly, and declining service ratings from patients and their families.”
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