2012 Medicaid Enterprise Systems Conference

Case Studies in Modular MMIS Solutions Summary of the Arkansas MMIS procurement experience Jim  Joyce,  Senior  Vice  President  Medicaid  Services  

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Clinton  Presiden-al  Library   Li2le  Rock  Arkansas  

  “Futuristic  Architecture”    

2012 Medicaid Enterprise Systems Conference

Arkansas Medicaid Program Summary              Department  of  Human  Services  (DHS)  administers  the  Medicaid  Program   through  the  Division  of  Medical  Services  (DMS).      Summary:      2011  Medicaid  Program  Costs    $4.5  billion      Medicaid  BeneIiciaries      770,692      Medicaid  Providers      12,300      Claims  (100%  FFS)  per  year    39  million    

 HPES  has  been  the  state’s  Fiscal  Agent  since  1983.    Current  MMIS  includes  legacy  mainframe  MMIS,  pharmacy,  data  warehouse.  

   

     

     

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Topics •  Arkansas  Case  Study     –  Developing  the  Arkansas  Modular  MMIS  Strategy   –  Results  of  the  2011  Procurement  and  Lessons  Learned   –  Plans  for  the  2012  Procurement  

A bridge to discovery. 2012 Medicaid Enterprise Systems Conference

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Developing  the  2011  Arkansas  MMIS  procurement  strategy Events  that  shaped  the  2011  procurement  -­‐     New     Medicaid     Director’s   Vision  

Draft   Procurement   Strategy  posted   for  comment  

CMS  Seven   Conditions  &   Standards   Published  

Revised   Procurement   Strategy  posted   for  comment  

Jan 2010

MITA   SSA  

Release  of   RFPs  

May 2011

Requirements   Sessions  

RFI  –  Modular  MMIS   &  Vendor  Meetings  

2012 Medicaid Enterprise Systems Conference

State  &  CMS   review  of  IAPD   and  RFPs  

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New  Medicaid  Director’s  Vision Vision  (2010-­‐2011):       •  Procure  modular  services  supported  by  modular  system  components   •  Use  of  the  Iowa  professional  services  model  and  the  MITA  framework  to   deIine  modular  components   •  Look  for  vendor  solutions  that  integrate  pre-­‐existing  MMIS  software   components  that  require  little  or  no  development       •  Look  for  vendor  solutions  where  the  development  and  implementation   phase  is  primarily  conIiguration,  data  conversion  and  testing     •  Look  for  vendor  solutions  that  allow    system  components  to  be  traded  when   state  Medicaid  Policy  changes    

“If you need new tires – you don’t go buy a new car.”

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Draft  Procurement  Strategy   •  Initial  Strategy:    Multi  vendor  -­‐  23  RFPs  and  23  contracts   RFPS  -­‐  SYSTEMS   SYSTEMS  INTEGRATOR  (SI) COMPONENT  1:    MEMBER COMPONENT  2:    PROVIDER   COMPONENT  3:    AUTHORIZE  SERVICES COMPONENT  4:    CLAIMS  AND  OTHER  PAYMENTS COMPONENT  5:    PHARMACY  POS  /  PBM COMPONENT  6:    PROGRAM  INTEGRITY COMPONENT  7:    TPL  /  COB COMPONENT  8:    CASE  MANAGEMENT COMPONENT  9:    WEB  PORTAL COMPONENT  10:    DATA  WAREHOUSE  /  DECISION  SUPPORT   COMPONENT  11:    HEALTH  INFORMATION  EXCHANGE  (HIE) COMPONENT  12:    ACCOUNTING  SERVICES

RFPS  –  BUSINESS  OFFICES   BUSINESS  OFFICE  1:    MEMBER   MANAGEMENT BUSINESS  OFFICE  2:    PROVIDER   MANAGEMENT BUSINESS  OFFICE  3:    RATES  AND  COSTS BUSINESS  OFFICE  4:    CLAIMS BUSINESS  OFFICE  5:    FINANCIAL   MANAGEMENT BUSINESS  OFFICE  6:    PROGRAM  INTEGRITY BUSINESS  OFFICE  7:  REVENUE  COLLECTION   AND  TPL   BUSINESS  OFFICE  8:  MEDICAL   MANAGEMENT BUSINESS  OFFICE  9:  PHARMACY BUSINESS  OFFICE  10:  SYSTEM  SUPPORT  

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RFI  –  Modular  MMIS  Vendor  Meetings Request  for  Information:    Vendor  Questions  and  Answers   •  Do  you  have  the  interest  and  ability  to  support  the  modular  professional   services  approach?     –  Positive  response  from  national  and  local  vendors.  

•  Do  you  have  operational  system  components  that  match  the  proposed   Modular  MMIS  architecture?     –  Positive  response  from  multiple  vendors.       –  Non  traditional  examples:    Provider,  Member,  Claims  Processing.   –  Not  all  system  components  identiKied.    

•  Do  you  have  the  interest  and  ability  to  integrate    and  support  a  modular   system  to  meet  future  Medicaid  compliance  requirements?   –  Positive  response  from  multiple  vendors.       –  Several  system  integrators  with  partnerships  with  MMIS  component  vendors.   –  Several  established  MMIS  vendors  with  modernized  MITA  based  architectures.   2012 Medicaid Enterprise Systems Conference

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CMS  Seven  Conditions  &  Standards  Published      Modularity  Standard          “This  condition  requires  the  use  of  a  modular,  Klexible  approach       to  systems  development  including  the  use  of  open  interfaces  and   exposed  application  programming  interfaces  (API),;  the  separation   of  business  rules  from  core  programming;  and  the  availability  of   business  rules  in  both  human  and  machine  readable  formats.    The   commitment  to  formal  systems  development  methodology  and   open,  reusable  systems    architecture  is  extremely  important  in   order  to  ensure  that  states  can  more  easily  change  and  maintain   systems,  as  well  as  integrate  and  interoperate  with  a  clinical  and   administrative  ecosystem  designed  to  deliver  person-­‐centered   services  beneIits  and  services.”     Enhanced  Funding  Requirements:     Seven  Conditions  and  Standards,  April  2011    

Key phrases: Open Interfaces Business Rules

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CMS  Seven  Conditions  &  Standards  Published ‘‘Modular’’ means reducing the complexity of a larger problem by breaking it down into small well defined pieces. For example, MITA business architecture reduced the complexity of the Medicaid program into eight high-level business areas. Each business area is further broken down/ decomposed into smaller and manageable business processes. These business processes can be described as ‘modules’. In the MITA initiative, we have urged States to focus on designing sets of overarching and reusable functions that traditionally might have been included within one particular application and that would have been specific to that particular application, but that now could be used, in a consistent manner, by multiple applications used by the State. “

Key phrases:

MITA based Re-usable

Re-usable function for several applications.

Federal Register / Vol. 76, No. 75 / Tuesday, April 19, 2011

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CMS  Seven  Conditions  &  Standards  Published “Modular technology solutions: As States, or groups of States, will begin to develop ‘‘modular’’ technology solutions, these solutions will be used by others through a ‘‘plug and play’’ approach, in which pieces of a new MMIS will not need to be reinvented from scratch every time, but rather, could be incorporated into the MMIS framework. “ “We expect that States will dispense with the need to engage in significant requirements analyses and the need to pay for new modules to be built when there are successful models around the country that they can draw down from a ‘‘technology bank’’ maintained by the Federal or State governments.”

Key phrases: Plug and Play

Dispense with new development

Federal Register / Vol. 76, No. 75 / April 2011 2012 Medicaid Enterprise Systems Conference

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Revised  Procurement  Strategy   Many  ways  to  de?ine  a  Modular  MMIS     •  Professional  Services  Driven  deIinition:    DeIining  Medicaid   service  units  then  deIining  the  associated  system   components.     –  Example:    Provider  Management  services  and  Provider    Enrollment       and  Provider  Portal  components  

•  Software  Product  Driven  deIinition:    Integrating  and   conIiguring  available  COTS  and  application  software.       –  Example:    Business  rules  engine  integrated  with  a  claims  engine  

•  MITA  Service  deIinition:      Building  modules  to  solve  the   smallest  atomic  business  process.   –  Example:    Inquire  Medicaid  Eligibility  (receives  a  HIPAA  270  and   returns  a  271    transaction)        

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2011  Procurement  Strategy  

Potentially  11  vendors.   Target  Implementation  Timeline:  22  months.   2012 Medicaid Enterprise Systems Conference

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Results  of  the  Procurement •  RFP  #1  Core  System  -­‐  Two  bids  received:    Accenture  and  CGI  

 -­‐    Proposal  evaluation  not  completed    

•  RFP  #2  Product  Systems        -­‐  No  bids  received  for  Data  Warehouse                -­‐    No  bids  received  for  Care  Management                  -­‐    One  bid  received  for  Program  Integrity    

•  RFP  #3  Professional  Services  (7  business  ofIices  )   –  Canceled  before    bids  received   •  Entire  procurement  cancelled  because  of  incomplete  industry  response  to   the  Product  Systems  RFP  and  the  high  level  of  risk  associated  with   completing  DDI  within  the  22  month  timeline.   2012 Medicaid Enterprise Systems Conference

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Lessons Learned – Vendors Feedback  received  from  MMIS  Vendors    during  debrief:   –  Vendor  1:    Prefer  two  RFPs  (one  Core  System,  one  Services);   Retain    modular  approach;    increase  payment  frequency;     separate  Rx  systems  to  save  the  state  costs.   –  Vendor  2:    Retain  modularization;    increase  payment   frequency;  less  restrictive  key  personnel  requirements;     promote  a  partnership  of  software  components.   –  Vendor  3:      Increase  implementation  timeline;    require   previously  certiIied;    increase  payment  frequency;    combine   systems  and  services.   –  Vendor  4:    Increase  timeline;    increase  payment  frequency;   combine  systems  and  services.   –  Vendor  5:  Prefer  two  RFPs  (one  Core  System,  one  Services);   Retain    modular  approach;  Increase  timeline;  no  performance   bond;  less  restrictive  key  personnel  requirements.   –  Vendor  6:  Prefer  a  procurement  structure  that  allows  small   local  healthcare  services  company  to  provide  professional   services.   2012 Medicaid Enterprise Systems Conference

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Lessons Learned - State What  Arkansas  learned:   Industry  is  not  ready  to  support  a  many  vendor  procurement     Industry  is  ready  to  provide  a  modular,  MITA  based  MMIS     Some  MMIS  modules  have  not  been  developed  to  be  re-­‐usable   More  development  and  implementation  time  is  needed  for  the  vendor   and  the  state   –  State  communications  of  the  evolving  Procurement  Strategy  with   industry  was  successful  over  the  Department  web  site     –  –  –  – 

2012 Medicaid Enterprise Systems Conference

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Procurement Strategy – 2012

Factors  Affecting  2012  Procurement   •  New  Medicaid  Director  (December  2011)   •  Plans  to  expand  the  Arkansas  Medicaid  population     •  New  Medicaid  Payment  Reform  Initiative  (2012-­‐13)   –  Moving  from  fee  for  service  to  episodes  of  care  

•  CMS’  Seven  Conditions  and  Standards  

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Procurement Strategy – 2012 [as posted on the Arkansas web site]

         Three  RFPs  and  Three  Contracts:  

–  Core  MMIS  and  Professional  Services  [Modular]              System  Function  /  Professional  Service   •  Member  Management   •  Provider  Management   •  Operations  Management   •  Contracts  Management   •  Financial  Management   •  Business  Relationship  Management  

–  Pharmacy  Systems  and  Professional  Services          System  Function •  •  • 

Point  of  Sale Drug  Rebate Prior  Authorization

             

         Professional  Services            •    Call  Center            •    Prior  Authorizations            •    Preferred  Drug  List  

–  Data  Warehouse  and  Support  Services            System  Function •  DSS   •  SURS  &  MARS •  Program  Integrity

       

           Support  Services              •    Operations              •    Systems  Support              •    Enhancements  

2012 Medicaid Enterprise Systems Conference

DDI  time  period       36  months  or  less                 12  months                     12  months                          

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Procurement Strategy – 2012 [as posted on the Arkansas web site] Procurement  Improvements  -­‐   –  Longer  Implementation  Timeline  –  Lower  Risk   •  Core  System  –  36  months  or  less   •  Data  Warehouse  and  Pharmacy  implemented  early     –  Limited  Vendor  Management  –  Lower  Risk   •  Potential  of  3  (or  less)  vendors   –  Greater  Services  and  System  Alignment    –  Lower  Risk   •  Core  System  and  related  services  together   •  Pharmacy  System  and  related  services  together     –  Easier  State  Participation  /  Involvement  –  Lower  Risk   •  Core  and  Pharmacy  /  Data  Warehouse  on  separate  tracks   •  Longer  Core  timelines  

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Summary •  Arkansas  Case  Study     –  Developing  the  Arkansas  Modular  MMIS  procurement  strategy   –  Results  of  the  2011  Procurement  and  Lessons  Learned   –  Plans  for  the  2012  Procurement  

“Discovering  the   Architecture  for  the  future”  

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Cognosante.com Jim  Joyce,  Senior  Vice  President  –  Medicaid  Services     [email protected] OfIice:    408-­‐480-­‐5945