case studies in modular mmis solutions - … studies in modular mmis solutions ... –...

2012 Medicaid Enterprise Systems Conference

Summary of the Arkansas MMIS procurement experience Jim Joyce, Senior Vice President Medicaid Services

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Case Studies in Modular MMIS Solutions



Clinton Presiden-al Library Li2le Rock Arkansas “Futuristic Architecture”


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

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Topics

A bridge to discovery.


Developing the 2011 Arkansas MMIS procurement strategy

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MITA SSA

New Medicaid Director’s Vision

Requirements Sessions

Draft Procurement Strategy posted for comment

RFI – Modular MMIS & Vendor Meetings

Revised Procurement Strategy posted for comment

CMS Seven Conditions & Standards Published

State & CMS review of IAPD

and RFPs

Release of RFPs

May 2011 Jan 2010

Events that shaped the 2011 procurement -‐


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

New Medicaid Director’s Vision

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


•  Initial Strategy: Multi vendor -‐ 23 RFPs and 23 contracts

Draft Procurement Strategy

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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


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.

RFI – Modular MMIS Vendor Meetings

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Key phrases: Open Interfaces Business Rules

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 ;


‘‘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. “

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


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MITA based Re-usable

Re-usable function for several applications.

Key phrases:


“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.”

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


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Plug and Play

Dispense with new development

Key phrases:


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)

Revised Procurement Strategy

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2011 Procurement Strategy

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Potentially 11 vendors. Target Implementation Timeline: 22 months.


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.

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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.

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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

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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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2012 Medicaid Enterprise Systems Conference 18

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 Professional Services

•  Point of Sale • Call Center •  Drug Rebate • Prior Authorizations •  Prior Authorization • Preferred Drug List

–  Data Warehouse and Support Services System Function Support Services

•  DSS • Operations •  SURS & MARS • Systems Support •  Program Integrity • Enhancements

DDI time period 36 months or less 12 months 12 months


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

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Summary

“Discovering the Architecture for the future”

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

case studies in modular mmis solutions - … studies in modular mmis solutions ... –...

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