OpenSourceProviderScreeningModule

MartinRice- CMSClyneiceChaney- MITRE

OSEHRASummitJune14,2017

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Agenda

• Introduction to Medicaid • The Medicaid IT Enterprise• Medicaid Management Information System (MMIS)• Opportunity for new entrants in Medicaid IT• Provider Screening Module (PSM) Project

• Background• PSM Approach• Current status• Projected long term outcomes• Questions

• Other CMCM Open Source Project - Cedar

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IntroductiontoMedicaid

• Established in 1965 as part of President Johnson’s “Great Society”

• Medicaid is an entitlement program initially established to provide medical assistance to individuals and families receiving cash assistance, or “welfare.”

• Federally and State funded, and State administered.• Functions like most commercial health insurance but

with broader support for home/community based care and other critical areas.

• Created a jobs engine in state and local economies.• A growing percentage of Medicaid beneficiaries receive

their care through managed care arrangements.• Patient Protection and Affordable Care Act (PPACA)

provides Medicaid expansion opportunity (coverage up to 138% of poverty).

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IntroductiontoMedicaid(Cont.)

TheMedicaidITEnterprise

§ Medicaid Management Information System (MMIS)Enrolls providers, processes claims, detects fraud and waste, generates reports

§ Eligibility and Enrollment systems (E&E)Determines eligibility and enrolls beneficiaries into Medicaid

§ State Level Repositories (SLRs) Collects HITECH Meaningful Use data from providers

§ Electronic quality measures systems Collect, clean, analyze and store electronic clinical quality information

The Medicaid Enterprise is a system of systems, composed of

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WhatisanMMIS?

What?A Medicaid Management Information System (MMIS) is an integrated group of procedures and computer processing operations – it is the primary system for administering Medicaid claims in each state. Objectives of the MMIS include Title XIX program control and administrative costs; service to recipients, providers and inquiries; operations of claims control and computer capabilities; and management reporting for planning and control.*

*http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MMIS/index.html?redirect=/MMIS

Contractual services may be used in the design, development, installation, or enhancement of a mechanized claims processing and information retrieval system.

Most MMIS are developed and operated under contract with a “fiscal agent” who is a private contractor to the state; some are state-run

Enhanced Federal Financial Participation (FFP) up to 90 percent of costs to design/build and 75 percent of costs to operate the MMIS

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Examples of MMIS Functions (75 percent FFP for operations for certified MMIS)

MMISFunctions

Examples of Supporting/Related Medicaid Systems (50 percent FFP for operations unless integral to certified MMIS)

Decision Support

Management Reporting

Cost Avoidance and Third

Party Liability Recovery

Beneficiary and Provider Enrollment

Monitor Fraud/Abuse

Process Health Care

Provider Claims

Clinical Decision Support Systems

Administrative Support Systems

Managed Care and

Case Management

Systems

Waiver Systems (HCBS,

TBI/SCI, MH*)

*Home & Community Based Services, Traumatic Brain Injury/Spinal Cord Injury, Mental Health 7

NotionalModularMedicaidEnterprise

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Goal/Mission Statement• Develop a sustainable precertification process to assist State Medicaid

Agencies in their procurement of MMIS solutions by providing, for their consideration, CMS evaluated vendor solutions that are modular, reusable and have been demonstrated to meet Medicaid business functions

Objectives• Spur innovation and competition in the Medicaid IT marketplace• Reduce risk for states and CMS by encouraging state use of modular,

reusable CMS pre-certified solutions• Facilitate modularity & interoperability among Medicaid systems through

open APIs and common, agreed-upon standards • Reduce effort and burden on CMS, states, and vendors for MMIS

certification

Module Precertification Program

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OpportunitiesforNewEntrantsinMedicaidIT

• New business models• Shared services (intra and inter state) • Administrative Service Organization (ASO)

• Adaptation of existing business solutions from comparable sectors• Banking, commercial healthcare, or large provider systems

• Technologies to improve integration across multiple health and human services programs

• Integration of Medicaid IT systems with federal and local Human Services IT systems

• Supplemental Nutrition and Assistance Program (SNAP) and Temporary Assistance to Needy Families (TANF)

• State-specific program IT systems.

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State Medicaid IT Opportunities

CMS has centralized links to current procurements on Medicaid.gov

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BackgroundofthePSMProject

• 2013:TheProviderScreeningChallengeproducedanopensourceProviderScreeningModule(PSM)withdeficiencies

• 2016:Agapanalysisofthemodulewasperformed• February2017:AnapproachwaspresentedtoCMSwith

recommendationstobridgethesegaps• April2017:Opensourcedevelopmentworkbegantoclosethe

identifiedgaps 12

2013 2016 2017

Ø Separate development into 4 phases

Ø Have a single product owner through MVP

Ø Involve states early and often

Ø Manage requirements centrally and publicly

Ø Follow an iterative development (Agile-like) process

Ø Use OS IV&V to oversee open source development

Ø Automate testing, focus on APIs, provide sample data

Ø Simplify codecontributionand automate deployment

OS IV&V

PSMApproach

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•Core development team now working in an open repository

•Coordinated state partnerships

•Acquired sample screening data from partner federal agencies

Central Authority

•Working with state teams during development

•Provide development team with state-specific provider types and external data sources

•Test system on a two week cycle and provide UI/workflow feedback

States’ Contribution

• Issue tracker integrates feedback from testers and SMEs

• Migrated away from proprietary dependencies

• Improved deployment documentation and automation

• Catalogued and documented APIs

• Tested access to federal data source with sample data

Technical Achievements

ProjectStatus

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Repository:https://github.com/OpenTechStrategies/psm

Projected Long-termOutcomes

lStates gain control and flexibility over screening

process

lImproved state process for exchanging data with federal databases, other external data sources,

and each other

lPSM meets State Medicaid Director Letter (SMDL) on Modularity

guidelines

lPSM is a model for procuring, developing, and maintaining shared

modules

§Vendors bid for support work competitively :

§New vendors enter this market§Recurring IT costs of provider

screening are reduced

§Available as a pre-certified module for PSM

vendor submission package

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OtherCMCSOpen-SourceProject:Cedar

Cedar is an open-source tool for testing the strength of eCQM collection systems that receive Quality Reporting Document Architecture (QRDA)

files

To learn more, and for a link to github site, go to www.projectcedar.org16

HowisCedarintendedtobeused?

• As a Complement to Cypress, popHealth, Bonnie, and Tacoma

• to improve the overall quality reporting ecosystem

• By measure collectors• to ensure that eCQM collection systems are correctly identifying

common errors, either via one-time testing or regression testing to structure conversations with EHR vendors re: QRDA file rejections

• By the open source community• to update the tool to address newly identified errors and

updated eCQM specifications, etc., and integrate the tool with existing systems 17

Questions?

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