HIMSS – National Capitol AreaRosslyn, VA

October 16, 2008

Medicaid IT Architecture and Interoperability

Rick Friedman, Dir. Division of State Systems

CMSO, CMS richard.friedman@cms.hhs.gov

Medicaid Background Information

Growth in Medicaid Beneficiaries

Millions of Medicaid

Beneficiaries

0

10

20

30

40

50

60

1965 1975 1985 1995 2008

Medicaid Summary

0

20

40

60

80

100Other

Children

Adults

Aged &Disabled

Percentage of Total

55.2 Million

$326.4 Billion

MedicalAssistance

Non-IT Admin

InformationTechnology

IT Spending as a Percent of Total Medicaid Less than 1 Percent – FY 2007

FY 2007 Eligibles and Spending

Claims Processing

Engine

Fraud Detection (SURS)Mgmt +

Admin (MARS)

3rd Party Liability

(TPL)

Provider Subsystem

Reference Subsystem

Six Original MMIS Subsystems

CURRENT PRIOR APPROVAL PROCESS

1. State Submits Plan/APD, RFP and Contract to CMS for IT Funding

2. CMS Approves Project: …90% FFP for MMIS Development …75% FFP for MMIS Operations …50% FFP for all other IT/Admin

3. CMS Certifies MMIS

MEDICAID: People and Money

$623 billion90 million*Medicaid and Medicare

$ 297 billion42 millionMedicare

$326 billion (1 of every 5

health care $s)

55 million(1 out of every 6

Americans)

Medicaid

$1.54 trillion325 millionU.S. Totals

MoneyPeople

*About 7 million duals have been subtracted from the total to avoid double-counting

Source: Kaiser Commission, 2007

CMS’ Perspective

1.Medical information follows the consumer; i.e., they are at the center of their care

2. Consumers chose providers based on clinical performance results

3. Clinicians have complete patient history, computerized ordering and electronic reminders

4. Quality initiatives measure performance and drive quality-based competition

5. From transactions to actions-- machines talk to machines; people focus on services; goal is health outcomes improvement

CMS Places a High Value On Cross-Agency Data Sharing

• Medicaid administrators lacked a comprehensive view of their world -- MMIS was not keeping pace with their rapidly changing world

• CMS decided to re-tool the MMIS into MITA -- the Medicaid IT Architecture– Web-based, patient-centric,

interoperable system based on industry IT standards

– Enterprise-oriented, rather than organization

– Data shared across boundaries– Provides basis for HIT/E -- EHR, eRx,

PHR

Medicaid Information Technology Architecture (MITA)

What Is MITA?

• MITA is a FRAMEWORK

• MITA is a TOOL KIT

• MITA is a ROAD MAP• NOTE: MITA is NOT a

one-size-fits-all approach

Each State builds its own IT solution based on standards, models and processes contained within the MITA Framework that have been developed with the help of all States and the IT industry

Key Principles--MITA• Support State-driven program

requirements as well as Federal• Provide Medicaid managers at all

levels with robust data sets thatsignificantly enhance their ability to focus on outcomes

• Business-driven enterprise architecture• Commonalities and differences

co-exist peacefully• Standards first• Built-in Security and Privacy• Data consistency across the enterprise

MITA’s Goals• Provide State Medicaid agencies with

a powerful analytical tool• Improve health care outcomes• Align with Federal Health

Architecture • Ensure patient-centric views not

constrained by organizational barriers

• Make use of common IT and data standards

MITA’s Objectives

• Foster interoperability between and within State Medicaid organizations

• Provide web-based access and integration while respecting patient privacy and confidentiality concerns

• Support software reusability with commercial off-the-shelf (COTS) software

• Integrate seamlessly clinical and public health data

MITA’s Orientation• Business-driven service oriented architecture

solution (focus on supporting biz not tech)• Firmly grounded in enterprise architecture

principles (in use by many other industries)• Defines a business transformation over a five

year and long-term (10 years and greater) timeframe

• Includes a technical architecture and a transition strategy to enable the business transformation

How Would CMS Handle Funding in a Collaborative Environment

that Focuses on Interoperability?

Three Scenarios and

e-Rx Data Flow

E-Health (e.g., eRx) Schematic

Note: The following discussion is a conceptual analysis of how CMS may be able to support e-Health activities using MMIS funding. While some of this thinking has been approved at various levels, final decisions will

depend upon specific conditions yet to be determined

DW HW/SW

WEB PORTAL

Examples

• eRx

• EHR/EMR

• PHR

NON-MEDICAID AGENCY

DW HW/SW

ACTIONS:

1. Medicaid Agency builds a data warehouse (DW) and web portal (WP) as a part of its MMIS.

2. Non-Medicaid agency builds its own DW and WB.

3. Both parties agree to build an electronic bridge linking both DWs and WPs

CURRENT FFP AVAILABILITY:

1. Medicaid Agency receives 90% FFP to build the DW/WP, and 75% FFP to operate them

2. Non-Medicaid Agency uses own funds to build and operate DW/WP

3. Jointly built electronic bridge is paid for by both parties per Federal CAP Principles. Medicaid receives enhanced 90/75 FFP rates for its share of costs.

MEDICAID AGENCY

Scenario 1: Medicaid Agency and Non-Medicaid Agency Both Build Their Own E-Health

Hardware/Software Facilitators

DW HW/SW

Dat

a

WEB PORTAL

M

M

I

S

WEB PORTAL

Other State Agency

DW HW/SW ACTIONS:

1. Medicaid Agency builds a data warehouse (DW) and web portal (WP) as a part of its MMIS.

2. Non-Medicaid agency/provider buys own equipment to access web as well as trains staff on its use.

CURRENT FFP AVAILABILITY:

1. Medicaid Agency receives 90% FFP to build the DW/WP, and 75% FFP to operate them

2. Non-Medicaid Agency/provider uses their own funds for their access ramps to DW/WP

MEDICAID AGENCY

Scenario 2: Medicaid Agency Builds and Operates E-Health Hardware/Software

Facilitators and Permits Access by Others

Dat

aM

M

I

S

WEB PORTAL

Provider

Other State Agency

DW HW/SW

ACTIONS:

1. Medicaid Agency accesses DW/WP through its MMIS

2. Changes/enhancements may be necessary to enhance use of DW/WP within MMIS.

CURRENT FFP AVAILABILITY:

1. Medicaid Agency receives 90% FFP to enhance, 75% FFP to operate its internal requirements with outside DW/WP

2. Changes to the outside DW/WP specific to Medicaid matched at 50% because it’s not part of the MMIS

3. Provider/Other Users costs not matched with MMIS FFP

MEDICAID AGENCY

Scenario 3: Entity Not Under Medicaid Builds and Controls DW/WP

MMIS

WEB PORTAL

Provider

Data

Data

E-Prescribing Data Flows

Physician’s Office

Electronic Switch

Pharmacy

State Medicaid Agency

MMIS Claims Engine

Rx Claims

1. Eligibility Inquiry and Drug History

2. Rx sent to Pharmacy

$

$

Office Visit Claim

Pharmacy Claim

3. Drug/drug interaction