Next Generation: Public Health and Medicaid

Matching Old Ideologies with New Technologies for Immunization Delivery and Monitoring

Jason C. Goldwater, MA, MPA

Centers for Medicare & Medicaid Services

March 24, 2004

Medicaid of the Past

• In 1972, the HCFA (now CMS) established the Medicaid Management Information System, which was a static, atomic-level system that’s primary functions were administrative in nature (claims adjudication)

Medicaid Today

• Medicaid is now more dynamic with the ability to utilize evolving technologies and newer, more reliable data sets.

How to Capture the Evolution

• There is a need for newer, emerging technologies to exchange and share data; as well as to store, tabulate and access historical and relevant data for Medicaid to make better informed and more timely decisions.

• This is predicated on the need and desire of Medicaid to share data, resources, ideas and energies with departments and agencies that fall outside their traditional domain.

It’s Really Just A Game

• To accomplish this feat is no small task. In fact it is somewhat like……

The Dating Game Indeed

You all remember how this works…

Three Eligible Bachelors

One Lucky Contestant

So Let’s Play!!!

• Matching up Medicaid with various partners is akin to choosing someone based on what they might offer, not what they might deliver.

Bachelor #1 “Old School”

A Single State Agency

Bachelor #2 “Version 2.0”

A Single State Department

Bachelor #3 “New! Improved! Better Than Ever!”The Entire State Health Enterprise

Bachelor #1

“What Are Some of the Charming Things You’ll Do On Our First Date??”

Bachelor # 1

“I am consistent and reliable. I will still give you the ability to enhance your data set, possibly adding new variables and characteristics that may be vital to quality of care, or additional administrative activities. Additionally, we can both continue to enhance the overall Medicaid enterprise. Oh, and I’ll bring over some flowers and chocolate.”

Bachelor #2

“Describe Your Idea Of A Perfect Date!”

Bachelor #2

“We would be able to share data across program lines, thereby offering a comprehensive assessment of a patient from multiple sources, and analyzing trends in care, utilization and quality in ways that have not been done before! It wouldn’t be just one agency, but an entire department with a vast supply of data. And I never kiss on the first

date. Ever.”

Bachelor #3

“How Would You Know That I’m In Your Future?”

Bachelor #3

“How would I know? I AM your future. Health care has evolved to include more programs and data than ever before. Our responsibilities have grown beyond our patients and stakeholders, but include social welfare organizations, provider groups and the like. I am the only one who can take you where you want and need to be. Besides, I am filthy rich.”

They All Sound Good, But……

• Each one has lots of potential, but also a substantial amount of risk;

• It is difficult to assess which would be a good fit when the results of such a union have either not been seen, or been seen on a limited basis;

• Oftentimes, the barriers discouraging a union are more than just physical, they are also cultural and political; and

• Sometimes joining with a new partner requires a “leap of faith.”

So, Who Would She Choose??

There really is just one choice. Bachelor #3 is the only one that truly speaks to the future of Medicaid. As difficult as this may be, the risk will hopefully be worth the reward. (Money doesn’t hurt either!)

So, Tell Them What They’ve Won!

• As Medicaid evolves into a patient-centric enterprise, the need for data, particularly from other sources, become essential and paramount for success;

• The architecture of a new system must encompass newer and broader technologies, metrics for evaluation and data standardization; and

• It must encompass other systems, in which the functionality and data supports and enhances the Medicaid program, like an immunization registry.

• SOUND EASY????? (A trip to Helsinki might be better?)

It Isn’t Easy

• Merging together a stand-alone system with various data elements with different formats is complicated;

• Moving systems into more dynamic technologies poses even more of a challenge;

• Often it involves factors that have little to do with either the data or the technology itself;

• In fact, most often it involves stakeholders getting together in a partnership; which is….

• …sort of like getting married.

Which Brings Us To…..

Remember This???

Married couples test their knowledge of each other to win wonderful

prizes, like a brand new Frigidaire.

Bob Eubanks was the host

So How About Our Happy Couple?

Question #1

“What Is the Most Important Thing You Both Have Learned About Each

Other?”

Her Answer:

“We communicate our feelings so well with each other”

His Answer:

“We both aren’t big talkers.”

What We Have Here…….

• A failure to properly communicate is often the largest barrier to successfully building shared systems and exchanging data;

• It is often the result of understanding different goals and having different ideas on how to reach them;

• Often times, Medicaid and other departments/agencies do not see system development or data linkage as a joint user/builder project; and

• There is often a conflict between the responsibility for the data and the responsibility for individual projects. (where does ownership begin and end?)

Round Two

Question #2

“Describe something romantic you do for your spouse each week.”

His Answer:

“Long walks, deep conversations, flowers by the bedside, breakfast in bed. Pretty much the usual.”

Her Answer:

“Nothing really. Who has the time?”

If Only There Were 25 Hours

• The issue of time can provide a major impediment to Medicaid evolution;

• Even with a willingness, there is usually never enough time to deal with the plethora of issues that accompany such projects; and

• The political realities of Medicaid will, at times, damper the enthusiasm given to potential ideas;

The Bonus Round

Question #3

“Who paid for the first date?”

Her Answer:

“I did”

His Answer:

“I let her.”

Money, Money, Money

• Someone does have to pay for all of this;

• Medicaid usually picks up the bill because of the potential of enhanced funding;

• However, at what point do these activities fall outside the context of Medicaid?

• Even with federal funding, the State still must pick up a portion, and it is difficult to ascertain where that will come from.

But, Imagine………….

MMIS/Immunization Registry

Schools

Medicaid Providers

Community Clinics

Other Federal Agencies

New Era of Medicaid Data

• Data files from multiple sources being exchanged with the MMIS provides opportunities that have not existed before;

• Potential exists for greater analysis and understanding of our beneficiaries;

• Yet, the vast amounts of data need to be stored to be access/cross-referenced with current data for multiple reasons.

Is It Live, Or Is It Memorex??

• Data sharing, in Medicaid, is still a new concept as much as a reality;

• It is also a set of hardware and software components that can be used to better analyze the massive amounts of data that Medicaid does and should collect; and

• It is not just data; it is also the architecture and tools to collect, query, analyze and present information.

A Potential Model

Medicaid Program Data

Provider Data

External Data

Extraction, Transformation, and Propagation

Data

Warehouse

Immunization Registry

Web Portal Interface

System Administration

Data Mining

Web Server

GPRA Measures

Data Mining Tools

How To Be Successful (We Think)

• Medicaid and public health data needs with respect to immunizations must be similar;

• Data exchanges should be done with common interfaces that are flexible, adaptable and scalable;

• Financing should be leveraged as much as possible with cost efficiencies built into the APD;

• Communication between all of the stakeholders in each State’s immunization program must be consistent and ongoing; and

• A willingness to change 35 years of culture and get this done!

But, It’s Not Over

• So, you found a potential suitor, went out on a date or two, took the plunge to get married, and still discovered you had things to learn about each other.

• After potential working those little matters out, you began to work on a long-lasting and fruitful relationship.

• DOES IT END THERE (Is marriage ever easy!)

This leads us to………………………

Outwit, Outplay, Outlast

The Game Has Just Begun

• It is never as easy at it looks;• Complications can arise at every corner;• So, who is going to get kicked off the island?

Medicaid Public Health Others

Immunity Challenge #1

“Have everyone make a raft out of tree bark and coconut shells, and sail 15 miles from one end of the island to the other. One catch, you all have to give directions to each other in a different language.”

All of these ideas are wonderful, but remember, it is NOT that easy. Most Medicaid and public health systems that contribute to activities such as immunizations do not have a common interface, or common messaging/vocabulary standards among them, and do not understand potential barriers and benefits to projects such as these, so the exchanging of data and the utilization of joint data sets never happens.

The Council Has Spoken

• While public health and Medicaid have some interfaces in common from past projects, many other agencies still communicate in old legacy formats with an inability or an unwillingness to change.

Bye-Bye

Immunity Challenge #2

“You are to take two twigs from the spot nearest to you, lie on your back, and catch as many fruit flies as possible while the sun shines directly in your eyes. Oh, and we are going to change the rules every three minutes.”

Despite the best laid plans, the ever-changing nature of Medicaid, usually through regulation or legislative mandate, causes the agency to reprioritize and focus resources on the matter at hand, rather than any long-term project.

The Council Has Spoken

• It seems as if Medicaid and Public Health almost belong together, but even while building common systems such as registries and sharing data seem like great ideas with practical utility, the need for Medicaid to refocus (i.e. HIPAA) happens more times than not.

Bye-Bye

And the Winner Is…….

• And we are back where we started, with Medicaid as the agency that can act as the catalyst for change, but has a difficult time initiating or maintaining that change for a long-period of time.

Yee-Haw!!!

So, Where Do We Go From Here

• Rome was not built in a day, and incorporating new systems won’t happen overnight either;

• A paradigm shift happens due to small successes;

• Understanding both the constraints and the opportunities are the keys to overcoming barriers;

• The inherent value to the Medicaid program is to make better decisions about the clinical and financial effectiveness of the care Medicaid pays for.

In Conclusion

• Medicaid is evolving as is the universe of health care;• Problems and barriers still exist and will probably always

be there, but there is also tremendous opportunity;• Education as to the benefits of immunization registries,

common interface standards, and the exchanging of data from multiple sources is essential;

• Understand the problems as well as the solutions;• Leverage the experience from both sides;• Don’t be afraid to ask for help. Many of us are all here

for the same reason.

So remember……

Every child deserves to grow up healthy….

And happy…..

With a bright future….

So, we all must work together…………..

To ensure that happens now and forever!

Questions or Comments

Jason C. Goldwater,MA, MPACenters for Medicare & Medicaid Services7500 Security BoulevardBaltimore, MD 21244(410) 786-0476

Thanks! We’ll see you next week!