Download - CMS MITA Presentation 10/16/2008
HIMSS – National Capitol AreaRosslyn, VA
October 16, 2008
Medicaid IT Architecture and Interoperability
Rick Friedman, Dir. Division of State Systems
CMSO, CMS [email protected]
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