The Road to Success: Medicaid Transformation

1
The Road to Success Medicaid Transformation
Health Information Technology Grants and MITA
Through the Multi-State Collaborative

• Patricia MacTaggart, MBA, MMA
• George Washington University
• NASMD National Fall Conference
• 11/14/08
• Hyatt Regency Capitol Hill

2
Transforming the Health Care Road While Were
Driving on IT

• People Processes
• Policy

Process
People
Policy
3
Driving Towards Value (Quality/Cost) HIT Always
a Tool
Purchasing for Quality (Determine Priorities)
IT
Strategies
4
Oversight that service was appropriate care at
appropriate time at appropriate price from
appropriate provider for best heath outcome
What provider/service delivery option will
provide the care?
Delivery Model
Receive Service
Service Paid
Where Provided
Financial Oversight
Program Mgmt/ Govt oversight
Quality Oversight

• Employer Premium
• Subsidy
• HSA
• MCO
• Partial MCO
• PCCM
• Provider within PCCM
• Care Mgmt
• Individual level

• PA
• Pre-cert
• Authorization for
• treatment
• Service Provider
• Where provided
• Drug Formulary

• Rate methodology
• RBRVS, DRG, etc.
• Claim Paid
• Person responsible
• Pay for Performance

• Home
• Institution
• Hospital
• NH
• ICF-MR
• Group Home

• Financial Mgmt
• Transaction
• Financial Reporting
• Audits
• Premium Invoice
• TPL

• SPA/Waivers
• Adm. Policies
• Budget Accounting
• Reporting
• Contract Mgmt
• Feedback

• Consumer Information strategies
• Provider information strategies
• FA/Program integrity
• Performance measures
• Information Mgmt
• Performance Mgmt
• Grievance and appeals

Evidenced Based Health Care Services Delivered
Validation of Value
Driving on the Medicaid Track isnt Easy for
State/Providers/Consumers
Who is health care purchased for? Eligibility
What Coverage is state willing to purchase
and what will an individuals benefit be?
Limitations (Individual and Family)
Coverage
Categorical
Functional
Financial (Hierarchical)

• Co-pays
• Cost sharing
• Caps/Limitations
• Individual and Family
• Plan of Care
• Treatment Plan

• SPA Services
• HCBW Services
• Basic Services
• Preventative Services
• LTC Institution
• ICF-MR
• NH
• Psych-Group
• Home
• Home Care
• Alternative 1115 Waiver
• EPSDT
• Administrative

• Programmatic
• Basic
• Temporary

• ADLS
• Diagnostic/Clinical
• Pre-Adm NH
• Screening

• Medicaid
• SCHIP
• PH Funded
• MH/SA Grants
• State only funded programs
• Not Eligible

Feedback
Outreach and Enrollment into Insurance
Coverage/Benefits
Feedback
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More than One Vehicle on the Road E-Health
Activities Implemented Within Medicaid
Source The Commonwealth Fund and National
Governors Association E-Health Survey, conducted
by Health Management Associates, 2007.
6
Medicaid Information Technology ProvidesRoad to
HC Reform Systems/Information Interoperability

• The Medicaid Road has Curved Data needed
  regarding enrollees from MH, Foster Care, WIC,
  Child Support, Food Stamps, Criminal Justice to
• Improve Program Performance
• Reduce Costs Administrative
• Service Delivery Efficiencies
• Improve Program Integrity
• Improve Quality of Care,
• Deliver Oversight
• Cross-Agency
• Outreach
• Education
• Oversight
• Examples Related to Foster Care Child
• Entering new school district
  Immunizations/Physicals
• Out of State Placement Pharmacy/Physical/Parent
  TPL

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Medicaid Transformation Grants One Vehicle to
Drive Health Care Transformation

• Example Texas Electronic Health Passport for
  Children

• 5 State agencies administer an array of programs
  Medicaid, Food Stamps, WIC, Epidemiology, Newborn
  /Children Health Screening, SCHIP Adult and
  Child Protective Services

• Building an enterprise data warehouse to link
  data from all 5 sources

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Medicaid Transformation Grants More than One
Vehicle on the Road DC Transformation Grant
Initial 2 Years
Medicaid MMIS
Separately funded
CMS
MDS OASIS

Completed - Black In process - Grey
Corrections

Clearing House
IMA
Record Locator
TG Patient Data Hub Enable Access Aggregator

CFSA
Clinics

6 Clinics
Record Locator
DYRS
Other Clinics
Metadata Repository
Record Locator
DMH
Hospitals

3 Hospitals
Record Locator

• Analytics Reporting
• Predictive Modeling
• Adm. Decision Support Tool

DCPS

Other Hospitals
DOH
Record Locator

• APRA
• MAA
• SHPA
• EPSDT
• MPCA
• WIC
• IR
• Lead
• Cancer
• HAA
• AIDS
• HEPRA
• Public Labs
• HCRLA

Labs


Private Labs
Master Patient Index
Record Locator
Providers

Other Providers
Safe Passage Portal (Limited Data
Set) OPERATIONAL DATA REPOSITORY
Medicaid Data Never Rolls Off Real time record
locator Analytical repository
- Scope

- Fully Funded

- Not funded
- Vision
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MITA Funding to Drive Health Care
Transformation Road Construction

• Traffic Rules
• Single State Medicaid Agency Direct Control of
  MMIS/MITA Funds
• Advance Planning Document (APD) Submitted and
  Prior Approved by CMS
• HIT Work
• Benefit Medicaid enrollees and providers (Build
  it for Medicaid use it beyond)
• Statewide (MTG could be for lesser regions)
• FFP
• 90-10 Design, Development and Implementation
• Operations
• Cost Allocation Principles apply (Begin with
  Medicaid)

From slides by Rick Friedman
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Shared DW Built Outside Both Medicaid and
Non-Medicaid State Agencies and Jointly
Administered
MEDICAID AGENCY

• Medicaid Agency and another agency agree to
  build and operate a DW together.
• Governance is a shared responsibility among
  participating agencies.
• Both agencies build electronic pathways to the
  DW for sending and receiving data

MMIS
Data
Shared Data Warehouse
Data
(Jointly Governed)
NON-MEDICAID AGENCY
Rick Friedman
11
Shared DW Built Outside Both Medicaid and
Non-Medicaid State Agencies and Jointly
Administered

• All costs are allocated among benefiting programs
  based on CAP (Cost Allocation Principles OMB
  Circular A-87).
• Medicaid Agency receives 50 FFP for its share of
  development and operating costs other agency
  pays its share. Medicaid electronic link eligible
  for 90/75 FFP.

Rick Friedman
12
Shared DW Built Outside Medicaid and Non-Medicaid
State Agencies But Governed by Medicaid
MEDICAID AGENCY

• Medicaid Agency and another agency agree to
  build and operate a DW together.
• Governance is controlled by Medicaid agency.
• Both agencies build electronic pathways to the
  DW for sending and receiving data

MMIS
Data
Shared Data Warehouse
Data
Medicaid-Governed
Virtual MMIS Boundary
NON-MEDICAID AGENCY
Rick Friedman
13
Shared DW Built Outside Medicaid and Non-Medicaid
State Agencies But Governed by Medicaid

• All costs are allocated among benefiting programs
  based on CAP (Cost Allocation Principles OMB
  Circular A-87).
• Medicaid Agency Medicaid Agency receives 90 FFP
  for its share of development and 75 operating
  costs of DW because it is considered part of the
  virtual MMIS other agency pays its share.

Rick Friedman
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Current Traffic Flow State Level HIE - An
Evolving Landscape
E-HI Survey
15
Increased Traffic Flow Top State E-Health
Priorities for Next Two Years
Source The Commonwealth Fund and National
Governors Association E-Health Survey, conducted
by Health Management Associates, 2007.
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Staying on the Road Twists, Turns
OpportunitiesMedicaid Multi-State Collaboration
on Health System Transformation First Annual
Summit

• 21st Century Medicaid Transforming Through
  Health Information Technology
• January 4-7, 2009 Tempe, Arizona
• See NASMD Website and Handouts

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Questions
Questions