MITA: Medicaid
Information Technology
Architecture
What MITA Is, Why It’s Important and
How It Relates to e-Health
Rick Friedman
Director, Division of State Systems
Centers for Medicare & Medicaid Services
Richard.Friedman@cms.hhs.gov
MEDICAID: People and Money
People
Money
U.S. Totals
294 million
Medicaid
52 million
$1.54 trillion
$305 billion
(1 out of every 6
Americans)
(1
out of every 5 health
care dollars)
Medicare
42 million
$ 297 billion
Medicaid and
Medicare
87 million*
$602 billion
*About 7 million duals have been subtracted from the total to avoid double-counting
Source: Kaiser Commission, 2005
Comparison of Medicaid
Spending
Most of Medicaid
program dollars
pay for benefits …
Spending on IT
constitutes less
than 1% of total
Medicaid spending
Program Benefit $’s
Admin $’s
IT $’s
National Growth in Medicaid Beneficiaries
1965 to 2005
Millions of
Medicaid
Beneficiaries
60
50
40
30
20
10
0
1965
1975
1985
1995
2005
Growth in the Medicaid
Program’s Complexity
•
•
•
•
Waivers
HIPAA—Privacy, NPI, etc.
Focus on Quality
Rising Concerns re Privacy and
Security
• Duals
• Medicare Part D
Medicaid Management
Information System (MMIS)
• Social Security Amendments of 1972 (PL 92-603)
• Claims processing and information retrieval
system
• Every state builds/buys/operates its own MMIS
within broad general federal outline
• 35 states contract with vendors
• Major contractors are ACS, EDS, Unisys, First
Health
• Eligibility Determination Systems are not MMIS
• Federal match = 90% to create; 75% operate
Challenges to the MMIS
• Historical focus -- pay Medicaid claims
accurately and timely
• Scope -- data limited to claim and what
Medicaid paid for; i.e., no clinical information,
public health, etc.
• Program shifts not easily reflected in MMIS
–
–
–
–
–
Paying Claims
Fee-for-Service
Institutional Care
Fixed Programs
Eligibility boundaries
Fixed/Well delineated
Managing Health Care
Managed Care
Non-institutional Care
Waivered Services
Eligibility boundaries
Changing/Flexible
What Does a Typical
State’s Medicaid
Information System
Look Like Today?
What Does the MMIS Look
Like in Many States Today?
Enter MITA...
MITA Is ...
...an IT initiative developed by CMS to transform the
MMIS into an enterprise-wide backbone architecture
capable of addressing the needs of Medicaid clients,
the providers of care and program managers.
It consists of 3 major components:
1. IT Architecture Framework
– Consolidation of principles, business and technical models and
guidelines that form a template for states to use to develop their
own enterprise architectures
2. Planning Guidelines
– Assistance to States to define their own strategic MITA goals and
objectives consistent with CMSO expectations and requirements
3. Processes
– For States to use in adopting the MITA framework through shared
leadership, partnering and reuse of solutions
MITA Operational Goals
• Provide a blueprint for inter- operability
across Medicaid enterprise and
potentially new data exchange partners
• Encourage free -- but protected -- data
exchanges among all health and human
services partners
• Provide access to multiple data bases
without rebuilding the data sources
• Meet state/CMS goals of client-centric,
outcome-oriented BUT without dictating
structural changes to the individual states
MITA Design Requirements
• Utilization of industry standards
• Reliance on off-the-shelf software
• Internet-based secure transmission
of data
• A common “look and feel” of
systems
• Common reporting requirements
• No requirement to use specific
hardware or software
MITA Is a Business-Driven
Architecture
l Vision, mission,
objectives come first
Medicaid Mission
& Objectives
l Architecture
responds to business
needs
l MITA Business,
Information, Technical
models are enablers
to meet the business
needs
Medicaid Business
Needs
MITA Enablers
Business
Architect.
Information
Architect.
Technical
Architect.
Purpose of the Business
Architecture
• Capture a common vision of the future for all State
Medicaid agencies
• Establish a generic business framework for all
States while recognizing their differences
• Describe how each State Medicaid agency can
mature over a +10 year period with the help of
stakeholders, leadership, and enabling legislation
and technology
• Provide a baseline against which States can assess
their current state of business capabilities and
measure progress toward improved capabilities
What Are the Components
of MITA’s Business
Architecture?
•
•
•
•
•
Concept of Operations
MITA Maturity Model
Business Process Model
Business Capability Matrix
State Self-Assessment
MITA State Self-Assessment
• CMS provided detailed information on how
to do a State Self-Assessment in August
via our MITA website
• We consider it a key document to be
submitted to our Regional Offices for any
APD seeking FFP for changes to, or
replacement of, your MMIS.
PURPOSE OF THE SS-A
• Provides a structured method for documenting
and analyzing a State’s current Medicaid
business enterprise
• Aligns States’ Medicaid business areas to
MITA’s business areas & sub-areas
• Enables the State to use defined levels of
business maturity to help shape the future vision
of their Medicaid Enterprise
• Provides the foundation for a gap analysis that
will support the State’s transition planning
• Focuses the APD to reflect the States current
project funding request and what is achievable
State Self Assessment
5
4
Program
Integrity
Relationship
Mgmt.
3
Care
Mgmt.
2
Member
Mgmt.
Provider
Mgmt.
Contractor
Mgmt.
Operations
Mgmt.
Program
Mgmt.
Business Process
1
Business
Area
Enroll Member
Enroll Provider
Manage Contract
Information
Edit/Claim
Encounter
Maintain Benefit /
Reference Info
Establish Case
Identify Case
Manage Business
Relationship
“As Is”
“To Be”
HIT
Implications of MITA
for HIT, HIE,
Medicaid
Transformation
Grants and CrossAgency
Collaborative
Initiatives
If you want to travel fast,
travel alone.
If you want to travel far,
travel together.
Wangari Maathai
Nobel Peace Prize Laureate 2004
East African Proverb
MITA Is Expanding Both Vertically
within Medicaid, and Horizontally to
Connect with Other Trading Partners
Behavioral
Health
Child
Welfare
MITA
WIC
Numerous Benefits for Medicaid Programs to
Work with Trading Partners via
Interoperability
1. We need data from other agencies regarding
many of the same clients to meet our goals
2. If we had a more comprehensive picture,
we could:
-- Improve program performance,
-- Reduce costs AND
-- Contribute to a better life for our clients
3. Better data could improve our need for
heightened program integrity
4. Interoperability could enhance our mutual outreach
and training opportunities with caseworkers, human
service providers, and clients
Medicaid, Child Welfare,
Behavioral Health and
Others All Face Common
Challenges
• Incompatible systems, data, cultures
• Change requires time, money, leadership and
institutional knowledge…all of which are
in very short supply
• Paradigm shift will require an accountability horizon
longer than the next quarter, this fiscal year, or,
even, the life span of the current administration
• Legal safeguards re data exchanges
Interoperability Between
Medicaid and Child Welfare
Systems
3 Examples
Example 1: School Enrollment
• Situation: Foster care child re-enrolled in a new school
and participating in school sports
– Helps them start off in new school and stay engaged
• Interoperability Can Help By:
– Providing access to Medicaid claims history
– Identify who was the previous primary care provider
– Indicate whether the child’s immunizations are up-todate
– Say whether the child has previously had a school
physical…when, where and with what results
• Benefits are “social” to the child, “administrative” to the
schools, and financial to the system
Bottom line: Foster care is tough enough without having to be excluded
from school and school activities!
Example 2: Out of-State Placement in
Therapeutic Foster Care or Special
Behavioral Health Programs/Facilities
• Such children typically get complete physicals all over
again in a new State because that State doesn’t have
the data
• Easy access to claims data would eliminate the need for
getting a completely new baseline, thereby saving time
and money
• Information about pharmaceutical use (for reactions and
history) is critical for medication management --without it
you don’t know if they are on a brand name because the
generic didn’t work or a generic wasn’t tried.
Example 3: Parental Insurance
• When child is in foster care, state is supposed to
verify and use parental medical support and
medical insurance
• Reality is that it’s just too difficult to find it,
secure it, and use it
• Most states default to just billing Medicaid
• …and, if it’s an out-of-state placement, it doesn’t
even bump up again in the state’s Third Party
Liability file as it isn’t in the “local” state Medicaid
data base
This is another area for improvement that lends itself readily to the
benefits of interoperability!
Collaboration between MMIS
and Medicaid Transformation
Grants
Texas Health
Passport
Texas Electronic Health Passport for
Children
• Medicaid Transformation Grant ($ 4M for 2 yr. period) + 3
additional yrs with MMITA funding support
• 5 State agencies administer an array of programs:
– Medicaid
-- Food Stamps
– Women, Infants and Children
-- Epidemiology
– Newborn /Children Health Screening -- SCHIP
– Adult and Child Protective Services
• Data currently resides in different organizational silos that
are neither linked nor integrated
• Texas is building an enterprise data warehouse consistent
with MITA