Maximizing State Returns on Next-Generation Medicaid Enterprise Systems


This perspective introduces the concept of a centralized entity dedicated to an overarching, integrated strategy for the systems and entities composing the statewide Medicaid enterprise – the Medicaid Enterprise Strategic Integration Management Office (SIMO). We discuss its benefits and describe how it might function in the context of an evolving Medicaid environment. 

Strategic Integration in Today’s Medicaid Environment

In 2015, the health and human services category will amount to 39.8 percent of all state spending − dwarfing every other category − and it continues to grow as a share of public spending. Medicaid is the driver for much of this growth, and states can realize large savings by improving its efficiency and effectiveness.

The next generation of Medicaid enterprise technology is arriving, and it promises to help state governments control Medicaid spending while improving health care outcomes for beneficiaries. New approaches to software components and integration are enabling the unprecedented aggregation and analysis of data related to health care payments and outcomes. Data analytics, eligibility determinations, and fraud detection are just a few of the areas where states are breaking new ground.

Improved program integrity and better health outcomes are not the only benefits of adopting a comprehensive and flexible architecture for the Medicaid enterprise. Tomorrow’s systems are designed for agility and change, allowing for the replacement of discrete modules without an expensive realignment of dependent services, and with a reduced risk of system failure. This lowers the cost of new components and increases competition, which drives innovation in the marketplace.

Information systems of the future also come with the ability to share data and services across the enterprise to perform common services such as eligibility determination and recipient management. This will come in especially helpful for state agencies serving beneficiary populations whose recipients also receive Medicaid.

Challenges for State Medicaid Programs

Despite the clear benefits of adopting new approaches to Medicaid architecture, states face significant challenges in adopting the new technology. States often operate legacy systems within fixed agency and departmental structures that make the adoption of a cross-cutting architecture difficult. In most cases, there is not a central entity with the responsibility and authority to manage the operations of separate, but interrelated, technology projects within or across diverse state agencies.

What is an Enterprise Strategic Integration Management Office?

The Enterprise Strategic Integration Management Office (SIMO) is an entity designed to support the development and execution of strategic direction within the Medicaid enterprise. Its portfolio of responsibilities range from the strategic (e.g., enterprise information management), to the transactional (e.g., project management), and the transformative (e.g., organizational change management).

The SIMO can be chartered in several different ways, for example:

  • In-house, using entirely a public sector entity
  • A private sector entity or entities
  • A mixture of in-house and private sector personnel

Building on the foundation of the right mix of public and private support enables the ongoing development of internal capabilities.


Potential Benefits 

Better health outcomes: Coordinating services via the Medicaid enterprise can help emphasize patient-centered care and support policies encouraging more personal responsibility and active patient participation.

Better use of data: Integrating and sharing health data across the Medicaid enterprise can support healthcare cost containment and evidence-based policies.

Greater program agility: Medicaid policies, procedures, laws, and regulations are in constant flux, so the information system must be designed for change. A flexible application and data architecture will allow for reorganization and alignment to new models of care.

Efficiency: Interoperability can help avoid duplication of efforts and technology, increase automation, and reduce manual activities.

MITA maturation: The SIMO provides a coordinated, enterprise-wide view to prioritize efforts and effectively advance MITA maturity.

Optimized FFP: Interoperability will optimize Federal Financial Participation (FFP) to maximize matching funds for projects, operations, and health care cost containment.


Concept Diagram and Activities

The SIMO, as exhibited in the following, will enable a coordinated approach, complement the work of the technical system integrator and provide a cohesive view across the Medicaid enterprise.

Within this organizational model, the SIMO can provide leadership and support for the vision, strategy, planning, systems governance, MITA state self-assessment and maturation, and information management.

1.  Medicaid Enterprise Vision, Strategy & Planning

At the most fundamental level, there should be an overarching vision, strategy, and plan that will support organizations composing the Medicaid enterprise. The SIMO will create and own an enterprise strategy map and plan, with supporting top-level metrics. This will ensure a coordinated direction, and provide the ability to measure and report progress against strategy.

2.  Medicaid Enterprise Systems Governance

It is critically important for the Medicaid enterprise to define, and operationalize all aspects of Medicaid Enterprise Systems (MES) governance, bringing together all relevant stakeholders to make decisions around information management, enterprise architecture, portfolio management, and technology reuse. The SIMO will be responsible for establishing and maintaining the MES governance framework, including details of all forums that support these activities.

 

3.  MITA State Self-Assessment and Maturation

The Medicaid enterprise needs a centralized point of contact to oversee the State Self-Assessment (SS-A) and be accountable for ensuring that actions designed to increase MITA maturity are executed properly. This will help to maintain the momentum and progress generated by the SS-A, provide the foundation necessary for measuring the effectiveness of continuous improvement activities, and maximizing the potential for ongoing FFP. The SIMO will facilitate governance and prioritization of improvement initiatives, track progress, and manage the process of continuous improvement.

4.  Enterprise Information Management

This function provides a holistic view of the information and master data management needs across the Medicaid enterprise (including interoperability with other states). To that end, the SIMO will create and maintain a strategy, which enables common data definitions between systems, simplifies data exchange, and improves information retrieval.

Conclusion

The SIMO solves the decades-old problem facing every state Medicaid program: multiple individual agencies, systems, and vendors operating in silos. The enterprise SIMO works across the Mediciad enterprise to establish a single strategic vision, encouraging the adoption of shared components and governance. The functions described enable the successful execution of enterprise architecture, enterprise portfolio and project management, integration management, benefits tracking, reporting, and vendor / contract management.

By serving as the entity responsible for centralized strategy coordination within the Medicaid enterprise, the SIMO allows state Medicaid agencies to realize to the fullest extent possible the value and benefits of their investments in next-generation Medicaid application architecture and technology.

Download

For more information, please contact: 

Rick Zelznak
+1 (850) 688-9309
Rick.Zelznak@northhighland.com

Barbara Ray
+1 (850) 222-4733
Barbara.Ray@northhighland.com

Maximizing State Returns on Next-Generation Medicaid Enterprise Systems


This perspective introduces the concept of a centralized entity dedicated to an overarching, integrated strategy for the systems and entities composing the statewide Medicaid enterprise – the Medicaid Enterprise Strategic Integration Management Office (SIMO). We discuss its benefits and describe how it might function in the context of an evolving Medicaid environment. 

Strategic Integration in Today’s Medicaid Environment

In 2015, the health and human services category will amount to 39.8 percent of all state spending − dwarfing every other category − and it continues to grow as a share of public spending. Medicaid is the driver for much of this growth, and states can realize large savings by improving its efficiency and effectiveness.

The next generation of Medicaid enterprise technology is arriving, and it promises to help state governments control Medicaid spending while improving health care outcomes for beneficiaries. New approaches to software components and integration are enabling the unprecedented aggregation and analysis of data related to health care payments and outcomes. Data analytics, eligibility determinations, and fraud detection are just a few of the areas where states are breaking new ground.

Improved program integrity and better health outcomes are not the only benefits of adopting a comprehensive and flexible architecture for the Medicaid enterprise. Tomorrow’s systems are designed for agility and change, allowing for the replacement of discrete modules without an expensive realignment of dependent services, and with a reduced risk of system failure. This lowers the cost of new components and increases competition, which drives innovation in the marketplace.

Information systems of the future also come with the ability to share data and services across the enterprise to perform common services such as eligibility determination and recipient management. This will come in especially helpful for state agencies serving beneficiary populations whose recipients also receive Medicaid.

Challenges for State Medicaid Programs

Despite the clear benefits of adopting new approaches to Medicaid architecture, states face significant challenges in adopting the new technology. States often operate legacy systems within fixed agency and departmental structures that make the adoption of a cross-cutting architecture difficult. In most cases, there is not a central entity with the responsibility and authority to manage the operations of separate, but interrelated, technology projects within or across diverse state agencies.

What is an Enterprise Strategic Integration Management Office?

The Enterprise Strategic Integration Management Office (SIMO) is an entity designed to support the development and execution of strategic direction within the Medicaid enterprise. Its portfolio of responsibilities range from the strategic (e.g., enterprise information management), to the transactional (e.g., project management), and the transformative (e.g., organizational change management).

The SIMO can be chartered in several different ways, for example:

  • In-house, using entirely a public sector entity
  • A private sector entity or entities
  • A mixture of in-house and private sector personnel

Building on the foundation of the right mix of public and private support enables the ongoing development of internal capabilities.


Potential Benefits 

Better health outcomes: Coordinating services via the Medicaid enterprise can help emphasize patient-centered care and support policies encouraging more personal responsibility and active patient participation.

Better use of data: Integrating and sharing health data across the Medicaid enterprise can support healthcare cost containment and evidence-based policies.

Greater program agility: Medicaid policies, procedures, laws, and regulations are in constant flux, so the information system must be designed for change. A flexible application and data architecture will allow for reorganization and alignment to new models of care.

Efficiency: Interoperability can help avoid duplication of efforts and technology, increase automation, and reduce manual activities.

MITA maturation: The SIMO provides a coordinated, enterprise-wide view to prioritize efforts and effectively advance MITA maturity.

Optimized FFP: Interoperability will optimize Federal Financial Participation (FFP) to maximize matching funds for projects, operations, and health care cost containment.


Concept Diagram and Activities

The SIMO, as exhibited in the following, will enable a coordinated approach, complement the work of the technical system integrator and provide a cohesive view across the Medicaid enterprise.

Within this organizational model, the SIMO can provide leadership and support for the vision, strategy, planning, systems governance, MITA state self-assessment and maturation, and information management.

1.  Medicaid Enterprise Vision, Strategy & Planning

At the most fundamental level, there should be an overarching vision, strategy, and plan that will support organizations composing the Medicaid enterprise. The SIMO will create and own an enterprise strategy map and plan, with supporting top-level metrics. This will ensure a coordinated direction, and provide the ability to measure and report progress against strategy.

2.  Medicaid Enterprise Systems Governance

It is critically important for the Medicaid enterprise to define, and operationalize all aspects of Medicaid Enterprise Systems (MES) governance, bringing together all relevant stakeholders to make decisions around information management, enterprise architecture, portfolio management, and technology reuse. The SIMO will be responsible for establishing and maintaining the MES governance framework, including details of all forums that support these activities.

 

3.  MITA State Self-Assessment and Maturation

The Medicaid enterprise needs a centralized point of contact to oversee the State Self-Assessment (SS-A) and be accountable for ensuring that actions designed to increase MITA maturity are executed properly. This will help to maintain the momentum and progress generated by the SS-A, provide the foundation necessary for measuring the effectiveness of continuous improvement activities, and maximizing the potential for ongoing FFP. The SIMO will facilitate governance and prioritization of improvement initiatives, track progress, and manage the process of continuous improvement.

4.  Enterprise Information Management

This function provides a holistic view of the information and master data management needs across the Medicaid enterprise (including interoperability with other states). To that end, the SIMO will create and maintain a strategy, which enables common data definitions between systems, simplifies data exchange, and improves information retrieval.

Conclusion

The SIMO solves the decades-old problem facing every state Medicaid program: multiple individual agencies, systems, and vendors operating in silos. The enterprise SIMO works across the Mediciad enterprise to establish a single strategic vision, encouraging the adoption of shared components and governance. The functions described enable the successful execution of enterprise architecture, enterprise portfolio and project management, integration management, benefits tracking, reporting, and vendor / contract management.

By serving as the entity responsible for centralized strategy coordination within the Medicaid enterprise, the SIMO allows state Medicaid agencies to realize to the fullest extent possible the value and benefits of their investments in next-generation Medicaid application architecture and technology.

Download

For more information, please contact: 

Rick Zelznak
+1 (850) 688-9309
Rick.Zelznak@northhighland.com

Barbara Ray
+1 (850) 222-4733
Barbara.Ray@northhighland.com

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