Leveraging a Standards- Based Architecture for Health Insurance Exchange & Medicaid Enterprise

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1 Leveraging a Standards- Based Architecture for Health Insurance Exchange & Medicaid Enterprise M. Reneé Bostick, Principal Health Management Associates August 21, 2012, 11:30 12:30

2 HIX Overview Tools to leverage HIX Architecture Implementation 1. Common infrastructure & architectural solutions for HIX, Integrated Eligibility & MMIS functionality - Cloud & Entity Index 2. Leveraging MITA across the Medicaid Enterprise process, data, applications & business rules 3. Leveraging Member & Enrollment business processes for a consumer- focused, cost effective HIX 4. Collaboration for standards- based, innovative 21st century customer experience solutions

3 Overview Health care reform Aim & State of Change Standards & Conditions Collaboration & Choice Architecture

4 Health Care Reform focus Quality Results ACA Goals Coverage Quality Affordability Triple Aim Health of Population Experience of Care Per Capita Costs National Quality Strategy Healthy People & Communities Better Care Affordable Care

5 State of (Ex)change State of Change 16 Established State Exchange 3 Planning for Partnership Exchange 16 Studying Options 9 No Significant Activity Whether states opt for State- based HIX, all will need new capabilities to determine eligibility (Exchange & MAGI) 7 Decision Not to Create State Exchange SOURCE:

6 Standards & Conditions Standards & Conditions Standards Conditions Open API & interfaces, business rules separation & in human & system readable formats 10. Modularity 11. MITA Maturity Advancement across business architecture & data 12. Industry Standard Operating Rules 1104, e- enrollment HIX 1561 HIX, HIPAA & accessibility 13. Leverage Reuse Leverage tech & multi- state services, reuse service 14. Business Results Timely eligibility, claims & communication - range of media 15. Reporting Data - program evaluation & CQI performance improvement 16. Interoperability Seamless coordination & integration SOURCE: Medicaid; Federal Funding for Medicaid Eligibility Determination and Enrollment Activities federal- funding- for- medicaid- eligibility- determination- and- enrollment- activities

7 16 Standards & Conditions 1. Efficient, economical & effective administration of the State plan 2. System requirements & performance standards in SMM 3. Compatible with claims systems (Medicare & CHIP) 4. Quality improvement data (QIO) 5. State owns software 6. DHHS reproduces, publishes & authorizes use of software, modifications & documentation 7. Cost allocation - 45 CFR 74.27(a) 8. Medicaid uses system for period specified in the APD 9. Medicaid safeguards information SOURCE: 42 CFR

8 Standards & Conditions Customer- centric agencies Address customers needs making it easy to find & share information to accomplish important tasks anytime, anywhere, any device Fundamentals of customer- centric design 1. Measure how well we are providing meaningful services 2. Focus on interactions with most use & value; 3. Measure & use performance information to continuously improve services

9 21 st Century Customer Experience 1. Customer experience same for all individuals, regardless of plan 2. High level of service support & ease of use 3. Seamless coordination Exchange, Medicaid, CHIP, navigators, plans & employers 4. Collaboration Federal & State agencies 5. Integration - systems, programs & administration; prevent duplication 80% of Medicaid beneficiaries text regularly - - highest rate of all other insured and uninsured individuals ENGAGE, EDUCATE, ENABLE & EMPOWER SOURCE: PWC, Health Unwired, local/hregister.cgi/reg/healthcare- unwired.pdf

10 HIX Key Processes

11 MITA & HIX Alignment From Business Areas & Process Mapping To Reusable Business Services MITA 3.0 Business Architecture Eligibility & Enrollment Management Eligibility and Enrollment Blueprint Exchange Business Architecture Supplement Eligibility & Enrollment Business Process Model

12 UX Design Thinking Understand Strategy Design Refinement 11 States Conceptual Data Services Hub System Flow Wireframe Design UX2014 Behavioral Segmentation Health Coverage Portal

13 Choice Architecture The way information is organized & displayed to help people make a decision Makes it easier for customers to navigate complex decisions INFLUENCES choice There is no such thing as neutral choice architecture. SOURCE: Kleimann Communications Group & Consumers Union (July 6, 2012) Choice Architecture: Design Decisions that Affect Consumers Health Plan Choices

14 Choice Architecture Health Plan Chooser Tool Findings Consumers Dread Shopping for Health Insurance Speed key to engagement Accuracy = trust Cost driving 1. Importance of choice architecture Support & shapes consumer choice 2. Clarify goals upfront What matters most to business customers? Site priority Decision support on key factors Single tool for range of audiences Enable choice Reliable decision- making Direct comparison

15 Choice Architecture 3. Initial search results radically affects consumers Default choice architecture becomes customer s anchor or baseline to which everything else is compared We don t know what we aren t seeing Frames everything else you will see on the site HEART of Site initial list of plans from which customers can choose How this list is sorted is key to CHOICE Architecture How information be presented and organized What information provided What alternative sorting or filtering options should be provided?

16 Health plan chooser tool 4. Consolidated provider information - important challenge Customers want to know if their provider is in the plan s network Integrated directory is needed Difficult & daunting to collect, consolidate & normalize data from disparate sources for shared use Carrier relationships & cooperation are critical to these real- time directories Tools Approaches Three sites provide an easy way for consumers to search for providers One integrates mapping to guide consumers to closest provider

17 Chooser Tool Exchange a customer- friendly marketplace 5. Customers want to know total cost Customers understand premiums but struggle to understand out- of- pocket costs (co- pays, deductibles, prescriptions) Tool Approaches Algorithms to predict customer costs (use, prescription costs) Provide range Estimated Annual Costs Ask questions to narrow plan comparison Not include total cost not yet robust enough to accurately predict total costs

18 Get the Picture Enterprise Core Diagram Enables managers to create a shared understanding of their organization architecture Has implications for design of roles & structures Provides discussion framework for IT & business communication Common Elements to clarify architectural stage 1. Core business processes (enterprise- wide capabilities) 2. Share data driving core processes (supply chain) 3. Key linking & automation technologies (middleware) 4. Key customers (channels or segments)

19 Architecture Maryland Structuring & Sharing the decision

20 Stages of Architectural Maturity Requires Collaboration Business Silo Standardized Technology Optimized Core Business Modularity Maximize functioning of individual business units IT efficiency through standardization; often results in centralization of technology management Organizational data and process standardization aligned with operating model Enterprise manages and reuses loosely coupled IT- enabled business process components to preserve standards and local differences Organizations move through these stages by building & then leveraging organizational learning on how to implement business process & IT discipline as a strategic capability

21 Reusability Progression Accelerating the Learning Curve REUSE Code, Libraries & Packages COLLABORATION Development, Procurement & Management SHARING Documents, Processes & Knowledge Fundamental challenge for future technologies is how best to support differing groups of people who see the world in fundamentally different ways to achieve a shared understanding

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