MEDICAID MANAGEMENTHow we got here; learn from our success and failure.

CA-MMIS System Replacement ProjectObjective:• To replace existing CA-MMIS Legacy Systems with new technology &

processes that provide business value and improvements to customers (end-users, providers, members), while enabling new levels of Medicaid Information Technology Architecture (MITA) business maturity.

Goals:• Enhance the quality of the project output while providing business value

earlier in the schedule • Improve Program Operations by providing opportunities for Business

Process Re-Engineering. This will be in parallel with the systems and business process implementations.

Medi-Cal Fiscal Intermediary Statistics2014 Average Daily Statistics

• 760,000 Claims processed per day*

• 40,000 paper claims

• 590,000 Medical claims

• 170,000 Point of Service (POS) claims

• 2,200 Live Provider calls per day

• 2,100 Live Beneficiary calls per day

• 12,000 Interactive Voice Response (IVR) calls

• 1,500 Paper Treatment Authorization Requests (TARs) processed

• 15,000 Beneficiary Identification Cards (BIC) produced

• $382 Million in claims paid, weekly

2014 Total Statistics• 197,629,924 Claims processed

• 10,465,798 paper claims

• 153,039,726 Medical claims

• 44,590,198 Point of Service (POS) claims

• 574,279 Live Provider calls taken

• 565,227 Live Beneficiary calls taken

• 3,049,664 Interactive Voice Response (IVR) calls

• 390,448 Paper Treatment Authorization Requests (TARs) processed

• 3,938,513 Beneficiary Identification Cards (BIC) produced

• $19,843,395,096 in total claims paid

$73,557,429,177.53 paid since Assumption of Operations on 10/03/2011

2014 v. 2013 Statistics• + 5,406,130 Claims processed (+2.8%)

• - 1,297,265 paper claims (-11.0%)

• + 3,115,281 Medical claims (+2.1%)

• + 2,290,849 Point of Service (POS) claims (+5.4%)

• + 38,437 Live Provider calls taken (+7.2%)

• + 194,163 Live Beneficiary calls taken (+ 52.3%)

• + 515,128 IVR calls (+ 20.3%)

• - 111,039 Paper TARs processed (- 22.1%)

• + 1,400,137 BICs produced (+ 55.2 %)

• + $2,905,185,719 in total claims paid (+ 17.2%)

• + $56 Million weekly claims paid (+ 17.2%)

Medi-Cal FI Responsibilities• Claims adjudication for Medi-Cal

95% Electronic claims, 5% paper 130,000+ Medi-Cal Providers and 11.5+

Million Beneficiaries

• Call Center for beneficiaries and providers; supports 11 languages

• Medi-Cal Eligibility Verification• Provider Relations Organization

Provider Outreach, Education, and Training: 1,800+ visits per year

Financial Cash Control Print Center

• Infrastructure (System Hosting and Maintenance) and Application Support 220+ Million web transactions 1,500+ Annual System Edits and Audits

• Other Services Fraud/Abuse Detection & Prevention Cost Containment

SR Release Roadmap Vision

Release 1

Release 2

Release 3

Release 4

Release 5

Release 2:Initial Claims ProcessingCHDP ClaimsCHDP Plan ManagementCHDP Financial ManagementEstablish FQHC Plan Mgmt.IHO Case Management

Release 3:Pharmacy, Medical Supplies, PADs, and LTC Claims and Drug RebatePharmacy, Medical Supplies, PADs, and LTC AuthorizationsPharmacy, Medical Supplies, PADs, and LTC ClaimsPharmacy , Medical Supplies, PADs, and LTC Financial MgmtDrug Rebate

Go-liveQ2 2016

Release 4:Medical Authorizations and ClaimsCCS/GHPP/OHP Claims Initial Supporting ProcessesFinancial Management

Release 5:Claims and Supporting ProcessesAll Other ClaimsAll Other AuthorizationsAll Other Supporting ProcessesAll Other Financial Management

Go-liveQ4 2016

Go-liveQ4 2015

Go-liveQ2 2015

Go-live Q4 2014

2014 2015 2016

StartApr 2014

StartJuly 2014

StartJan 2014

StartNov 2014

StartJan 2015

Release 1:Health Enterprise FrameworkInfrastructureSecurity/Single Sign-On (SSO)Member Eligibility ServiceProvider EnrollmentInitial Plan Management

Agile is a time boxed, iterative approach to software delivery that builds software incrementally from the start of the project, instead of trying to deliver it all at once near the end.

Individuals and interactionsover

Processes and tools

Working softwareover

Comprehensive documentation

Customer collaborationover

Contract negotiation

Responding to changeover

Following a plan

CA-MMIS Paradigm Shift to Agile• Our highest priority will be to meet our business objectives through early and

continuous delivery of the most valuable software.

• DHCS business people and Xerox developers must work together daily throughout the project.

• The most efficient and effective method of conveying information to and within a development team is face-to-face conversation.

• Working software, rather than documentation, will be our primary measure of progress.

• Agile processes promote sustainable development. DHCS sponsors, DHCS business owners and Xerox developers should be able to maintain a constant pace for the duration of the project.

• At regular intervals, the project team will reflect on how to become more effective. It will then tune and adjust its behavior accordingly.

Continuous Process Improvement

Requirements Design Coding Testing Release

In a traditional software development approach, projects analyze “lessons-learned” at the end of the project (or phase) in order to share their mistakes with other projects in the future.

In an agile project we constantly repeat the same iterative development process every month. Mistakes become process improvements on a regular basis.

Requirements

Design

CodingTesting

Release

Requirements

Design

CodingTesting

Release

Requirements

Design

CodingTesting

Release. . .

Delivering Value Instead of StatusRequirements Resources Time

Resources Time Features

Estimation Driven

Priority Driven

WATERFALL AGILEOpposing Approaches

Agile Projects at DHCS

Short Doyle Medi-Cal Maintenance and Operations Project

DMH-ADP to ITSD Migration Project (Medi-Cal systems)

DMH-ADP to ITSD Migration Project (Non-Medi-Cal systems)

CalHEERS (California Health Benefit Exchange)

THE DECK IS STACKEDSome days it feels like…

Change is HardIt requires a change in:• Organizational culture• Personnel with the right skills• Management support• Communication• Values• Decision Making

What are the Obstacles?• Government wants Legal Protection• Government Decision Making• Public Oversight• Government is Risk Adverse• Contracts• Budgeting

IS THERE HOPE?If the system is designed for waterfall

“Firm fixed price development tends to create situations where neither the government nor the contractor has the flexibility needed to make adjustments as they learn more about what is feasible and affordable as well as what needs to be done to achieve a design that meets requirements during a product’s design and testing phases.”- Frank Kendall, Under Secretary of Defense for Acquisition, Technology and Logistics

A False Sense of Security• Everything about our current waterfall process is

intended to eliminate uncertainty.• While this may be successful on small projects, it

creates a false sense of security on large projects.• How many projects’ definition of success remains

constant from inception?• Agile processes are designed to create transparency

and expose risk.

The Case for Agile• Agile provides a direct pathway to transform

government solutions through the development of value-driven solutions that focus on the public’s priorities.

• However, government is inhospitable to outsiders, agile included. From decision making, to budgeting and procurement, the public sector has been designed for waterfall.

Agile Myths• Agile teams don’t plan

• Agile is not predictable

• Chaos with no ownership

• It’s a silver bullet

• No documentation

• Agile is easy

• Agile only works for web projects

• Agile implementations are more expensive

• Agile is not scalable

• Cowboy coding with no best practices

PLAYING TO WIN

Being prepared for the obstaclesto adopting agile in state government.

People

TechnologyProcess

People• Start small and create a culture that embraces

change• Choose your team carefully, choose change agents• Educate your team before you begin• Coach your team as you go• Engagement with your customer is just as

important as with your development team

Process• Choose a non-reportable (delegated authority)

IT project• Establish your agile processes before you

execute them – then improve them as you go• Agile processes are intentionally

light weight, so adhere to theprocesses that you value

Technology• Local development

environment• Source code control –

daily code merge• Build and test systems –

automationRegression

Test

Build/ Deploy

Commit

Most Common Agile Techniques1. Daily Standup2. Iteration Planning3. Unit Testing4. Retrospectives5. Release Planning6. Burndown/ Team-

based Estimation

7. Velocity8. Coding Standards9. Continuous Integration10. Automated Builds11. Dedicated Product

Owner

VersionOne, State of Agile Survey 2013

QUESTIONS?

Contact informationPeter KellyCA-MMIS PMOpeter.kelly@dhcs.ca.gov(916) 373-7722

Nilay PatelXerox Govt. HealthCarenilay.patel@xerox.com(770) 866-0628