MITA Maturity Model

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See Also: MMM

Overview

The MMM is subdivided into five complex levels of progressive enterprise business and technological maturity. It illustrates how to transform goals, objectives, and business capabilities of the Medicaid Enterprise[1].

MMM Levels of Maturity Explained

Level 1

  • All Technology, policy, statutory enablers exist and are widely used.
  • The SMA complies with baseline requirements.

The SMA focuses on meeting compliance thresholds for state and federal regulations, aiming primarily at accurate enrollment of program eligibles and timely and accurate payment of claims for appropriate services.

Level 2

  • All technology, policy, and statutory enablers exist and are widely used.
  • The SMA improves important parts of its business.

The SMA focuses on cost management and improving the quality of and access to care within structures designed to manage costs (e.g., managed care, catastrophic care management, and disease management).

Level 3

  • Industry Standards are widely used.
  • The SMA promotes collaboration, data sharing, interoperability and consolidation of business processes.

The SMA focuses on coordinating and collaborating with other agencies to adopt national standards and develop and share reusable processes to improve the cost effectiveness of health care service delivery. The SMA promotes intrastate information exchange and business services.

Level 4

  • Widespread access to clinical information improves healthcare outcomes.
  • The SMA promotes interstate information exchange.

The SMA, now with widespread and secure access to clinical information, can improve health care outcomes, empower members and provider stakeholders, measure objectives quantitatively, and focus on program improvement. The SMA promotes interstate information exchange and business services.

Level 5

  • Leverage and reuse of technologies is widely used for national interoperability.
  • The SMA focuses on program management rather than daily routines.

The SMA focuses on fine-tuning and optimizing program management, planning, and evaluation, with national (and international) interoperability improvements that maximize automation of routine operations.

Business Qualities for MMM

The MMM includes a set of 6 measurable business qualities to help distinguish performance at one level from another level for each business process. These qualities are as follows:

  1. Timeliness of Process– Time lapse between the SMA's initiation of a business process and attaining the desired result (e.g. length of time to enroll a provider, enroll a member, pay for a service, respond to an inquiry, make a change, or report on outcomes).
  2. Data Access and Accuracy- Ease of access to data that the business process requires and the timeliness and accuracy of data used by the business process.
  3. Effort to Perform, Efficiency- Level of effort necessary to perform the business process given current resources.
  4. Cost Effectiveness- Ratio of the amount of effort and cost to outcome.
  5. Accuracy of Process Results- Demonstrable benefits from using the business process.
  6. Utility or Value to Stakeholders- Impact of the business process on individual members, providers, and Medicaid staff.

Qualities defined for each level differentiate clearly between the levels and show a realistic progression toward improvement for each business process.

To develop the MMM, the MITA team took a general description of the levels and definition of the qualities and applied them first to the Medicaid Enterprise’s and the MITA’s mission, goals, and objectives, and then to the business processes referenced in the Business Process Model (BPM). The MMM defines information and technical capabilities across 5 levels of maturity as well. The next section gives examples of the impact of the MMM on mission, goals, and objectives.

This table illustrates the quality of timeliness of the business process.

Table: MITA Maturity Model Detailed Business Qualities

General Description Level 1 Level 2 Level 3 Level 4 Level 5
Timeliness of Process Business processes meet threshold, mandated requirements for timeliness, i.e., the results achieved within the time specified by law or regulation. Enhancement of business process timeliness with the use of Web portal; Electronic Data Interchange (EDI). Prioritized business processes that result in cost savings Timeliness exceeds legal requirements. Timeliness improves via collaboration, data sharing, and use of intrastate information exchange hubs. Clinical data is available in real time. Processes using clinical data provide immediate action, response, and results. State or regional stakeholders are interoperable, optimizing timeliness. Enhancement of timeliness of business process through connectivity with other States and federal agencies. Most business processes execute at the point of service. Results are as close to immediate as we can envision at this time.

Information Capabilities for the MMM

The MMM for the IA includes a set of 4 qualities to help distinguish performance at one level from performance at another level for each of the MITA business model business areas. See Part II, Chapter 6[2], Information Capability Matrix, for detailed descriptions. The information capabilities are as follows:

  1. Data Management Strategy- Provides a structure that facilitates the development of information/data, effectively shared across a State Medicaid Enterprise to improve mission performance.
  2. Conceptual Data Model- Represents the overall conceptual structure of the data, providing a visual representation of the high-level data needed to run an enterprise or business activity.
  3. Logical Data Model- Identifies all of the logical data elements that are in motion in the system or shared within the Medicaid Enterprise.
  4. Data Standards- Identifies the applicable standard for each MITA data element.

Technical Capabilities for the MMM

The MMM for the TA includes a set of 3 technical services areas with specific technical service classification qualities to help distinguish performance levels for each of the MITA business model business areas. See Part III, Chapter 7[3], Technical Capability Matrix, for detailed descriptions. The technical capabilities are as follows:

  • Access and Delivery– Encompasses design drivers and enablers such as web browser connectivity, language support, Customer Relationship Management (CRM), and forms and reporting services.
    • Client Support
    • Business Intelligence
    • Forms and Reporting
    • Performance Measurement o Security and Privacy
  • Intermediary and Interface– Contains drivers and enablers, such as process orchestration, work flow and relationship management functionality.
    • Business Process Management o Relationship Management
    • Data Connectivity
    • Service-Oriented Architecture
    • System Extensibility
  • Integration and Utility- Includes design drivers and enablers such as solution stacks, database access layer services, scalability, application versioning and verification type utility services.
    • Configuration Management
    • Data Access and Management
    • Decision Management
    • Logging
    • Utility

Seven Standards and Conditions Capabilities for the MMM

The Seven Standards and Conditions Maturity Model serves as a reference model to define boundaries for establishing business capabilities. See SS-A Companion Guide, Appendix A, Seven Standards and Conditions Details[4] for more detailed descriptions. The Seven Standards and Conditions Capability Matrix (SCM) defines the business qualities for the 5 levels of maturity for each:

  • Modularity Standard– Uses a modular, flexible approach to systems development, including the use of open interfaces and exposed Application Programming Interfaces (API); the separation of standardized business rule definitions from core programming; and the availability of standardized business rule definitions in both human and machine-readable formats. The States commit to formal system development methodology and open, reusable system architecture.
  • MITA Condition– States align to and advance increasingly in MITA maturity for business, architecture, and data.
  • Industry Standards Condition– Ensures alignment with, and incorporation of, industry standards;[5]
  • Leverage Condition– State solutions should promote sharing, leverage, and reuse of Medicaid technologies and systems within and among States.
  • Business Results Condition– Systems should support accurate and timely processing of claims (including claims of eligibility), adjudications, and effective communications with providers, beneficiaries, and the public.
  • Reporting Condition– Solutions should produce transaction data, reports, and performance information that contributes to program evaluation, continuous improvement in business operations, transparency and accountability.
  • Interoperability Condition– Systems must ensure seamless coordination and integration with the Exchanges (whether run by the state or federal government), and allow interoperability with health information exchanges, public health agencies, human services programs, and community organizations providing outreach and enrollment assistance services.

Maturity Levels Applied to Medicaid Mission and Goals

Part I, Chapter 2, Concept of Operations, presents the Medicaid mission and goals, a statement in business terms of the long- range vision of the Medicaid Program. The BA describes the Medicaid mission and goals for each level of maturity in the Maturity Model Details[6].

This table provides an example of these descriptions using the Medicaid goal to improve health care outcomes for Medicaid members. These descriptions illustrate improvements identified for each higher level. Visioning sessions conducted with a number of state agencies and recent national initiatives such as the Nationwide Health Information Network (NwHIN) have shaped Medicaid mission and goals.

The MMM and the Improvement of Health Outcomes

Component Level 1 Level 2 Level 3 Level 4 Level 5
Improve Healthcare outcomes for Medicaid Member The SMA focuses on compliance with regulatory requirements for enrollment of providers and members, and payment of claims within a specified timeframe to encourage the participation of providers and thereby promote access to care. Improved health care outcomes are a by-product of new, creative programs primarily focused on managing costs, e.g., managed care and waiver programs. There is widespread adoption and use of national standards for administrative data, and sharing of business services that provides a better base for comparing outcomes. Coordination and collaboration across intrastate health care programs contributes to improved outcomes. All stakeholders have access to clinical data that produces a major leap forward in analysis of health care outcomes. In addition, the SMA empowers members and providers to make decisions affecting outcomes. National interoperability among state and federal agencies in the most comprehensive way we can envision at this time. Agencies now have access to necessary data to compare outcomes across a broad spectrum of other agencies and States.
''Levels of maturity do not suggest good or bad values, though MITA encourages States to achieve higher levels for some or all business processes.''

Maturity Levels Applied to MITA Goals and Objectives

The MITA goals and objectives support the Medicaid mission and goals. The Medicaid mission draws on a variety of sources, including policy making, strategic planning, and legislation. MITA is one of the key supports for achieving the Medicaid mission. MITA has its own stated objectives and goals that align with the Medicaid mission and with federal initiatives such as the Federal Health Architecture (FHA) and the NwHIN. The MITA Framework has built Medicaid and MITA goals and objectives into it. Each level of maturity describes the realization of these goals at each level of maturity. This is the capstone of the MMM.

This Table shows how progressive levels of maturity improve the ability of the SMA to meet the MITA goal to “promote an environment which supports flexibility and adaptability and rapid response to changes in programs and technologies.”

The MMM and the SMA Adaptations to Changes

MITA Goals Level 1 Level 2 Level 3 Level 4 Level 5
Promotes an environment which supports flexibility and adaptability and rapid response to changes in programs and technologies Agencies meet mandatory changes, but lack technical flexibility. Program changes are costly and time consuming to implement. Agencies introduce elements of flexibility in program design and selection of technology driven by requirements to manage costs and implement new programs. Agencies improve on flexibility and adaptability through implementation of shared and extensible business services, adoption of nationally accepted standards, and increased collaboration among intrastate agencies, with use of intrastate agencies information exchange. Integration of clinical data calls for increased flexibility and adaptability. Immediate access to the clinical information speeds of response time in critical business processes. Agencies have full interoperability within the intrastate, interstate and federal agencies. Agencies can collaborate on response to changes and share solutions.
This table illustrates another MITA goal to “provide data that is timely, accurate, usable, and easily accessible in order to support analysis and decision making for health care management and program administration.”

The MMM and the SMA ability to Provide Data

MITA Goals Level 1 Level 2 Level 3 Level 4 Level 5
Provide data that is timely, accurate, usable and easily accessible in order to support analysis and decision making for health care management and program administration The source of data is primarily the claim. Data is accessible via a request/response process that meets the current goals, but management experiences delays and inconsistencies in acquisition of data. Data is non-standard, and the SMA primarily uses it to manage operations. Claim data and managed care encounter data are available. Decision support tools provide faster, better analysis, and improve decision- making. HIPAA mandates some data exchange standards for limited external stakeholders, but few agencies use the standard data in their internal processes. The SMA uses MITA Framework, industry standards, and other nationally recognized standards, such as the Council of Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) Operating Rules for intrastate exchange of information. Intrastate information exchanges improve efficiency of access. This results in improvements in accessibility and accuracy of data used in program administration. The SMA uses MITA Framework, industry standards, and other nationally recognized standards for interstate exchange of information. Access to standardized clinical data through regional health information exchange using the Enterprise Master Patient Index (EMPI) greatly enhances the decision-making process. With clinical evidence, decisions can be consistent and decisive. Access to Master data management exchange on a national scale optimizes the decision-making capabilities of state, regional and federal agencies.

Notes

  1. http://ehr-llc.com/wiki/index.php?title=Category:Medicaid_Enterprise
  2. http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/MITA/Medicaid-Information-Technology-Architecture-MITA-30.html
  3. http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/MITA/Medicaid-Information-Technology-Architecture-MITA-30.html
  4. http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/MITA/Medicaid-Information-Technology-Architecture-MITA-30.html
  5. the Health Insurance Portability and Accountability Act of 1996 (HIPAA) security, privacy and transaction standards; accessibility standards established under section 508 of the Rehabilitation Act, or standards that provide greater accessibility for individuals with disabilities, and compliance with Federal Civil Rights laws; standards adopted by the Secretary under section 1104 of the Affordable Care Act; and standards and protocols adopted by the Secretary under section 1561 of the Affordable Care Act.
  6. Part I, Appendix B,