1. The Iowa Medicaid Enterprise
Building of an Enterprise
Lessons Learned
Mary Tavegia
With the expiration of the Iowa’s fiscal agent contract set for June of 2005, Iowa began preparation to procure a new set of services to begin July 1st of that year.

2. IME – The Early Years Began with procurement of support services
Development of a scope of work
Joint Application Design (JAD) Sessions
Analysis of MMIS Production System
Administration Changes
This preparation began in June, 2002 with an RFP to procure support services to prepare an RFP that would be necessary to contract for such services. FOX Systems won the bid for those support services and early in August the work to develop the RFP began. By fall numerous JAD sessions had been held and an analysis of business needs and system needs were documented. Along the way the development of the RFP took two major hits to direction. Changes in Medicaid Directors caused directions to shift. But in June of 2003 Iowa’s current Medicaid Director came on board and the direction that became known as the Iowa Medicaid Enterprise was born.

3. Critical Decision Points
Structure
One RFP, multiple components
“Best of Breed” Contractors
System
MMIS basically met needs; move to State platform
Develop new Data Warehouse on State platform
The decision for the State to increase control over services provided to members and providers began with an RFP that involved a scope of work for systems and professional services in one RFP with multiple functional components. A bidder could submit a bid for one, several or all components. Each component was evaluated separately to determine the best contractor for the functional area. An analysis was completed that determined the current MMIS system met the business needs and early in 2004 the transfer of the MMIS system began. Development of the data warehouse on State hardware began January that same year.

4. Critical Decision Points (cont’d)
Facility and Tools
Co-locate State and Contractor staffs in same facility
Common set of tools
Workflow Process Management System
Same data sources used by all Contractors
MMIS
Data Warehouse
OnBase
The co-location of State and Contractor staff in the same location was intended to facilitate communication and provide a flexibility that would allow an organization able to change more quickly. Within the facility collaboration rather than competition would foster partnerships among the units. All Contractors would work under the banner of the Iowa Medicaid Enterprise and while they maintain their company’s policies in things like HR and dress code, in the facility they would work as units of the IME.
A common set of tools would allow all Contractors and State staff to communicate internally, have the work flow through the necessary Units, and have a common set of data sources from which to base decisions.

5. Critical Decision Points (cont’d)
Performance Based Contracts
Accountable Government Act
Common Contracts
“Report Card”
Major performance outlined for all Contractors in each Contract
Enterprise performance the goal
Renewal of Contracts
Different Base Year Contracts
Renewal on a staggered schedule
Due to legislation previously enacted in Iowa all service contracts in Iowa must be performance based. There was a significant increase in performance measures in the RFP over the previous contract with the fiscal agent. Over 250 performance measures guide the IME. Each IME Contractor had all “report card” measures for each Contractor listed in their Contract. This allows the Contractors to see not only the expectations of the IME for their performance but the performance of all Contractors working toward the success of the IME. Base years for each Contract vary so that renewal of Contracts will take place at different perioids thereby not implementing all new Contracts in the future at the same time.

6. IME Success Increased State Control and Accountability
Moved MMIS System to State Platform Early
Built State infrastructure to support IME
Common facility
New hardware to support MMIS and Data Warehouse
State owned equipment for Contractors
Staggered renewal of Contracts
Flexibility of Model
Some of the high points of this business centric model include the increased control of the State over operations, something that in the previous model had been harder to achieve. The IME is accountable to its providers, members, and other stakeholders through a set of performance measures that will be published annually.
The decision to move the MMIS system to the State’s data center early in the process not only gave the State greater control of the system but by moving it early allowed it to be ready for operations by the required date.
Building an IME infrastructure including facility, equipment, hardware, software, state run support operations such as printing and mailing will allow for future changes to the IME to be accomplished more efficiently with less interruption. One example of the flexibility of this model has already played out. With eight weeks to implement a new Medicaid expansion of Medicaid reform, staff, located in the same facility, were able to implement phase 1 of Iowa’s Medicaid reform which included required a waiver from CMS, in a minimal amount of time while at the same time finishing all DDI requirements. This would not have been possible in the short timeframe if the IME did not exist.

7. Opportunities
Improved definition of overlapping tasks within Scope of Work
Business Office function
Earlier involvement of State staff in process
Unit Managers
Policy Staff
Limit required staffing of Contractors to Account Managers
Things that we might do differently if we were to do it again would include a better definition of the interactive activities between units. In assuming more control one area overlooked in the RFP was the business office function. Many of those functions were taken in-house however some contracts were modified to add small scopes of work. Another point would be an earlier involvement of state staff in the process. We waited to appoint unit managers until after the contract process. Earlier involvement would have helped the learning curve for the new positions. Policy staff was also brought into the concept a little later. Earlier involvement would have assisted that learning curve as well. In the RFP we required all Contractors bring an account manager and systems operations managers as well as an implementation manager. Hindsight shows that the critical required position would be the account manager with the Contractor suggesting the layout of additional supervisory staff.

8. Why this Choice?
Multiple Contractor Model with State infrastructure provides:
Flexibility
Accountability
More participation by niche Contractors
State involved in more day to day management of activities and decisions
Business centric focus
This model, a business centered model, allows for flexibility,greater participation by specialized Contractors bringing best practices to Medicaid functional areas to allow quality, integrity, and consistency and giving the State greater control over business and operational decisions.