Caring for the public sector people: A success story

Effective healthcare systems are essential for individual and societal well-being.  Even so, large and complex systems sometimes struggle to keep pace as healthcare needs evolve. Legacy platforms no longer support business needs and become increasingly cost prohibitive. As healthcare demands increase and patient expectations rise, it’s important for states to modernize these systems to support the delivery of efficient, accessible and high-quality care. This was the challenge the State of California faced with its Medicaid program.

Medi-Cal is California's Medicaid healthcare program serving California’s Medicaid beneficiaries. The California Department of Health Care Services (DHCS) operates the California Medicaid Management Information System (CA-MMIS), a complex system supporting Medi-Cal. CA-MMIS processes about 200 million claims annually for almost 15 million beneficiaries, the largest Medicaid population in the nation. It also helps DHCS manage healthcare provider information and perform other administrative functions related to Medi-Cal. Over time, the decades-old CA-MMIS application, critical to the smooth functioning of Medi-Cal, had begun to hinder the healthcare program.  

DHCS partnered with IBM Consulting® to address this challenge, and this initial step resulted in a transformative journey—for both partners and for California's Medicaid program.

In 2009–2010, IBM Consulting entered a complex and uncertain landscape within the State of California. The  team navigated the state’s technological and cultural constraints, carefully considering the existing infrastructure and the state’s operational norms and practices. The team also demonstrated a strong commitment to innovation and clearly articulated the potential for transformative change. By consistently working with the state toward a shared vision, IBM successfully expanded the state’s initial understanding of what was possible and helped make that shared vision a reality.

The commitment of IBM Consulting to the CA-MMIS transformation project and the team’s perseverance in understanding the state’s perspective resulted in the State of California awarding a sole source contract to IBM Consulting in 2018–2019. This contract empowered IBM to take the reins in managing the entire suite of CA-MMIS applications and marked a pivotal step forward in achieving the shared vision for CA-MMIS and Medi-Cal.

IBM Consulting established credibility with the state early by showcasing its expertise and understanding of IBM’s relevant capabilities. The team then spent months understanding the aspirations, desires, goals and objectives of the state—not just those of DHCS, but also those of the CA-MMIS clients. The team also identified hidden pain points and additional opportunities, including the critical need to improve healthcare provider satisfaction and streamline administrative processes. This empathetic approach fostered a sense of shared purpose and aligned the efforts of IBM Consulting with the state’s strategic goals. IBM Consulting developed an overall approach that was mapped to the state’s needs and preferences as well as to those of its individual representatives.

To bring the vision to life, the IBM Consulting team harnessed its expertise and resources, placing the state at the heart of its approach. The team employed IBM Garage™ methodologies to gain a deep understanding of the user perspectives, including their motivations and unique ways of thinking. The team also sought to shift the mindset of CA-MMIS administrators from “process managers” to “product owners” who drive innovation beyond mere technology improvement. By employing Design Thinking methods and Agile practices, IBM Consulting synthesized a solution that went beyond technology to better serve the people of California.

This human-centered approach, coupled with IBM’s proven track record of successful Medicaid IT projects, fostered a collaborative and trusting environment built on mutual respect and open communication. It enabled IBM Consulting to effectively address the concerns of DHCS, navigate the complexities of the project and ensure the final solution truly addressed the state’s specific requirements and individual aspirations. The collaboration between DHCS and IBM Consulting resulted in the state approving the development of a cloud-based Provider Portal for CA-MMIS as a proof-of-concept (PoC). 

In the PoC, the IBM team ensured that the CA-MMIS Provider Portal was user-centric and efficient. They challenged status quo ways of doing business so that inefficient business processes were not carried over into modern technology solutions. For instance, paper-based processes were transitioned to fully electronic processes, and business processes with little or no value were decommissioned. As a result, business processes that previously took weeks and months, with considerable human effort, now take only minutes, with minimal or zero human interaction. In addition, robust security measures were implemented to meet the Health Insurance Portability and Accountability Act (HIPAA) compliance standards, bolstering the upgraded system with stringent security protocols to protect sensitive information.

The features developed for the Provider Portal, such as single sign-on and shared cost applications, were successfully deployed and made available to all active provider organizations. The initiative onboarded over 30,000 providers and helped the provider and submitter communities achieve faster service turnaround. For instance, Personal Identification Numbers (PINs) are now reset in real-time, while the previous approach took 30 days. The initiative also delivered new capabilities such as management of the CA-MMIS organization and its users, electronic migration of paper records and scalable frameworks, all on a highly availabile and performant system.

The CA-MMIS Provider Portal PoC demonstrated the benefits of cloud technology, such as faster time to market and efficient deployment. The PoC also built the state’s confidence in cloud technology and proved that collaborative co-creation between DHCS and IBM was a successful and beneficial approach. Finally, the PoC showed that IBM could deliver innovative and transformative work, which inspired the state to consider migrating its entire suite of CA-MMIS applications to the cloud using IBM cloud consulting services.

IBM Consulting also recognized the potential of cloud technology to improve operations and efficiency. The CA-MMIS Provider Portal PoC sparked a broader cloud platform transformation for improving consistency, security and scale, with IBM Consulting and Red Hat^®. The development, maintenance, operations and infrastructure teams of IBM Consulting worked with the state’s teams to develop a roadmap for migrating CA-MMIS to a more secure, multi-tenant IBM Z^® system, using Red Hat OpenShift® on AWS. As a result, DHCS was able to migrate more than 30 functions from legacy systems to the AWS Cloud platform, with the remaining functional apps in the pipeline for future migration.

By embracing AWS Cloud technology and adopting a user-centric transformation approach, IBM Consulting has delivered significant value and paved the way for future digital transformation initiatives within CA-MMIS. The key achievements of the CA-MMIS stabilization project include:

• Migration of 96.7% of Medi-Cal user volume to the cloud
• Migration of 60% of daily business transaction volume to the cloud
• Migration of 76% of legacy End-of-Service/End-of-Life (EOS/EOL) applications to the cloud
• Reduction of delivery cost by 30% since the beginning of the cloud journey
• Implementation of 5 new programs leveraging hybrid cloud
• Deployment of more than 2 features per week on average
• Adoption of paperless processes by over 3,100 providers
• Automation of numerous business workflows

The successful partnership between the State of California and IBM Consulting has transformed the legacy CA-MMIS system by enhancing it with the latest technology and cloud framework. It has also set a new standard for innovation and collaboration in the healthcare industry.

Other benefits of the modernized CA-MMIS application include:

• Improved communication and collaboration between providers and the state, which facilitates better coordination of care and ultimately promotes improved health outcomes for beneficiaries
• Streamlined claims processing and reduced administrative burdens for providers, which has led to faster and more efficient access to care
• Enhanced data security and privacy, which protects the sensitive information of Medi-Cal beneficiaries

Access to quality healthcare is a fundamental right for all, and the Medi-Cal program plays a vital role in ensuring that millions of low-income and vulnerable individuals in California receive the care they need. By modernizing CA-MMIS and enhancing its Provider Portal, this project has improved Medi-Cal and directly impacted the lives of Californians.

The California Department of Health Care Services (DHCS) is California’s  primary healthcare agency, serving over 15 million Californians through Medi-Cal, the state's Medicaid program. DHCS is committed to providing equitable access to quality healthcare for all Californians by focusing on whole-person care, expanding access, improving health outcomes and strengthening its workforce. Through initiatives like CalAIM and ongoing program enhancements, DHCS strives to improve the health and well-being of all Californians while ensuring the efficient and effective use of taxpayer dollars.