Tl:dr - The CA-MMIS team is working to replace a legacy system that can no longer keep up with the growing needs of Medicaid payments. The organization was trying to modernize the system while moving the legacy system to a new support vendor. The OI team helped test the proposed modernization vision to discover the parts that best resonated with staff. They also helped craft the concept of a high-level sponsorship team made up out of internal and external stakeholders to work through the approval processes collaboratively to improve speed and efficiency.

CA-MMIS Engagement Summary Findings

Team Members: Crystal Favareille, Darci Delgado, Kim LaBonte, Janelle Graham
Office of Innovation Director: Chaeny Emanavin
Department Engagement Champion: Ben Damman

The California Department of Managed Health Care protects consumers’ health care rights and ensures a stable health care delivery system. DMHC responds to consumers’ disputes with their respective DMHC-regulated health providers through independent medical reviews and complaint resolution processes. This makes DMHC a critical part of success delivery of the managed health care system.

The Initial Problem:

CA-MMIS Division oversees the operation of mission-critical Medicaid enterprise systems that are over 35 years old. Various subsystems experience outages every month. Although there was never a missed deadline, such an event could result in collection delays worth billions, possible sanctions from the Federal Centers for Medicare and Medicaid Services (CMS) and cause significant issues for the state. Additionally, both the CA Health and Human Services senior leadership and CMS are requiring states to develop or acquire more modern, modular systems and then use them to incrementally decommission legacy subsystems. This is a complex process and represents a fundamental switch in how the units operate, collaborate and report progress. Moreover, the organization is trying to maintain the legacy system while building the modern replacement system. This adds to the overall complexity the organization is trying to manage.

“How do we pull apart a monolithic system into pieces and keep everything running?”

Previous attempts to replace the system failed due to lack of understanding of the system complexities and struggles with the project planning and approval processes. These difficulties pushed the timelines beyond reasonable expectations. In addition, there were significant vendor changes, multiple independent oversight teams, and a lack of clarity around the approval requirements. This created a difficult environment to satisfy the stakeholders and users. Moving to a more agile, cloud-based digital service based model required them to submit non-standard technical requests. Each request required a specialized escalation process causing further delays. The CA-MMIS leadership wanted to change the approach and reposition their efforts in order to achieve success in producing outcomes and forming effective partnerships.

Discovery

The team conducted over 40 interviews with CA-MMIS staff on both the legacy and modernization projects. They included state and contractor staff. The sessions were contractor heavy as CA-MMIS has a very high percentage of contract staff performing the PAL documentation work. Overwhelmingly, the messaging was that CA-MMIS, as currently configured, is ill suited for modernization. The current IT structure does not allow for modern development practices such as open source, code repositories or cloud-based computing. For example, getting a DNS for a virtual server must be requested via a Remedy ticket. Fulfilling the request can range anywhere from two hours to three weeks to be completed. When a developer needs a Virtual Machine (VM) to run a test, this would cause massive delays for something that should take minutes to complete.

Moreover, interviewees expressed concern that the complexity of the effort to transition to a new contractor to manage the legacy system could result in a massive failure within the next 6 to 18 months. This puts additional pressure on getting the modernization effort to deliver working code as soon as possible. Interviews also expressed concern that the lack of clear documentation of business intent led to awkward workarounds that do not support actual business needs.

“How do we pull apart a monolithic system into pieces and keep everything running?”

Communication gaps lead to knowledge gaps which exacerbates the problems.

Additionally, interviewees expressed concern that the actual business needs and refined workflows are not adequately captured in modernization plan. The CA-MMIS business operations staff do not having access to the scripts created by the current vendor and therefore can not easily articulate causes of system failure or how a workaround is coded. This provides a bigger issue when trying to provide DHCS or Agency the reason for the urgency, as CA-MMIS are not able to get accurate measures on the frequency or severity of these incidents. As the infrastructure ages, knowledge of how to maintain the system fades as well.

The interviewed staff stated there is no physical, virtual or organizational space to support a successful plan to maintain the legacy and move to a more modern approach. This is reflective of a difficult culture pervasive in the organization. Interviewees expressed that the culture made honest discussion to identify and solve systemic problems difficult. Interviewees stated that management did not acknowledge their warnings that the current plan as stated is unworkable and will not be successful. One interview summed it up as “unwavering support for an unworkable plan”. Communication and collaboration between teams is tightly controlled and therefore exacerbates the silos. The team discovered the best return on effort would be to focus on fixing the communications issues both within CA-MMIS and with external stakeholders.

New Challenge Statement

The challenge statements we initially generated changed quite significantly during the process.

The technical challenges were too complex to address in a single six-week engagement. Therefore, the team decided to focus on defining and prototyping two high priority issues.

• How might we help CA-MMIS document, communicate and model the modernization vision to stakeholders so they can work collaboratively and move it forward? Experts from software engineering, program, legal, product, oversight, and management were unable to clearly understand the overall plan and how they each fit into it. Creating a tight visualization and explanation of the modernization plan that spoke to each stakeholder group individually would help create a unified strategic direction for CA-MMIS modernization.
• How might we streamline internal project approval processes Analyzing the project approval process found that the longest delay occurred during the internal review process before the plans were provided to external stakeholders. Moreover, the documents were written by several entities without close collaboration so the plan was disjointed and missing key steps. Creating a group where all interested parties could craft the plan and document decisions together would be key in avoiding time-consuming misunderstandings.
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  Prototyping

  The team conducted iterative workshops on the internal PAL process to find redundant reviews and inefficient authoring steps. The participants identified and modeled new structures that would allow multi-disciplinary teams to craft the documents together to align the plan and resolve potential problems before finalizing the documentation. The team conducted several review and feedback sessions on the new modernization vision document. The feedback focused on rating the completeness of vision, clarity of articulation and level of confidence the vision could be executed. Additionally, the team conducted workshops specifically to build collaborative communication techniques and opportunities between the functional roles and leadership. These sessions encouraged establishing psychological safety so experts could bring up problems and trust that decision makers would hear them, discuss options with them and make well informed decisions.

  What you can use in your department:

  • Sponsor team and “Away” Team - blended group of CA-MMIS practitioners, Agency, AIO, DHCS, DOF, CDT and a digital service team of 2-3 full-stack developers, 1 product manager, 1 designer and 1 user researcher.
  • This team will test business assumptions and generate the learnings to craft a workable plan. They will build prototype modules that can then be the foundational pieces scalable for modernization.
  • The sponsor team will review their roles every 2-4 sprints to determine if they have the right membership and if they need to revise it.
  • Most importantly, the sponsorship team decisions must be driven by strong engineering and product learnings. Too often in government business decisions are made without engineering or product expertise. This leads to decisions based on assumptions which cause sub-optimal decisions at best and lead to failure at worst.
  • Too often the state is starved of competent development expertise and we all suffer as a result of it.
  </ul>
  • Get feedback on strategic planning documents/product roadmaps from a diverse audience of stakeholders
  • Collect quantitative measures by way of Likert rating scales (i.e. 1 - not clearly articulated to 5 - very clearly articulated)
  • Collect qualitative measures via written notes about the plan (these can be anonymous to help people leave honest feedback)
  • Create clear visuals for both the plan and the feedback so participants can see the impact of their feedback
  </ul>

  Quotable Quotes:

  “CA-MMIS finally have bona fide coding expertise at the state willing to take this ridiculously low pay; we need to take advantage of this even through the inevitable culture clashes and discomfort. We must else we are giving into our fears and we will reap the unsavory results of our inability to get out of ‘business as usual’ mode.” “Having seen the power of the sticky note combine with walls, some staff are using affinity mapping and such on their own.” “Leadership needs to communicate vision to decrease staff anxiety.” “Need to have face-to-face contact with oversight partners.” “The why needs to be told”