Building a roadmap for Medicare Payment Systems Modernization
The challenge
The Centers for Medicare and Medicaid Services (CMS) provides health insurance to over 60 million beneficiaries and pays out their claims to healthcare providers across the nation. CMS has four legacy mainframe systems collectively called the ‘shared system’ that process these claims. This 50-year-old system cannot easily be modified to serve the changing needs of healthcare providers and beneficiaries. It needs modernization: moving to a modern system architecture in the cloud to provide flexibility and maintainability.
The Integration Contractor (IC) team was asked to create a strategic roadmap to guide this modernization effort. The team conducted a technical discovery to understand how the shared system works. The shared system is complex, mission-critical, and aging rapidly. Understanding the system technically was the first step toward building the roadmap. The team reached out to Blue Tiger to partner on facilitating a series of workshops to consider mission needs and technical constraints to build a strategic roadmap for modernization.
Our approach
Blue Tiger joined the team to facilitate a series of 40-person collaborative product management workshops to help develop the roadmap for systems modernization.
Desk research and interviews
Based on our background research our goals were to:
Inform the development of the strategic roadmap
Build alignment and consensus throughout the organization
We decided to run a series of workshops to understand dependencies and prioritize the modernization work. We had 40+ workshop participants with varying experience in agile and product management. We needed to develop a collaborative and inclusive approach that would lead to a successful modernization.
The existing systems are complex and process complicated claim scenarios. In order to make it easier to discuss and reason about the system in a workshop setting, we built a more simplified conceptual model, bucketing system functions into four components that represented the lifecycle of a claim.
When developing large systems, we often recommend building and testing the common functions first to create a base for additional and more unique features. While each claim type has unique processing needs, there are common actions that need to be performed across all claim types.
We recommended a two-phased approach for the modernization strategy. The first phase modernizes components common across all claim types. This creates the platform for the second phase, where the processing for each claim type is modernized.
To ensure we’re creating value with each iteration, we needed to develop a framework to help decide how to prioritize each component. We were inspired by the Weighted Shortest Job First (WSJF) method from Scaled Agile Framework to create an approach that takes into account business value, complexity, and technical feasibility.
We developed a workshop series as follows:
Workshop 1: Brainstorm pain points and challenges with current systems, identify functionality that is common across all claim types, and determine the relative complexity of each functionality of the system
Workshop 2: Determine the business value of common functionality (as realized from modernization)
Workshop 3: Review map of business value vs. complexity and discuss the technical feasibility
Workshop facilitation
With everyone still working from home, we had to create engaging virtual workshops where we maintained everyone’s attention for the entire duration. Our workshop facilitation objectives were:
Inclusivity, collaboration, and participation
Shared and mutual understanding
Consensus and a sense of shared responsibility
We used ice-breakers to allow us to interject humor and make participants feel comfortable. Throughout the workshops we co-created tangible visuals to ensure everyone could follow along. We intentionally designed simple activities so that everyone could take part and provide their point of view.
Business value
To facilitate the discussion around business value, we facilitated an activity to sort system components by relative business value. As a group, we’d discuss where to place each blue tile from the left into the business value bins on the right. The discussion around each move was critical to understanding capabilities, dependencies, and needs.
Business value vs. complexity quadrant.
Similar activities over a few sessions led to creating the quadrant on the right to inform a prioritization process that considers complexity and business value.
After workshop 2, we placed each system functionality on this quadrant to visualize the first sequencing for modernization. We built a directed acyclic graph reflecting the dependencies between the various features.
Then, we used this quadrant and functionality graph to help draft the roadmap.
Creation of the roadmap
After the workshops, we synthesized the discussions and brought everything together in a draft roadmap. We first established some principles to help guide the creation of the roadmap:
Deliver highest business value early
Aim for small, frequent releases
Start with simpler modernizations
Avoid dependencies within a release
These principles allowed us to use the quadrants developed during the workshops to sequence the order in which the various system functionalities should be modernized.
Results
Building a roadmap for a large and complex modernization is difficult. A good roadmap considers multiple factors including business value, complexity, technical dependencies, and organizational capacity. In addition, large systems have a large number of stakeholders. Our workshop approach allowed the creation of a first draft of the strategic roadmap. The roadmap will drive the development teams' work and is an input to the program’s increment planning process.
Project team
Shashank Khandelwal
Practices used
Complex system design
Product management
Human-centered design
Workshop facilitation
