Every state Medicaid agency divides the work of eligibility, claims, care management, program integrity, and IT differently among state staff, county staff, managed care organizations, and vendors. Those structures will dictate the resulting system's architecture.
Some IT standards can be created to enable flexibility for different architectures. Others, like dictating the architecture itself, will fail to achieve the desired intent.
If CMS is hoping to use this RFI to create a standardized architecture, it will be a mistake to do this without addressing the much larger standardization problem underneath it: no state looks alike from an organizational standpoint.
Could a focus on technology be used to learn about a standardized organizational structure that works? We think so, and we've proposed strategic methods for accomplishing this. But applying these methods requires CMS to shift the mindset entirely and look at transformation as an operating model change, not an IT change.
We have been describing the implications of Conway’s law throughout this response. X1 describes decisions made by people far from the work, producing systems that serve the concerns of the deciders rather than the people doing or receiving the work. X2 describes systems getting called products because organizations are structured around owning systems, not around owning the service a person receives. X3 describes MITA producing documentation instead of transformation, because a framework cannot change an architecture without changing the organization that builds it. S1 and S10, creating a protected environment isolated from the current org and letting standards emerge from protected end-to-end slices, are both recommendations to change the organization first so a different architecture becomes possible.
If CMS wants architecture standards to actually hold, the standards will need to target the organizational structure directly, not just the solution it's expected to produce. Right now, it doesn't have a strategy to do that.
This RFI response provides many elements of such a strategy. We'd encourage CMS to apply as many of them as it can, because fighting Conway's Law is a losing battle.