HealthCare.gov: CMS Management of the Federal Marketplace
Ruth Ann Dorrill, a Deputy Regional Inspector General for the Office of Evaluation and Inspections Dallas Regional Office, is interviewed by Tyler Daniels, a public affairs specialist in Washington DC.
[Tyler Daniels] What role did management play in the breakdown of HealthCare.gov?
[Ruth Ann Dorrill] The poor launch was attributable to many organizational missteps, not just problems with the website technology.
[Tyler Daniels] That's what we're discussing today. I'm Tyler Daniels, and welcome to the HHS IG's Podcast. Before we start. Here's a little background on healthcare.gov:
When the Affordable care Act became law, it required that every state give its citizens access to a marketplace to purchase private health insurance. The states had a choice in how to go about this. They could create their own marketplace or the states could use the marketplace created by the Federal government, which was primarily healthcare.gov. The agency in charge of creating and running healthcare.gov was the Centers for Medicare & Medicaid Services known as CMS.
When healthcare.gov launched on October 1, 2013, and for some time after, users were met with website outages and technical malfunctions. So CMS, and its contractors, took corrective actions to fix these problems. And when the first enrollment period ended in March 2014, 5.4 million individuals selected a plan through the federal marketplace. The second open enrollment period was between November 2014 and February 2015. And this ran smoothly.
Recently, the HHS office of inspector General has released a report that details the development and implementation of healthcare.gov by CMS.I spoke with one of the report's authors, Ruth Ann Dorrill, to ask her what the report found.
[Ruth Ann Dorrill] This Case Study focuses primarily on CMS management surrounding Healthcare.gov, from passage of the ACA, the Affordable Care Act, in 2010, through the second open enrollment period, ending in 2015. We conducted extensive data collection. We interviewed 86 current and former HHS and CMS officials, staff, and contractors who were involved with the website, and we reviewed thousands of HHS and CMS documents, including management reports, internal correspondence, and website development contracts. The case study also incorporates other OIG work regarding the Federal Marketplace. And the report identifies factors that contributed to the website's poor launch and subsequent improvement, and lessons for employing core management principles in navigating program implementation and change. Particularly as it involves government working with IT contractors.
The Case Study report is in chronological order and it provides three global takeaways:
- The first half illustrated what happened from the time period of early development through the launch of the website. And our key takeaway was that poor launch was attributable to many avoidable, organizational missteps, not just problems with the website technology, which was widely reported. Although there were certainly significant technological problems as well.
- And the second half of the report picks up from after the poor launch. And we found that CMS improved processes and worked with contractors, and others, to fix the website. And that in doing so, they led to broader organizational changes focused on better leadership, decision-making, and communication.
- We closed the report indicating that more work is needs to improve the Federal Marketplace and Healthcare.gov. The website is not completely built. Other technical challenges remain and new challenges will arise. CMS needs to make continued progress in applying lessons learned from HealthCare.gov.
[Tyler Daniels] Let's look at that first takeaway, the poor launch. HealthCare.gov was an important project for HHS and CMS. How did things go so wrong?
[Ruth Ann Dorrill] From the beginning, HealthCare.gov faced a high risk of failure, given the complexity needed, a fixed deadline, and a high degree of uncertainty about the mission, scope, and the funding available for the project. The project also started in the Office of the Secretary, in HHS, and was there for the first 10 months and then transitioned to the Centers for Medicare and Medicaid Services. And that transition ended up problematic for the project because they had to integrate into a large organizational structure. There were differences of opinion about the mission of the project and a clear lack of leadership. CMS at no point had assigned a project leader who had a centralized vision of what should be taking place and on what kind of timeframe. They had additionally substantial problems with the IT contracting. They had accepted only limited bids for the key marketplace contracts in order to save time. And there was some uncertainty in funding so some contractors didn't want to bid. And then they had disjointed contract management throughout. No acquisition strategy in who to hire, and then a different divisions had responsibilities and didn't coordinate in monitoring the contractors' performance. They also detailed to us that there were some poor technological decisions in regard to the platform that they were to use and the software development mythology.
[Tyler Daniels] The report indicates that HealthCare.gov was alarmingly behind schedule by early 2013. CMS received many warnings of problems. Why didn't CMS take action to correct problems or delay the launch?
[Ruth Ann Dorrill] CMS received a number of scathing reviews of the website review in late 2012 and 2013. But the problem here was that there was still no clear leadership. And so no one had a global view of the project. And no one received all 18 of these formal warnings. And so there was no ability to look across the project and see what correction may be made. The business school speak that we use in the report is that they became path dependent. There was no one who was able to, with energy, move the project in a different direction, or tighten the deliverables-so that they could actually accomplish what needed to happen by October 1. By the time they did take action, in the final two months of the build, those actions were insufficient because they were too late. They finally took drastic action at the very end to cut pieces of the build. But this caused more problems because it's hard to take out pieces and have it not affect the other pieces of the website development. But at no point did they discuss delaying the launch, even though the website was not fully built, not fully tested, and didn't have adequate capacity for the consumers they expected.
[Tyler Daniels] How did CMS go about turning around the website?
[Ruth Ann Dorrill] Initially, there were so many technical problems that it was difficult to know what direction to go in. And the first few weeks then were a bit chaotic. They had far more users than they had anticipated, 250,000 - the government shutdown that began that same day, on October 1st - but by about three weeks in, they were able to develop a new system of working at the command center. They had a few technological experts come in, who had been recruited by the White House. And CMS and contractors brought in additional staff, and these groups worked together to fix the website and the software and make things more usable, by December 1st, within a tight timeframe-just two more months. In doing so, they developed what they called a "badgeless culture" where it didn't matter who you worked for, or what your position as, you were all in it together to try to fix what was wrong with the website. And this productive culture, we think, began to seep into the CMS culture overall and made for a more productive working environment. They also established a number of redundancies and were able to organize their processes and their visibility of what was happening at the website using more sophisticated technological systems. Then after the first enrollment period, they still had a very tight timeframe to get ready for second enrollment, only seven months later. So they quickly pivoted there, and employed a process they called "ruthless prioritization", that they cut down anything that was not necessary in the build, so that they could have a more perfect execution of the core elements.
[Tyler Daniels] In the report, OIG calls on CMS to continue its progress in applying lessons learned from HealthCare.gov. What are those lessons and what challenges remain?
[Ruth Ann Dorrill] The 10 lessons articulated in the report comprise core management principles that could apply to other organizations, including assigning clear project leadership, identifying and addressing factors of organizational culture that may affect project success, and also integrating policy and technological work to promote an operational awareness of what needs to happen in order for the project to succeed. They also took steps to ensure greater effectiveness of IT contracts and promoting innovation and integration between the CMS staff and the IT contractors. And rigorous oversight of the performance of those contracts.
We think all of those lessons have broader implications for government, and for technological contracting. And in the case of CMS, we hope that they employ those as they face future challenges in implementing the Federal marketplace, and improving operations. They still have yet to complete the website build. They backend financial management portions are not yet complete. And there are also some consumer tools that they hope to integrate to make the website more useful.
Other OIG work has also identified problems with the Federal Marketplace. We've made around 30 recommendations to CMS regarding improvements in eligibility determinations, payment processes, contracting operations. CMS concurred with our call for continued progress. And so OIG will continue to monitor CMS's actions to address specific recommendations. And also follow that they continue to apply the lessons learned from the healthcare.gov breakdown and recovery, as they manage the website further.
[Tyler Daniels] Ruth Ann, Thank you for your time.
[Ruth Ann Dorrill] Thank you.
[Tyler Daniels] That was Deputy Regional Inspector General Ruth Ann Dorrill, speaking about the OIG report "HealthCare.gov: CMS Management of the Federal Marketplace." You can view the report on our website oig.hhs.gov. And follow us on twitter @OIGatHHS. I'm Tyler Daniels. Thanks for listening.