Delivering a positive consumer experience
The Patient Protection and Affordable Care Act (ACA) created new health insurance exchanges, at both the state and federal level. These exchanges are public-private marketplaces where Americans can apply for a tax subsidy and shop for health insurance plans, across insurance companies. HealthCare.gov, the website for the federal exchange, is the front door for the Federally Facilitated Marketplace (FFM).
Many people are aware that the initial launch of HealthCare.gov had a number of challenges, which received extensive coverage and political, media and public scrutiny. People may not be aware, though, that the FFM is much more than just a website. It includes:
A rescue of the website began in November 2013, and in January 2014, the federal government hired Accenture Federal Services as the prime development contractor, with responsibility for stabilizing and improving the website, and finishing development of the additional systems and interfaces.
In just six weeks, Accenture mobilized more than 500 skilled professionals to transition the project at an unprecedented speed. Within eight weeks, Accenture delivered significant technical improvements to the website, stabilizing it during the peak of HealthCare.gov’s initial enrollment period. This enabled millions of Americans to enroll in health insurance, many for the first time.
The Centers for Medicare & Medicaid Services, CMS, is part of the Department of Health and Human Services (HHS). The organization administers programs, including: Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and the Heath Insurance Marketplace.
The initial launch of the HealthCare.gov website was historic—yet it had its share of challenges. CMS urgently needed help navigating to a successful outcome. Not only was CMS transitioning from an incumbent to a new contractor during a critical time, the agency also was transitioning to a new data center provider, the overall program was complex with multiple stakeholders, the customer base was demanding, there were issues with the underlying technology and the project was under high scrutiny.
CMS chose Accenture Federal Services to rescue, stabilize and enhance HealthCare.gov to build a positive experience for consumers. Accenture created a collaborative and comprehensive transition plan that mitigated the transition risk and enabled Accenture to begin hands-on delivery immediately.
CMS also needed Accenture to build new software for IRS tax forms, risk adjustment and re-insurance payments to insurance companies, and small business enrollment.
Using an innovative workcell transitioning approach, Accenture ramped up more than 500 people in just over six weeks. Critical to the transition was successfully gathering knowledge from multiple organizations internal and external to CMS.
Accenture conducted more than 450 knowledge transfer sessions to capture over 700 knowledge artifacts. The team also hosted 16 days of intensive, requirements “lock-in” sessions that included Accenture developers, testers, business architects, technical architects and CMS business executives. The team captured 3,300 testable and traceable requirements.
This successful transition—unprecedented in its scale and sense of urgency—reduced risk and positioned the team to start hands-on delivery and rescue activities as soon as possible. The entire transition of the program from incumbent to Accenture took eight weeks…four weeks faster than originally proposed.
To stabilize the site, Accenture completely took over maintenance and operations during the peak period of the 2014 open enrollment. The team tackled defects and delivered urgently needed fixes ahead of schedule, thereby maintaining operations throughout the peak enrollment period.
The effort included:
To keep the system fully functioning, especially during peak enrollment, Accenture provided continual monitoring and reporting for HealthCare.gov. Each week, the team delivered multiple software releases, with significant enhancements.
Accenture quickly mobilized a team to take over Small Business Health Options Program (SHOP). In just eight months, the team started with requirements analysis and successfully delivered a commercial off-the-shelf (COTS) package.
This included customization, performance testing, functional testing, security auditing and integration with other CMS systems. Accenture collaborated closely with the COTS manufacturer to launch a new line of business for the marketplace in this very short time period, with a smooth go-live and very low defect count.
Innovative, Cloud-Based Solutions
The new federal and state health insurance exchanges created new marketplaces for insurance companies to sell new insurance products to new consumers. To stabilize the pricing of risk, the ACA included new reinsurance and risk adjustment programs.
The former helped offset larger-than-expected claims, and the latter helped transfer payments from issuers that took on lower-than-expected risk to those that took on higher-than-expected risk.
These programs required gathering confidential claims information from 800 different insurance issuers and then performing complex, risk stabilization calculations and analytics. CMS needed to provide a solution where issuers-maintained control of their confidential claims information, as input to the risk calculations, but CMS controlled the risk algorithms, software and reference data.
Accenture developed a cutting-edge solution that provides issuers a complete data processing environment, which each issuer owns and operates. The “EDGE” system uses Amazon Web Services (AWS) to connect with more than 800 issuers, to share and process claims information in the cloud according to the CMS analytical algorithms. Issuers maintain complete control of their proprietary claims and pricing data; CMS has visibility to the outputs, but not the inputs, of the algorithms. Additionally, 135 issuers elected to participate as AWS-deployed servers, using a fully automated environment provisioning process that has successfully and securely processed the issuers’ data without requiring internal infrastructure investment. The other issuers used an on-premise deployment model, which still took advantage of the same software images and upgrade processes.
The EDGE system enables CMS to create a level playing field for all issuers. It provides consistent software and data version management across the universe of independent installations. EDGE simplifies and expedites deployment for issuers, reducing time from several days in a standard software distribution and configuration model to as little as 15 minutes, while enabling hands-free software upgrades and execution of remote commands.
Millions of Americans count on the integrity of their enrollments and tax subsidy calculations. And the 800 issuers count on the integrity of how their plans are displayed on HealthCare.gov, how their enrollments are processed, and how they get paid for reinsurance and risk adjustment.
Accenture worked with CMS to build in program integrity. We built an entirely new system for policy-based payments, to make sure the tax subsidy payments to issuers resolved to the penny, for each and every enrollment in the FFM. In addition, CMS hired an independent contractor and auditor to vet the EDGE system for reinsurance and risk adjustment payments. That contractor determined that a full 100 percent of the billions of dollars in payments was accurately calculated.
At a detailed level, we built in logging and auditing capabilities for all key transactions. And we worked with CMS to build a robust security program, which proactively detects potential vulnerabilities. Our joint security team achieved Authority to Operate (ATO) on schedule, for all of the systems that Accenture built and maintained.
Technology. Delivery. Discipline.
Rescuing the website required immediately instilling technology discipline, along with significant investment in automation and tooling. To improve the fully manual test and release process, the Accenture team created fully automated, regression test suites at all levels:
This comprehensive regression suite runs on a regular basis, and provides automated emails and executive dashboards for monitoring. The automated functional testing consists of more than 300,000 test steps and is typically executed five times per week. The automation of this functional testing saves over 50,000 hours per year in manual testing. This high level of automation has allowed the team to dramatically improve the quality, reliability and speed of new software builds.
Accenture also created automated build and deployment scripts, not only for the software, but also for the software environments. Development and testing teams can now “click a button” to automatically provision new environments in AWS. They can also click a button to deploy software releases to those environments. This includes checking out the versioned code from the repository, building the software, checking code quality, running it through a battery of automated tests, validating performance and moving the software items into the environment. We have moved from fully manual processes, which are time-intensive and error-prone, to a fully automated Development and Operations (DevOps) capability.
Moreover, Accenture created a robust operations monitoring stack. The stack includes a suite of monitoring tools and dashboards that integrate with:
In addition to monitoring live traffic on the site, down to the level of individual transactions, the stack also monitors the performance of synthetic transactions. The synthetic transactions run every few minutes, around the clock, to proactively uncover production issues before consumers do.
Beyond just the technology, Accenture also brought methodology discipline to the program. This included introducing delivery techniques to make sure CMS realized business benefits incrementally, over time, without having to wait for a full-blown or big bang solution.
Additionally, Accenture and CMS together created an enterprise-ready agile approach, for new development. Accenture combined its proven, enterprise agile methods with CMS’ Expedited Life Cycle (XLC) system development process. This approach blends the benefit of agile with government requirements for documentation, auditing, traceability and independent verification. In sum, this approach enabled efficient delivery with sound risk management and proven software delivery practices.
CMS embraced agile, with actively engaged product owners, who represented multiple stakeholders and made decisions quickly. After each three- to four-week sprint, Accenture demonstrated the updated software for CMS acceptance, giving CMS real-time visibility into progress of the software build. This built confidence and allowed agile teams to incorporate feedback and re-prioritize along the way. The program’s use of agile has also helped improve collaboration between IT and the business on strategic system initiatives.
HealthCare.gov, as originally built, had technical debt built up from the technical complexity of the software. The Accenture team innovated and simplified the technical plumbing of HealthCare.gov and other related systems.
This had multiple business benefits:
This approach was so successful that another contractor is considering doing architecture simplification on its software, for similar benefits.
Cloud First Approach
Accenture delivered the new EDGE software in the cloud, as mentioned. That is not the only use of the cloud—Accenture has taken a “cloud first” approach, wherever using the cloud makes sense and meets CMS’ security needs.
For example, the suite of automated functional tests is run from servers in the cloud, which can scale up or scale down, as necessary. As another example, the new environments for new software capabilities are deployed in AWS. Accenture made it as simple as literally pushing a button: provisioning a new environment plus the COTS middleware plus the application software is fully automated.
Accenture recommended using salesforce.com to quickly build a Customer Relationship Management (CRM) solution that would help improve collaboration and outreach with issuers. The initial prototype was deployed within weeks; the full solution was complete and operational in four months.
The unified CRM solution replaced dozens of disassociated email templates, contact lists and Excel spreadsheets. Email generation improved from 30 minutes to 10 minutes. Issuer lookup and update time improved from 20 minutes to 1 minute. Reporting time improved from 30 minutes to 2 minutes. These results all occurred on a platform that is now more accurate and easier to use.
Accenture implemented full DevOps processes and technologies to accelerate development and deployment. Automated tasks across environments include code check-out, build and packaging; code quality scanning; security scanning; unit testing, functional testing and initial performance testing; software deployment; and release smoke testing.
The team used tools such as Junit, github, Amazon Web Services, Splunk, JIRA Software (including Jira, Confluence and HipChat), Fortify, Python and Bash to support continuous delivery.
The DevOps approach has significantly reduced manual errors, improved software release quality and allowed the team to deliver faster.
Transforming HealthCare.gov required a shift in culture. Team members adopted a “one team, one goal” mindset and created a blame-free environment, where everyone would succeed or fail together.
It was not a client/vendor relationship that had clear lines of separation. Rather, it was one cohesive team that worked collaboratively and transparently. Everyone was open about schedules, risks and defects, and all worked together to share knowledge and solve problems proactively. Instead of finger pointing, people were rewarded during daily meetings for candidly acknowledging, “This isn’t working…and here’s what we need to do to fix it.”
CMS is now recognized as a leader among federal agencies for pivoting to the new: using agile techniques, DevOps and next-generation architectures in the cloud to deliver meaningful digital experiences for consumers.
The joint team, along with CMS, made significant progress quickly. Highlights of the work include:
Mobilized 500 people with the requisite industry, functional and technical skills in six weeks. We created a transition plan with the incumbent that included 450 formal knowledge transfer sessions.
Closed critical defects, resulting in a significant reduction of error rates.
Delivered 256 releases, 99 percent on time with the remainder delivered no more than 7 days after the planned release date.
Generated more than 18 million notices, 2.9 million inbound account transfers and 1.7 million outbound account transfers during the 2015 enrollment period.
Improved the loading time for healthcare plans by 98 percent for small business consumers; load time went from ~200 plans per day to ~420 plans per hour.
Implemented the first-ever automated policy-based payments process, for program integrity.
Worked with CMS and issuers directly to successfully on-board and conduct outreach for more than 800 issuers for the Risk Adjustment / Reinsurance program, using the EDGE solution.
Implemented Salesforce in a matter of weeks, ensuring more than 1,200 issuers received high levels of assistance in tasks related to their acceptance of marketplace policies and tools.
The stability of the website and the program contributed to year-over-year increases in enrollment. For 2016 open enrollment, HealthCare.gov enrolled & re-enrolled 9.6 million consumers in 38 states.