Access Health CT: a first-hand account of Connecticut’s Health Insurance Exchange (Part 1)

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Originally printed in the July 2014 Edition of the Health Insurance Marketplace News, Authored by Peter B. Nichol.

In Part I of a two-part report, Nichol details the events of October 2012 through March 2013; next month’s installment will focus on what happened from April 1 through the official launch of Obamacare last October.

Oct. 1, 2012—with less than a year until the Oct 1st, 2013 open enrollment deadline for the nation, Connecticut made its push to create the Number 1 Health Insurance Exchange in the country.   Medicare and Medicaid Services (CMS) leaders still touted the State of Maryland and the State of Washington as the top states and dangled the carrot: “Connecticut is improving but Maryland and Washington are ahead [and out of reach].”  Connecticut leadership reset the stage to establish a foundation that could withstand both the volatile political pressures and the enormous operational and technical challenges they faced in standing up a three-year program in just 9 months. 

The core Information Technology leadership had been filled by October 2012.  In July 2012, the position of Chief Information Officer of Access Health CT (Connecticut Health Insurance Exchange dba Access Health CT) was filled.  In October 2012, Peter B. Nichol accepted the role to oversee the Connecticut application and system portfolio. Nichol would later take over of as Head of Information Technology with accountability for technology and operations across the organization, and pioneered the digital transformation for Access Health CT.  

October 2012 was a busy month indeed.  The priority was onboarding the new system integrator Deloitte Consulting LLP.  Nagen Suriya, Deloitte Program Director, joined the project as the system integrator head accompanied by Newton Wong, Engagement Manager with Deloitte Consulting LLP.  Shubh Singh was recruited into the fold as the Technical Delivery Head and Solution Architect — accountable for the design and development teams scaling to 205 Deloitte technical resources.

KPMG was engaged as the technical advisor for Access Health CT (ahCT) in May 2012.  The role of KPMG was to assess existing technical models such as that of the Connecticut Department of Social Services and the Connecticut Insurance Department from a business perspective in order to determine the level of leveragability while supporting the tactical and strategic direction of ahCT.  Roger Albritton, Engagement Manager with KPMG, spearheaded technical and strategic advisory services.

Hosting the three production-like environments in Connecticut, the Connecticut Department of Administration Services, Bureau of Enterprise Systems and Technology selected Eric Lindquist, Director of Platform Services, for the role of standing up these environments under aggressive timelines.

With time-consuming requirements sessions ramping up, it was evident there was a high dependency on integration of legacy systems.  These legacy systems spanned across the CT Dept. of Social Services (CTDSS) website, Interactive Voice Response (IVR) systems, and paper enrollment application printing for existing state programs.  Other dependencies were barely mitigated with the Call Center Request for Proposal (RFP) and the Connecticut Bureau of Enterprise Systems and Technology (BEST) running behind schedule on hardware installation to support the base platform for the integrated eligibility system.

Under immense pressure to deliver a successful Exchange, technologically stable and operationally supported by integrated processes, the ahCT Leadership team decided early to adopt a Business Process Outsourcing (BPO) model to substantially decrease the Exchange risk footprint.  This included four core decisions: outsource Call Center/IVR capabilities, outsource print vendor services (currently being done by same vendor for CTDSS), outsource scanning of paper applications, outsource systems integrator and outsource technical advisor services.

Nov. 1, 2012—No sooner did November start and ahCT IT leadership knew the infrastructure schedule had slipped by more than two weeks and the gap was growing.  Immediately a critical path was established to monitor key activities against baseline dates including: Procure hardware, Procure Software, Build Machines, Install Vanilla Software, Configure Software and Validate Configuration.  This critical path was communicated to the entire Program Management Office (PMO) leadership team and included a “Get to Green Plan.”  Even with a supporting plan, turning up seven individual environments was complicated by the fact that these were in two separate data centers managed by two separate entities —   Deloitte Consulting LLP hosting soon-to-be four development environments in Tennessee and BEST managing and soon-to-be hosting the three production-like environments in Connecticut.

It was evident that what was being reported by vendors and entities across the organization wasn’t reflective of our true state of the union.  Connecticut was just above the surface, bobbing among the ocean waves.  The ahCT Senior Leadership Team (SLT) took swift action and implemented the “Top 5.”  This was a one page report that every resource and vendor was responsible to report into the PMO weekly to ensure transparency of status against plans.  Specifically, this one pager included: Top 5 Biggest Risks, Top 5 Biggest Dependencies, Top 5 Accomplishments and Top 5 Priorities for Next Week.  Even after the 1st week, the understanding of issues deepened. This enabled IT Leadership to collect issues, identify problems and address the real root causes.

In the midst of IT leadership re-alignment of technology delivery, many factors were impacting the IT team affecting change.  The Independent Verification and Validation (IV&V) RFP was issued to provide a third-party assessment of current state and progress-to-date to the Federal government.  Meanwhile, Operational teams defined the Qualified Health Plan (QHP) solicitation process, wrestled with network adequacy challenges with carriers, and the board and standard plan designs (gold, silver and bronze) were all in need of more attention.

The good news was, the technical architecture to support the Integrated Eligibility System was completed and two major release dates were defined to deploy system functionality.  Release 1 (June 1) would be a deployment in support of Plan Management (plan publishing on website) and Release 2 (Oct 1) covered all remaining functionality required for support of Oct 1, 2013 open enrollment.

As Detailed Technical requirements started, ahCT found themselves out of space at the existing location of Capitol Ave., Hartford, CT and signed a new lease for 280 Trumbull, Hartford, CT.  Along with all of the ongoing challenges, we’d be adding relocation of the company to the list.

Dec. 1, 2012—With the onset of numerous staff and consultant vacations looming, it was imperative to refocus technical staff on essential business functions and critical path activities.  This process started by clearly defining the top 19 functions that were required to stand up an Exchange and articulating how success was defined within each function.  This process also led to the first scope reductions.  It was clear that non-essential functions needed to be delayed.  A few of the items removed from scope impacted support for mobile devices (it later turned out the application worked well on an iPad’s browser), content management web portlets for multi-agency involvement, real-time interfaces moving more to batch, degree of coupling with legacy Eligibility Management Systems and limiting reporting capabilities.

After the adjustment of scope, Deloitte Consulting LLP was required to have a more visible leadership presence physically located in Connecticut.  This increased presence of Functional leads immediately paid off with more interaction with staff and tighter collaboration as technical design reviews continued.

A detailed Systems Integration Solution fit and gap analysis was completed that aligned “Out of the Box” functionality with “Custom” or functionality to be developed. The outcome of this analysis was a clear picture of the delta between the Washington State code we started with and the future state ahCT envisioned. This provided for clear line of sight for subsequent prioritization exercises.

Not any too soon, the four Deloitte-hosted development environments were completed and the architecture framework development was started.  This success was muted by the procurement delays for hardware and software necessary for the production environments.

The ahCT IT leadership initiated a Vendor Management Office (VMO) to enable ahCT to understand, proactively manage, and control the total cost of delivery of the systems integrator.  This process included establishing controls for approval by the IT leader closest to the delivery, tracking all approvals and creating metrics to gauge vendor progress.

Shortly after the establishment of the VMO focus looked farther down the road.   Harder questions started to be asked like, “Can we get there from here?” and “If we deliver this solution will it even meet the needs of the organization?”  Focus again shifted from management by metrics to block-and-tackle activities to ensure critical milestones were being met leveraging the critical path.  This encompassed drafting EDI guidelines for carriers and creation of a system integration test plan focusing on system performance service level agreements (SLAs).

Although technical design sessions were in progress, the National Association of Insurance Commissioners was still evolving their System for Electronic Rate and Form Filing (SERFF, pronounced “surf”), the Electronic Filing Submission which provides a cost-effective method for handling insurance policy rate and form filings between regulators and insurance companies. This meant that ahCT was still unsure of the format of benefits and plans, making defining system specifications difficult and riddled with assumptions.  Access Health CT Plan Management continued with credentialing of carriers, certifying of plans, and defining the QHPs standards for Connecticut.

Jan. 1, 2013—By January system delivery expectations were starting to take shape. It was also unmistakable that the March release (pre-release for June) was overcommitted and scope must be removed to ensure a successful deployment.  This led to a review of the architecture independence of legacy systems between ahCT IT leadership and Deloitte IT leadership.  These conversations were done late at night often after 11pm and covered topics such as hardware failure scenarios, what part of the system would be impacted if “x” technical component went down, how to isolate and limit business functionality impact due to system failures, and how quality of infrastructure would be measured at a technical and strategic level.

Up to this point there had been one unified PMO.  This worked great up until January.  However, dozens of technical work streams surfaced which demanded individual attention previously glazed over by the PMO as “too much information.”  The PMO was not meeting the needs of IT.  Therefore at this point IT Leadership made the suggestion, which was adopted, to break the PMO into two groups: an ITPMO and an OPSPMO.  The ITPMO would focus on IT critical path activities and the OPSPMO would focus on business operational critical path activities.  This was a turning point.  Within a week the ITPMO was using a detailed dashboard for tracking technical design requirements and development progress by technical components and business essential functions.  This change in focus centered the IT team on hard release dates and clear interim milestones allowing for defined IT leadership decision points.

Feb. 1, 2013— “Contingency and mitigation plans…HAVE one!” was the slogan for February.  Functional design was completed which was a big win and infrastructure scalability testing was in full swing now that hardware was on-site racked and stacked for the production environment.  Even with all the forward progress the end-to-end design walkthroughs were behind schedule and RED. Immediate action was required to ensure a successful and stable system delivery.  This exercise led Peter Nichol to the decision to cut 30% of the total system scope committed for delivery on or before Oct 1, 2013.  The success of the entire exchange was at stake and despite the systems integrator being adamant they could deliver in full, previous history indicated this decision was necessary.  This resulted in an exercise to review all functionality and tag each requirement either “core” or “deferred.” 

Mar. 1, 2013—Operational work streams started to leak into IT work streams.  Initial assumptions made and agreed upon had to be revisited.  For example, the requirements for the application were done, but the enrollment application process on the website didn’t align to the workflow of the paper application.

IT leadership also reassessed roles and skills needed in order to be successful.  This strategic planning was done every three weeks and spanned topics such as functional areas — including Eligibility and Enrollment — and technical component expertise.  Realignment of staffing was done frequently to establish a model that covered new blind areas.

The design was completed by the end of March, another huge milestone.  However, ahCT was having quality problems with the system integrator Deloitte.  The quality problems were a symptom of delays in staffing and compressed timelines.  Quality concerns were focused around the deliverables and specifically system documentation.  Was the documentation maintainable?  Could that documentation be transferred?  The ITPMO was tracking metrics showing significant requirements traceability gaps, unclear technical component design among others issues.  Access Health CT IT leadership made a call to split the system documentation into two categories.  The first category was required for “go-live” and the second category was required for maintenance and transition.  The result of this decision removed the burden on the system integrator to document 100% of the system by Oct 1st. This enabled all system integrator teams to focus on documenting only critical elements required for a seamless enrollment process.

Connecticut was in the first group of states to test with the Federal Data Services Hub (FDSH), called Wave 1 testing, for service integration required for checking income and citizenship status for example.  This naturally led to Disaster Recovery planning which focused on Recovery Time Objectives (time to restore system) and Recover Point Objectives (data loss window).  It was within this timeline that IT leadership made a conscious decision to ensure application tier technology components were not dependent on legacy systems.  This helped Connecticut to raise recovery objectives standards to the level of other state Exchanges.

There were two major events towards the end of March.  The first was a Federal Security review which Connecticut passed.  The second was a Federal Detailed Design Review (FDDR), part of the formal Centers for Medicare and Medicaid Services (CMS) review required for continued grant funding.  The review was exhaustive and covered architecture, 300+ website screens, business rules, process flows and security flows front and back end. The amount of preparation into these reviews was intense and detracted from other essential activities.
 
As we neared the end of the month, CMS released guidance that all IT activities should be 70% complete by April 1, 2012.  Although the foundational development was underway, design was just completed and we were just shy of this target.

By month’s end, ahCT moved into the new space at 280 Trumbull Hartford, CT.

 

Note: If you are interested, you can find Part 2 here:

https://leadersneedpancakes.com/connecticut-health-insurance-exchange-rise-part-2/

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Peter is a healthcare business and technology executive, recognized for Digital Innovation by CIO 100, MIT Sloan, Computerworld, and the Project Management Institute. As Managing Director at OROCA Innovations, Peter leads the CXO advisory services practice driving digital strategies. Peter was honored as an MIT Sloan CIO Leadership Award Finalist in 2015 and is a regular contributor to CIO.com on innovation. As Head of Information Technology, Peter was responsible for Connecticut’s Health Insurance Exchange’s (HIX) industry-leading digital platform transforming consumerism and retail oriented services for the health insurance industry. Peter championed the Connecticut marketplace digital implementation with a transformational cloud-based SaaS platform and mobile application recognized as a 2014 PMI Project of the Year Award finalist, CIO 100, and awards for best digital services, API, and platform. He also received a lifetime achievement award for leadership and digital transformation, honored as a 2016 Computerworld Premier 100 IT Leader. Peter is the author of Learning Intelligence: Expand Thinking. Absorb Alternative. Unlock Possibilities (2017), which Marshall Goldsmith, author of the New York Times No. 1 bestseller Triggers, calls "a must-read for any leader wanting to compete in the innovation-powered landscape of today." Peter also authored The Power of Blockchain for Healthcare: How Blockchain Will Ignite The Future of Healthcare (2017), the first book to explore the vast opportunities for blockchain to transform the patient experience. Peter has a B.S. in C.I.S from Bentley University and an MBA from Quinnipiac University, where he graduated Summa Cum Laude. He earned his PMP® in 2001 and is a certified Six Sigma Master Black Belt, Masters in Business Relationship Management (MBRM) and Certified Scrum Master. As a Commercial Rated Aviation Pilot and Master Scuba Diver, Peter understands first hand, how to anticipate change and lead boldly.