The rollout of healthcare.gov - a perfect example of what not to do
“We are going to build the most sophisticated, highly automated software platform with a feature set that will rival the most popular software services and it will be a huge success.” Very sexy isn’t it. This was not meant to be a direct quote – but if I was at those initial planning meetings I am fairly sure this was the message. In my years of experience as a technology consultant this is how, many times, an initial conversation starts with many non-technically minded stakeholders with deep pockets and a grand vision. In this case it’s the Obama administration funded by tax payer dollars – approximately $300 million of them.
This is not meant to be a politically driven rebuke of the Affordable Care Act and its’ well guided intentions or a comprehensive analysis of such an ambitious undertaking. A thorough analysis would be nearly impossible at this point as much of the hard facts have not been revealed. Where are you when we need you Mr. Snowden? In my world the grander the vision and the more all encompassing a service usually marches side-by-side with a much higher probability of unexpected outcomes or outright failure.
Being the dutiful consultant that I am, I objectively look at the healthcare.gov initiative through the lens of Lean Startup and Agile Development methodology – which I do regularly. This has become a significant portion of my business and I believe these principles apply to companies of all sizes from startups to large institutions. To start, I view the Affordable Care Act and healthcare.gov as a new business line and e-commerce website, respectively, of a large corporation - the Federal government.
Those of you who are not familiar with Lean Startup or Agile Development the concept is pretty simple. The start of any new venture is a hypothesis that needs to be proven. This proof reveals itself through a series of “experiments” based on the build, measure, learn approach. Its’ principles promote discovery, are iterative and agile, in order to identify misguided assumptions early and support quick reactions (pivots) via real world learning through measurement. Rather than commit a lot of time, money and resources to create what a few people think is the perfect product or solution, initially deliver only what is absolutely necessary to learn what stakeholders (customers, business partners, etc.) want - all else should be eliminated. In sum, the goal is to create a Minimum Viable Product to bring to market a product or service. In this case it is a service.
What is the hypothesis? Provide a method for all Americans without health insurance to sign up and buy health insurance via the Federal government. I believe Lean Startup and Agile methodology could have been applied to the Affordable Care Act and healthcare.gov launch which would have preempted the current usability issues.
Create a Minimum Viable Product (MVP)
#1 Get out of the building (in the case the White House) and test the product solution
The Affordable Care Act has mandated many provisions regarding individuals and insurance companies. This significantly affects buying decisions and configuration of health plan offerings. These are complicated products and significant monetary purchases thereby nearly mandating the need for access to large amounts of information and the ability to make comparisons prior to purchase.
Creating a MVP, a website whose sole focus was to prove the hypothesis and be accessible by the main stakeholders - consumers and insurers - could have went a long way in iterative learning and measurement of what needed to be provided in terms of information, features and user experience in presenting insurance plan options from multiple insurers in order to properly choose an appropriate insurance plan.
In addition to basic usability the government could have been provided with invaluable information regarding which provisions of the Affordable Care Act are most important to consumers when purchasing insurance and for insurance companies who could have utilized information to create and refine product offerings and compete more effectively in the marketplace – driving more value.
In my view, the Healthcare Plan purchasing process is similar to purchasing a car. Cars are large purchases and have many features. We use car configuration applications as a tool to choose a brand, a model and add options. When you have found the correct combination of configuration and affordability you “checkout”, enter the approval and income verification process, get approved, and buy the car – this was the intention but it wasn’t ground in a methodology as it would have been if approached from a Lean Startup mentality.
Build, Measure, Learn
Creation of an MVP - “build” - in conjunction with an agile development approach could have quickly brought clarity, with continuous feedback - “measure” - and implementationof refinements - “learn” -from end-to-end within the first 3 - 6 months of the passage of Obamacare at an insignificant cost. This would have brought tremendous value to formulate design and system architecture prior to the hiring of government contractors. The Health and Human Services Department would have been able to deliver a vetted product and rock solid kick-off document outlining usability, feature and architecture requirements to appointed government contractors.
The timeline to build healthcare.gov was 3 years. Awards for development of healthcare.gov were given to approximately 6 different companies. Let’s estimate there were a total of 100 developers and product managers. Needless to say this obviates the need for a strong lead contractor, project management team and supporting software tools to coordinate all these vendors. Most of the articles I have read refer to: the complexity of the software, data integration from various information sources for verification / validation of consumers and load factors were very high.
I am here to tell you that 6+ companies and 100 team members for 3 years is overkill for a project of this size. Doing some quick math – online reporting estimates the cost anywhere between $175 to $300 million that is approximately $1.75 to $3 million per team member and 480,000 man hours. Reasonable cost? I think not. In fact, the number of disparate vendors, subcontractors and respective development teams severely hindered the successful build-out of healthcare.gov. I don’t believe that the building of healthcare.gov was much more difficult than development of a software product resembling, for example, Dell’s online store.
#2 Agile development
I don’t want to second guess the award process so let’s assume that all of these vendors were necessary. What was the project management and development methodology? Apparently the waterfall approach (vendors working autonomously coding to a predefined specification) – each vendor built features in a vacuum until completed, unaware if it would play nice with the other kids (codebases) and was not tested as a whole unit until the final days before roll-out.
Build, iterate and test again and again
I would have recommended Agile Development as an effective method for building the healthcare.gov website. Most of the opinion articles I have read diametrically oppose this view pointing to the complexity and scale of building healthcare.gov but as I have pointed out earlier I don’t share that view. This is how I would have set up the process. Set up 3 teams: Client user interface, Integration and Backend. Each team consists of a product owner/s and 8 -10 developers and a chief product manager to coordinate the 3 teams. The Agile process would work like this.
A perfect example of what I am speaking about which demonstrates the key principle of Lean startup methodology – initially deliver what is only absolutely necessary. An article from Nov. 8 CBS evening news S.F. programmers build alternative to HealthCare.gov http://www.cbsnews.com/8301-18563_162-57611592/s.f-programmers-build-alternative-to-healthcare.gov/ and visit http://healthsherpa.com. Essentially in two weeks they created a much more effective way of evaluating exchange plans by zip code to help users make a better decision.
So what would the Lean and Agile approach have that gotten the Obama administration?
A Minimum Viable Productthat delivers only what is absolutely necessary rapidly. In this case, a usable system that allows consumers to access, evaluate and select a proper plan and then purchase insurance. The most important point is that there is a minimum viable product that works from Day 1.
Agility - the ability to measure, learn and add features progressively. There isn’t a hard rollout date – the system works in its current form. As the product owner (Federal government and Health and Human Services) measure and receive feedback, features and functionality are added progressively to build a more robust system to better support users. The Agile development teams and workflows are in place to support continuous improvement.
Low burn rates save on time and cost. The launch of healthcare.gov using the proper methodology could have been in the hands of consumers well in advance of the Oct. 1 deadline and at a total lower cost. I am generously estimating $30 – 40 million for a similar technology solution, an order of magnitude less than the current cost.
So the sophisticated, highly automated HealthCare.gov website with a feature set that should rival the most popular software services is barely operable as of this writing and the ripple effects of not releasing early and often could have dire consequences on the Obama administrations new business line. No users, no business. The window of opportunity is closing and its competitors – Republicans – I am sure will be attempting to propose a pivot to a new business model.
Not very sexy - it looks like Healthcare.gov lost the MVP.
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