Health and Human Services

Tale of TIERS

Lessons from the epic pursuit of the perfect records management system.

by / July 17, 2007 0

Texas had big plans for its new health and human services application and eligibility program. After a heavy investment to get it off the ground, officials looked forward to processing Medicaid, food stamps and other public aid claims more efficiently. Data would be stored more reliably. It would be a technological leap.

When it came time to roll out the program, however, employees were up in arms. They were already used to the old system; they knew all the old tricks. Adjusting to this new program was just another burden atop their already heavy caseloads. Why bother with all this hassle?

With that unceremonious debut, the System for Application, Verification, Eligibility, Referral and Reporting (SAVERR) was implemented. "Of course we've all forgotten that," said Stephanie Goodman, spokeswoman for the Health and Human Services Commission (HHSC). "That was 30 years ago."

Now the HHSC is in the middle of another rocky rollout, this time replacing SAVERR and various other eligibility programs with a new program called the Texas Integrated Eligibility Redesign System (TIERS), which was designed to integrate the application and eligibility process for at least 50 public assistance programs. TIERS will link nearly 25 government agencies - as opposed to the old systems, which required case workers to enter information for each program separately.

Official reports issued this year, however, as well as state legislative hearings and widespread media coverage, have said the switch to TIERS has wasted hundreds of millions of dollars. Worse, the death of a 14-year-old boy, whose health insurance was mistakenly withheld, according to newspapers around the state, has been connected in the public memory to the agency and its beleaguered program.

For TIERS, evolving demands, an inflexible regulatory and contract framework, and aggressive implementation timelines combined to frustrate a smooth rollout. The story of the system's implementation holds lessons for agencies across Texas - and across the nation - working to integrate complicated systems that operate under such conditions.

There's just no easy way to introduce a new eligibility program, Goodman said, and tackling the number of records her agency handles doesn't make it any easier. Even as auditors and legislators continue to probe the agency, the HHSC is standing by its new program.

 

An Aging System

The state Legislature asked for a replacement 10 years ago for SAVERR, which was implemented in the late 1970s. The program is still used in all but a few counties, Goodman said. Written in COBOL, a programming language that dates to 1959, SAVERR was built to run on old machines with black-and-green screens and noisy keyboards. Intended for face-to-face consultations with aid recipients in government offices, SAVERR requires employees to enter data a few fields at a time before moving on to the next screen. Data is batched overnight and printed periodically for hard-copy records. When people change their address, or enroll or drop out of any program, the old entry is overwritten, and no historical record is left in the program. To access historical data, employees must search through electronic and paper archives. In April, the Austin American-Statesman reported the monthly cost of running SAVERR on HHSC computers at $1 million.

In 1999, the agency was ready with a blueprint for a new system. Where SAVERR processed records for each benefit program individually, the new system, called TIERS, was designed to handle Medicaid, food stamps, and Temporary Assistance for Needy Families benefits in an integrated database.

By 2003, TIERS was ready to roll out in Travis and Hays counties. That same year, the Legislature reorganized the Department of Human Services - which was responsible for developing TIERS - under a much larger umbrella agency that became the HHSC, which accounts for one-third of Texas' annual operating budget. At the same time, the Legislature asked the HHSC to explore

using call centers, rather than walk-in offices, for processing requests for benefits.

 

Signs of Trouble

According to a report published in April by HHSC Inspector General Brian Flood, the young TIERS program suffered hiccups during its pilot phase: longer case entry times and the inability to create certain case history reports necessary for federal compliance.

Despite these early problems, the HHSC needed a data management system to support the new call-center model of doing business. HHSC officials had to choose between using SAVERR, TIERS or a vendor's proprietary call-center software. The call centers became a wild card that seriously complicated the TIERS changeover.

SAVERR worked, but the agency had already been directed to find a replacement, and the technology was quickly becoming outdated and unsupportable. TIERS - developed for the state by Deloitte Consulting LLP - was still a work in progress, but the HHSC had invested more than five years and a few hundred million dollars in the program. Neither SAVERR nor TIERS was designed to work in a call center; both were built with in-person interviews in mind, Goodman said.

According to Flood's report, the HHSC considered allowing the call center contractor to use its own software to calculate eligibility when the contract was awarded, but managers decided they'd rather control the data management tool so they wouldn't be forced to remain with a given vendor to run the call centers.

The HHSC decided to stick with TIERS and try to get it running smoothly in time for the call center rollout. TIERS needed to be tweaked to fit this new demand however. For example, the data entry fields were shrunk to fewer pages because the condensed format makes more sense for taking information over the phone.

Even before being adapted to call centers, TIERS was very complicated, and both Flood's report and a separate federal audit found that the program had serious design flaws as an eligibility-processing tool.

Still, when the HHSC submitted a plan for the changeover with the federal Food and Nutrition Service, which provides the state money for food stamps, the state commission said it would push ahead with TIERS. Based on what HHSC officials were learning from the TIERS pilot, the agency already had a full plate, and the move to call centers complicated the program further.

 

A Growing Behemoth

Yet, officials continued to add functions to the program. When the HHSC was reorganized to include a handful of other state services, management decided to let TIERS power as much of the agency's work as possible, according to Flood's report, and TIERS grew into a benefits-calculating behemoth. "The project was so large and tech-driven that some of the business needs were not properly designed into the system," Flood said.

Goodman contends the HHSC has handled deployment of the sprawling program just fine, but she agrees it's a big job. "It's like remodeling a house with 4 million people, and they're still living in it," she said.

Accenture LLP won the contract to operate the new call centers in 2005, and the HHSC handed the company the contract for running TIERS as well. The program still needed work, but to speed things along, the HHSC cut off its contract with Deloitte and handed Accenture the job of fixing TIERS, along with starting up the call centers. Accenture eventually contracted some of the work of fixing and modifying TIERS back to Deloitte, at a hefty cost to the HHSC, according to Flood's report.

Accenture Senior Executive Dave McCurley said the project's biggest problems didn't arise from the scale of the program, but from how little wiggle room the company had - due to detailed laws at the state and federal level, and a

very specific contract with the HHSC.

"The challenge from our perspective was that the contract vehicle was very detailed and prescriptive," he said. "It was very inflexible."

According to Flood's report, the HHSC built the call centers into its plans with the federal government so it wouldn't have to start a separate approval process for the call centers.

"We spent a lot of money on the application, so we just didn't want to throw it away," said Gary Gumbert, the HHSC's chief information officer. "Why go out and have to go through certification again? It's a waste of money."

Development of the TIERS program itself was no longer the sole factor in the changeover; the switch to call centers became the agency's driving force.

The first call centers were scheduled to open in late January 2006 - a pace that became a problem when TIERS wouldn't cooperate with another program slated to power the call centers, according to Flood's report. Instead of pushing back the schedule to allow more time for getting the programs working together, managers stuck with the original timetable and had employees enter enrollment data into two programs at once.

By that time, however, fewer people who knew SAVERR were working the cases - hundreds of staff members who used SAVERR for years took new jobs when the HHSC announced that call centers would replace their offices.

The low cost of operating and staffing phone bays rather than lots of small local offices was one of the call center plan's most attractive parts. The Legislature originally hoped to save hundreds of millions of dollars by switching to the call centers.

In practice, however, losing that much institutional memory may have come at a heavy cost. Flood said that even as complicated as data entry became, the old staff picked it up more easily. "The amount of training was different for the contractor staff who were brought on in great numbers," he said, "but had almost no background knowledge."

Gumbert said getting staff - both new and old - comfortable with the new program, when some had been using SAVERR for 30 years, has been a huge challenge, but an unavoidable one. "I wish I could make it easy, but it's just painful for the current staff," he said, adding that the agency is hoping to set up new training labs to help bring employees up to speed.

 

Things You Can't Plan For

Any large program like TIERS runs within some margin of error, McCurley said - for SAVERR it was between 5 percent and 7 percent. But TIERS was under the microscope because of the hype associated with the call center switch.

When the pilot indicated there were problems with the application, public outcry was swift because social services are of such vital importance and are under such close watch by the media.

The way employees adapt to the program and the most commonly made mistakes are things you can't plan for, McCurley said - they're the reason you start with a pilot and make adjustments.

"No matter how good a job you do of drawing up the process in a lab, they're going to do what they're going to do," he said. "You really have very little control over their behavior."

The controversy around TIERS and the push for private call centers blew in April, with the release of Flood's report and a series of Legislative hearings. House committees questioned Albert Hawkins, executive commissioner of the HHSC, on management decisions and ultimately put the program under closer Legislative oversight.

"When you're doing a project this massive, it's a best practice to be sure you have a single point of oversight," Flood said. "That oversight

makes sure that the technology side of the house communicates with the business side of the house. So it's not a tech marvel that produces nothing, and it's not a tech flop that produces everything the business side wanted. It's a mixture of the two."

The oversight committee will hold public hearings to get input on the program, and come up with recommendations for the next Legislature by December 2008, according to a bill passed in May by Rep. Patrick Rose, D-Dripping Springs.

Goodman said that today, the HHSC uses TIERS to handle 5 percent of its cases, and the pilot in Hays, Williamson and Travis counties accounts for most of that. In January, the agency began a new Women's Health Program and uses TIERS for enrollment. The HHSC also converted the state's foster care records to the program in March.

Still, the federal government is holding back on approving the program's further rollout to handle food stamps in any new counties until a few new functions can be built into the program, including the ability to track historical records of food stamp fraud.

The HHSC cut off its contract with Accenture in March, and rehired Deloitte to manage TIERS, and HHSC staff handles call center operations. Deloitte declined to be interviewed for this article, citing a company policy against commenting on projects while under contract.

"I think the future is going to continue to move in this direction, to more and more distance encounters and distance enrollments. It's just getting the technology to a reliable state," Flood said. "We were the test state."

People forget how big Texas is, Gumbert said, and what a strain it can be when everyone calls in at once. It's been a long struggle to get TIERS where it is today, and Gumbert said he's prepared to be working on the program for a long time. "We're taking small steps," he said. "That's the only way to do something like this."

Many more states will be moving to new eligibility systems in coming years, and Goodman said Michigan, for one, is using TIERS as the basis for its own program. To venture so far into uncharted waters, with so many people's critical benefits on the line, is an inherently touchy proposition. As other states move ahead with similar programs, Goodman said all managers can do is prepare themselves to face inevitable challenges.

"When you have a system that serves 30 million people and approves critical benefits," Goodman said, "there is no margin of error."

 

 

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