Texas had big plans for its new health and human services application and eligibility program. After investing heavily to get the new system 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 in the 1970s, however, employees were up in arms. They were accustomed to the old system; they knew all the 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 of Texas' 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), 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, contend that the switch to TIERS 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 snarl its rollout. The story of the system's implementation holds lessons for agencies across the nation that are working to integrate complicated systems.
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 stands by its new program.
An Aging System
Texas' 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 use during 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. 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 two Texas counties: Travis and Hays.
At the same time, however, policy changes were brewing that would significantly complicate deployment of the new system. First, the Texas Legislature reorganized the state 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 the state's annual operating budget. Then, the Legislature directed the HHSC to explore using private call centers, rather than walk-in government offices, for processing requests for social services benefits.
Signs of Trouble
As the call center plan moved forward, HHSC needed a data management system to support its new phone-based eligibility operations. The situation put HHSC officials on the horns of a dilemma: They could revert to SAVERR, a 20-year old program that was never designed to work in a call center environment. They could adapt TIERS, which already had cost the state hundreds of millions of dollars, but also wasn't designed for call-center operations. Or they could use proprietary software provided by the company chosen to operate the newly privatized call centers.
SAVERR worked, but the agency had already been directed to find a replacement, and the technology was quickly becoming outdated and unsupportable. HHSC managers decided against letting the call-center vendor use its own eligibility software because they didn't want to be locked into a proprietary solution, according to a report from HHSC Inspector General Brian Flood.
TIERS - developed for the state by Deloitte Consulting LLP - remained a work in progress, but the HHSC already had invested a substantial amount of money and time in the new program. Therefore, 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 task, 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 for call center use, TIERS was very complicated. During pilot deployments, TIERS encountered problems that led to longer case-entry times and an inability to create certain case history reports needed for federal compliance. A report by HHSC Inspector General Brian Flood and a separate federal audit found that the program had serious design flaws as an eligibility-processing tool.
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. Still, when the HHSC submitted its call-center plan to the federal Food and Nutrition Service - which provides the state money for food stamps - the state commission said it would push ahead with TIERS.
A Benefits Behemoth
Despite the problems, 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, which was released in April.
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 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.
When Accenture won the call center contract in 2005, the HHSC handed the company the job of running TIERS as well. The program still needed work, but to speed things along, the HHSC cut 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."
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, according to the report.
"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 CIO. "Why go out and have to go through certification again? It's a waste of money."
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 call-center workers enter enrollment data into TIERS and SAVERR concurrently.
By that time, however, hundreds of HHSC employees who were proficient in SAVERR had taken new jobs because their offices were being replaced by call centers staffed by the contractor's personnel. 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 Texas Legislature hoped to save hundreds of millions of dollars from the switch.
In practice, however, losing that much institutional memory may have come at a heavy cost. "The amount of training was different for the contractor staff, who were brought on in great numbers," Flood said, "but had almost no background knowledge."
Gumbert said getting staff - 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 instance, SAVERR had an error rate of 5 percent to 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 under such close watch by the media.
Furthermore, it's difficult to predict how employees will adapt to new programs and which mistakes they will make, McCurley said, explaining that those factors are why an agency starts with a pilot and makes adjustments to employees' actions.
"No matter how good a job you do of drawing up the process in a lab, [employees are] going to do what they're going to do," he said. "You really have very little control over their behavior."
The HHSC cut off its call-center contract with Accenture in March, and the controversy around TIERS and the push for private call centers came to a boil 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.
The state rehired Deloitte to manage TIERS, and HHSC personnel handle call center operations. Deloitte declined to be interviewed for this article, citing a company policy against commenting on projects while under contract. Today, TIERS handles about 5 percent of the HHSC's cases, according to Goodman, with pilot deployments in Hays, Williamson and Travis counties accounting for most of that.
In January, the HHSC began a new Women's Health Program and uses TIERS for enrollment. The commission also converted the state's foster care records to the program in March. Still, the federal government is withholding approval of TIERS rollouts for food stamp programs in additional counties until new functions can be built into the program, including the ability to track historical records of food stamp fraud.
Despite the struggles involved in launching the call centers, Texas officials remain convinced that their efforts eventually will pay off.
"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, and what a strain it can be when large numbers of citizens call in at once, Gumbert said, adding that he's prepared to work on the program for a long time.
"We're taking small steps," he said. "That's the only way to do something like this."
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."