The launch of HealthCare.gov — the federal health insuranceexchange website mandated by the Patient Protection and AffordableCare Act — went live Oct. 1. So many problems plagued the site thatit prompted Congress to hold hearings about it in late October,with House GOP members demanding answers from involved parties thatranged from site contractors to Department of Health and HumanServices Secretary Kathleen Sebelius.

Experts outlined many of these issues in the September BenefitsSelling cover story “SystemFailure,” which predicted the project’s schedulingchallenges, necessary system interfaces and user experiences couldlead to problems. But the scope of them went far beyond the site’sinability to process complex individual applications, as evidencedby the software crashes that rendered HealthCare.gov inaccessibleto users.

Not only that, but enrollment numbers recently released by HHS fell short of expectations.Nearly 27,000 people signed up for private health insurance thoruhgHealthCare.gov one month into enrollment.

So what went wrong? What, if anything, went right? And what’sbeing done to resolve these issues?

Problem areas

The most obvious issue was the website’s inability to manage aheavy use load: On the first day of the launch, it crashed due tothe sheer number of potential plan enrollees hoping to register andshop online. Although the situation has improved, it didn’t instillfaith in consumers or legislators that the site was ready toprocess the seven million applications the administration expectsto log on before the end of March.

Last-minute software changes emerged as another pain point. Forexample, when the site first launched, users were required toregister for an account before they could start shopping for plans— a design issue consumers found frustrating and experts said wasantiquated.

“Anybody who has any type of website or ecommerce experience orunderstands anything about user experience knows that’s a bigmistake,” says Andrew Carricarte, chief executive officer of IOSHealth Systems, in Miami. “And I think the decision was made bysomebody from the outside with no knowledge of how the technicalaspects work — particularly that late in the cycle and that late intesting.”

The site’s decision-makers have since changed course, allowingconsumers to browse what’s available before registering.

Read: A walkthrough of HealthCare.gov

“That being said,” Carricarte adds, “that should not have led tothe performance issues they experienced, even if you had everybodyregistering for an account. When they use these big numbers —700,000 people visiting the site to purchase health insurance — tomost people, it sounds like a big number, but it’s really not ahigh number in respects to most websites. When you look atcompanies like Amazon, Google or Facebook, which are in thebillions. By comparison, it’s an extremely small number.”

The site’s ability to interface with other websites, includinggovernment sites such as the Internal Revenue Service or theDepartment of Veterans Affairs, probably made things worse, expertssay.

“When you sit down and decide what the requirements are thatthis system has to do, somebody has to start mapping out theinterfaces,” says John Sarich, vice president of strategy at VUESoftware, in Omaha, Neb.

“Those systems weren’t designed and structured so hundreds andthousands of people can access them. You’re going to go to othersystems from other government agencies to get and validate moreinformation. So consequently, you have to interface to thosesystems. And those systems are old. Tapping into those systems wasnever intended to be this extensive, so consequently, they createdbottlenecks, and they should have seen that very early on.”

Health care information technology attorney Tatiana Melnik sayscorrupt data is another issue that’s been reported already — andlikely to get worse.

“The insurance carriers are receiving bad data,” she says.“There isn’t any specific information about how many applicationshave gone through to insurance providers, but from the reports I’veseen, the ones that have gone through have had some problems in theclassification of dependents and things of that nature. This is areal costly issue — and this is why the IT issues are soproblematic, because many companies are relying on the data beingcorrect.”

And with more than 50 different vendors working on differentareas of the site, it was almost inevitable glitches wouldappear.

“You’ve got various disparate or siloed platforms — a federaldata hub, Medicaid systems,” notes Michael Weiskirch, humanrelations and benefits technology consultant at HNI, in New Berlin,Wis. “It’s a hodgepodge of platforms as well as consultants andvendors working on this thing that’s supposed to come together, andit got really rushed. There’s an issue of lack of alignment notonly from a project management standpoint, but also from a systemsstandpoint.”

Although information security hasn’t been an issue yet, expertssay, it’s likely to become one as more consumers flock toHealthCare.gov to seek out insurance.

“I suspect that in the next three or four months, there’s goingto be some type of security breach or issue with that website,”Carricarte says. “If they were that lax with what they needed toaccomplish with basic testing and performance, one can only assumethat there is some laxness and oversight with the securityprotocols, especially given all of the new changes they are tryingto implement in a short period of time. It’s a high-profile targetand this should have been their first priority.”

Testing

The biggest thing the government could have done to preventthese problems, experts say, is allot more time for testing.

“There are very extensive test criteria,” Sarich explains. “Youcome up with hundreds and hundreds of scenarios of somebody who’saccessing the system — maybe they forget something and their logintimes out, or they forgot their password. All the different casesyou can get, you’ve got to test for them from the ground up.”

Aaron Mulder, an IT expert for Chariot Solutions inPhiladelphia, says load tests would have helped site creatorspinpoint problem areas before the site launch, which could haveprevented the system crashes.

“We have to take it for granted that there are going to behundreds of thousands of people trying to use this site,” he notes.“When we put the load on the system and see which part is breakingdown, then we can put a fix in. And a combination of testing iswhat’s called for — you want to make the site more user-friendlyand fix the underlying problems that make everything available andbring it up to speed.”

“There simply wasn’t enough time to adequately test thesesystems,” says Dan Schuyler, a director at Leavitt Partners whohelps guide the firm’s exchange practice. “And as a result, we’regoing to have problems like we’ve been seeing.

“I think the pieces are in place that need to be in place,” headds, “However, because all the connections weren’t thoroughlytested, we’re seeing the problems we’re having.”

Data corruption

“There have been errors with the applications going to thecarriers,” Schuyler says. “That’s another areathat needs to be addressed and resolved quickly. Thoseapplications, when submitted in large volumes, have to be 100percent error-free because the carriers don’t have the time orresources to go through the applications one at a time to resolvethose errors.”

Carricarte agrees, “If you get an incomplete applicationreceived by an insurer, it’s incomplete. Any errors on thatapplication, and they can’t assume the risk. They’ll either deny itor send it back as incomplete. No one has said much about the dataintegiry issues, which I believe will become a much larger problemas the initiative continues.”

And these data issues are costly, wasting time and money acrossthe spectrum.

“The escalating costs aren’t just for project-specific costs,they’re all down the line,” Melnik says. “The insurance company hasto undertake additional steps checking and correcting data; and theconsumer may need to go back and fill out the application again;and everyone is spending all this time doing duplicate work.”

There’s also the question of industry standards — carriershaven’t had to align their application process, and as Muldernotes, the data fields must be able to handle multiplepossibilities.

“It could be you lost your job, added new children to yourfamily, or you want continue your plan,” he explains. “There are 20ways to convey the same piece of information. The result is thatyou really need to work back and forth with some realistic requestsand see what happens.”

Security

Although there haven’t been security breaches yet, thosefamiliar with health care data say it’s only a matter of timebefore the specter becomes a reality. And another problem thatshould have been anticipated, experts say, is the proliferation ofunofficial health care exchange websites that show up in searchengines and entice unwitting consumers to enter their personalinformation.

“If you type ‘health insurance exchange’ into a search engine,there’s a whole series of websites that pop up that appear to beexchanges, and it’s very confusing,” Carricarte says.

Dr. Deane Waldman, a board member of the New Mexico stateexchange, says security is a key worry — and one New Mexico wasmore prepared for than the federal government.

“We spent a lot of time preparing for the scams we knew werecoming down the pipe,” he says. “Part of our advertising campaignis to make sure that people in our state are talking to the rightpeople and not giving their information to the wrong people.”

Systemic problems

Schuyler sees another big systemic problem that’s hopefully beenresolved.

“I think the other issue, which was startling, is that CMS wasthe general contractor, the foreman for this massive IT project,and that’s something that they should have contracted out for,” heexplains. “They don’t have the knowledge or resources to be able tomanage a project of this size and magnitude; that they’ve decidedto put a contractor in this position is reassuring. They chose avendor who’s already working on HealthCare.gov instead of findinganother vendor, and considering the timeframe, that makessense.”

Weiskirch believes that instead of setting up exchanges throughthe federal government, the administration should have pushed forlegislation that expanded current programs for wider use.

“The whole concept of the exchanges was overengineered andpoorly designed,” he argues. “We have existing infrastructure —Medicaid, COBRA and other things — that theycould have changed or modified to handle the uninsured, and then legislated some of theother things like dependent children and pre-existing conditions.You didn’t need to build this elaborate system.”

And the website itself could lead to a big systemic problem: notattracting enough of the young, healthy Americans desperatelyneeded to help fund expanded insurance for sick Americans.

“You’re having an adverse selection situation simply because thepeople who are less healthy have a greater appetite and toleranceto move through the process,” Weiskirch says. “If you’re 22 yearsold, just out of college and not eligible for subsidies, theindividual mandate penalty is really not motivating you to apply.To make matters worse, you’re reading the news that HealthCare.govisn’t working. So you’re going to delay registering as long aspossible, and those are the people who need to be in the system sowe can spread the risk.”

Silver linings

With all the problems, it’s difficult to see what went well withthe exchange rollout — but there are some silver linings. “The userinterface and the visual, graphical interface is easy,” Carricartesays. “It’s something that’s simple for most people to understand.They followed a lot of the neo web 2.0 look and feel to try toattract the younger insured.”

Melnik adds that the promotion of the website was done well, asevidenced by its popularity.

“Clearly they had enough interest because people were trying toregister, so their marketing efforts paid off,” she says. “There’sa huge interest in getting insurance.”

And the site is relatively easy to use, too.

“It gives you the information you’re looking for,” Mulder says.“You can put in your family size and say you want coverage foreverybody, and it’ll tell you which providers are in your area,which plans they have. It looks nice, and it’s not like it’simpossible to find the basics.”

Next steps

Sumit Nijhawan, chief executive officer of software companyInfogix, in Naperville, Ill., notes that controls could be put intoplace to streamline the data.

“If someone is hitting the submit button twice, resulting in aduplicate enrollment, a control upfront would catch thoseduplicates, but it appears they haven’t built enough upfrontcontrols,” he says. “So whether it’s duplicates, incomplete data,incorrect data, it’s up to the health plans to catch those issues.And they can, but they have to go back to the marketplace team tocorrect the issues. And all that takes time, which means eventhough the enrollments have been initiated, they haven’tnecessarily been completed. If the checks and balances were inplace to ensure data integrity upfront, things would gosmoother.”

Nijhawan adds that continuous monitoring of the data is vital toensure that the information health plans are receiving is completeand correct.

“Putting the controls in place in an end-to-end way so thehandoffs are being looked at from all sides, depending on how manytrading partners are involved, would mean that at any given time,one can prevent the issue as soon as possible to prevent delays andgive the members an idea of where the application is.

“It’s very doable,” he adds. “We just have to take the rightsteps. As the volume picks up and there are more issues, there areonly so many ways to catch issues manually, and it’s going tobecome unsustainable and the enrollment issues will lead to otherissues — payment-related issues, reconciling payment and subsidies— and in January, it will lead to claims issues.”

“They’ve got to step back and start looking at what’s importantto be able to do today in order to get people enrolled and what canthey phase in over the next year or so,” Sarich says.

Carricarte thinks delaying some of the 2014 deadlines is goingto be necessary, given the site’s glitches.

“They’re going to have to postpone and delay, certainly thepenalties and perhaps some of the policies,” he says.

And regular behind-the-scenes updates and enhancements alsoshould be implemented to help maintain the site.

“Only deploy what you can get out the door,” Mulder suggests,“and then update it a week later or a day later.”

Also read: A walkthrough of HealthCare.gov