Medicare Transaction System: Serious Managerial and Technical Weaknesses Threaten Modernization

Published by the Government Accountability Office on 1997-05-16.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                          United States General Accounting Office

GAO                       Testimony
                          Before the Subcommittees on Human Resources and on
                          Government Management, Information and Technology,
                          Committee on Government Reform and Oversight,
                          House of Representatives

For Release on Delivery
Expected at
11:30 a.m.
May 16, 1997              TRANSACTION SYSTEM

                          Serious Managerial and
                          Technical Weaknesses
                          Threaten Modernization
                          Statement of Joel C. Willemssen
                          Director, Information Resources Management
                          Accounting and Information Management Division

Messrs. Chairmen and Members of the Subcommittees:

We are pleased to join you today in examining the status and prognosis for
success of the Health Care Financing Administration’s (HCFA) Medicare
Transaction System (MTS), being designed to bring Medicare claims
processing into the next century. Developing this system is not an easy
task. Attempting to replace nine separate automated information systems
with a single, unified system is clearly a very complex endeavor.

The goals of MTS include improved customer service; reduced operating
expenses; more effective control over claims processing; better oversight
of contractors; substantial administrative savings; better protection of
program funds against waste, fraud, and abuse; and the ability to
accommodate managed care and other alternative payment
methodologies. One specific, basic improvement that MTS is expected to
provide over the current environment is the need to modify only one
system when changes, such as those following enactment of legislation,
affect Medicare payments. At present, each system must be individually
changed—an expensive, time-consuming process.

Both we and the Congress have had long-standing concerns about the
development of MTS.1 Today, we are issuing a report that discusses our
analysis of HCFA’s progress in managing the development of this system.2
Eighteen months ago we similarly testified on early symptoms of
unnecessary risk to this project, and in 1994 we reported on its benefits
and acquisition risks.3 The fact remains that despite much hard work and
some progress, critical weaknesses—both managerial and
technical—continue to exist. These weaknesses call into serious question
whether MTS, without significant change, will be able to perform as
required. Further, as we will illustrate, costs have been escalating sharply;
even if performance is as expected, we would have to ask: Is it worth the
estimated $1 billion price? Could similar system functions be acquired at
significantly lower cost? We believe that more can and must be done if
HCFA is to obtain the type of system it needs. Our report includes 20 major
recommendations to help HCFA enhance the likelihood of acquiring the
kind of system it must have in a cost-effective manner.

 A list of reports and testimony related to MTS appears at the end of this statement.
Medicare Transaction System: Success Depends Upon Correcting Critical Managerial and Technical
Weaknesses (GAO/AIMD-97-78, May 16, 1997).
 Medicare Transaction System: Strengthened Management and Sound Development Approach Critical
to Success (GAO/T-AIMD-96-12, Nov. 16, 1995) and Medicare: New Claims Processing System Benefits
and Acquisition Risks (GAO/HEHS/AIMD-94-79, Jan. 25, 1994).

Page 1                                                                             GAO/T-AIMD-97-91
                     My statement today will discuss the actions HCFA has taken to date, and
                     where these steps leave the agency in its development of a system that can
                     handle Medicare claims processing into the next century. I will then cover
                     the three related major areas that we believe need the most attention. The
                     first area involves HCFA’s management of the interim claims-processing
                     environment in which it must operate until conversion to MTS or another
                     system has been completed; this includes addressing adaptations required
                     by the century change that is only 959 days away.4 The second area of
                     concern relates to managing the development of MTS as an investment.
                     This means using cost-benefit analyses and other tools to continually track
                     and assess whether funds spent on MTS will contribute to a return on this
                     investment, as measured not only monetarily but against the system’s own
                     goals as well. Finally, sound systems-development practices are critical in
                     order to reduce risk and help ensure quality, timeliness, and cost
                     containment. We continue to see major gaps in HCFA’s application of sound
                     systems-development practices—practices that are essential to assisting
                     management in controlling the development of systems requirements and

                     Medicare is an enormous program, and it will only get bigger. As the
The Medicare         nation’s largest health insurer, it serves some 38 million Americans by
Transaction System   providing health insurance to those aged 65 and over and to many of the
                     nation’s disabled. It now disburses over $200 billion in health care benefits
                     every year. With an aging population and a rapidly expanding workload,
                     this figure is expected to reach $288 billion by 2000, at which time the
                     Medicare program expects to be processing one billion claims annually.

                     The Medicare program is divided into to areas—part A and part B. Part A
                     encompasses in-patient services, with claims paid to hospitals, skilled
                     nursing facilities, hospices, home health agencies, and rehabilitation
                     centers. Part B comprises outpatient services, with claims paid to
                     physicians, laboratories, equipment suppliers, and other outpatient
                     providers and practitioners.

                     Claims processing for the Medicare program is handled at some 45 sites
                     throughout the country by about 70 private companies under contract with

                      In brief, this entails expanding the date field or rewriting program code to differentiate between 1900
                     and 2000; many systems today use only two digits for the year, such that “00” could be read as either
                     1900 or 2000. For an explanation of the expected impact of the year-2000 change on computer systems,
                     see Year 2000 Computing Crisis: Strong Leadership Today Needed To Prevent Future Disruption of
                     Government Services (GAO/T-AIMD-97-51, Feb. 24, 1997).

                     Page 2                                                                            GAO/T-AIMD-97-91
                       HCFA.Contractors handling part A services, called intermediaries,5 have
                       been using three different computer systems to process claims; those
                       handling part B, called carriers, use six different systems.6

                       In order to handle the anticipated increases in volume and improve the
                       efficiency and effectiveness of Medicare operations, HCFA is developing
                       one unified computer system to replace today’s operating environment. In
                       January 1994, HCFA awarded a contract to a software developer to design,
                       develop, and implement a new, government-owned, automated
                       claims-processing information system, to be called the Medicare
                       Transaction System, or MTS.

                       As part of my presentation today, I would like to discuss three charts that
HCFA Actions to Date   should help illustrate our major points. Copies of these charts appear at
                       the end of my statement. In an attempt to achieve some savings before MTS
                       is fully operational, HCFA is now undertaking several actions to prepare for
                       the interim operating environment, while simultaneously continuing its
                       development of the final system.

                       As our first chart indicates, one interim step involved selecting one system
                       from the initial nine systems to process claims for Medicare part A, and
                       another for part B. The part A and part B systems have been selected and
                       conversion has begun. A second, planned step entailed cutting the number
                       of processing sites by over half, to about 20 nationwide. HCFA then planned
                       to move data processing from these 20 consolidated sites to two planned
                       MTS processing sites in mid-1998. During this interim period, HCFA is also
                       relying on its contractors to revise their systems to accommodate
                       year-2000 processing. Throughout this process HCFA’s software
                       development contractor was to be conducting activities to develop the MTS

                       These software development plans are now, however, on hold for 90 days.
                       On April 4, 1997, HCFA announced that following a recent management
                       review, it was redirecting its software development contractor to focus
                       solely on the managed care module of MTS—the first of six planned
                       releases. While reaffirming its faith in MTS as the best information
                       technology to take Medicare into the next century, HCFA officials said that
                       they will use this time to examine alternative methods for achieving their
                       MTS goals.

                        Intermediaries also process some part B claims.
                        One of the three part A systems was recently converted, leaving a total of eight—two part A systems
                       and six part B.

                       Page 3                                                                          GAO/T-AIMD-97-91
                        The first main problem area involves HCFA’s interim operating
Interim Environment     environment—before MTS—and the challenges of the coming change of
and Year 2000 Present   century. HCFA has approached managing the environment in which it will
Serious Challenges      operate for the next 3 years without adequate planning. To successfully
                        handle the claims workload, consolidate existing processing sites, address
                        year 2000-related issues, and convert from the original nine systems to
                        two, careful and detailed planning is necessary. This has not been done.
                        While HCFA is already beginning to convert its systems and consolidate its
                        sites, few plans exist to guide these activities. What sorts of plans are
                        needed? At minimum, a schedule and estimate of resources required for
                        transition to the interim environment, details defining contractor
                        responsibilities, and an approach for tackling the potentially complex
                        year-2000 issue.

                        To simultaneously convert systems for the interim environment while at
                        the same time managing ongoing development of MTS is risky enough; this
                        risk is further magnified by HCFA’s lack of experience in undertaking such
                        a complex project. In such an environment, we believe it is especially
                        important that HCFA develop specific performance measures against which
                        the interim systems can be assessed. Performance measures could show
                        that the “interim” systems may be all that is needed, or could be used to
                        help management make refinements to its modernization effort as it

                        We also see unnecessary risk in HCFA’s reliance on its Medicare
                        contractors to address the year-2000 issue. Information systems
                        worldwide—including those that process Medicare claims—could
                        malfunction or produce incorrect data simply because they have not been
                        designed to handle dates beyond 1999. Failure to adjust systems for 2000
                        and beyond could cause payment delays, as well as losses due to bypassed
                        system controls that flag claims that should be paid by a beneficiary’s
                        other insurer. Since “00” could be read as 1900 instead of 2000, all
                        date-dependent calculations would be affected; this would have an
                        obvious impact on the computed age of a beneficiary and, therefore, on his
                        or her eligibility. For example, an individual born in 1920 might have been
                        receiving benefits since turning 65 in 1985. Such benefits could, however,
                        cease in 2000 if the computer system, reading 2000 as 1900, saw the
                        individual as negative 20 years old—not even born yet.

                        The timing of HCFA’s transition strategy makes the claims-processing
                        contractors’ task—assessing, planning, and implementing whatever
                        changes are necessary—even more of a challenge. For example, the

                        Page 4                                                     GAO/T-AIMD-97-91
                       contractor for the single system selected to process part B claims will have
                       to handle the conversion of the five other, existing part B systems—while
                       modifying the chosen system to be year-2000 compliant. Yet HCFA officials
                       have not closely monitored these critical activities, or demanded
                       certification from contractors that their systems will be made year
                       2000-compliant. A further complication is that these contractors may not
                       have much incentive to make these adaptations properly because HCFA
                       intends to eliminate them once MTS has been fully implemented. Officials
                       are “surveying” contractors on the year-2000 issue, however, and have
                       requested estimates of when the systems will be made compliant.

                       To help HCFA effectively manage its interim Medicare processing
                       environment, our report recommends that the Secretary of the Department
                       of Health and Human Services (HHS) direct that the HCFA Administrator

                   •   prepare plans that detail the steps involved in making the transition to the
                       single part A and part B systems, define how systems will be converted to
                       address potential year-2000 problems, and delineate the steps necessary
                       for thorough systems testing before conversion;
                   •   establish a means of assessing performance in the critical early stages of
                       the transition, and apply any lessons learned to planning for MTS; and
                   •   help ensure reliable operation of systems through the year 2000 by
                       identifying management and oversight responsibilities, assessing the
                       timing and likely severity of impact if adaptations are not adequate,
                       developing contingency plans, and reporting progress regularly to HHS.

                       Our second major area of concern involves investment management. One
MTS Is Not Being       cannot make informed technology investment decisions without a valid
Managed as an          cost-benefit analysis, knowledge of available alternatives, and an
Investment             evaluation of how proposed technology benefits will contribute to
                       improved mission performance. Carrying out these assessments is more
                       than simply a best practice; it is required by law. As you know, last year’s
                       Clinger-Cohen Act seeks to maximize the return on investments in
                       information systems by instituting sound capital investment

                       Under Clinger-Cohen, agencies must design and implement a process for
                       maximizing the value and assessing and managing the risks of information
                       technology acquisitions. Further, this process is to be integrated with the
                       processes for making budgetary, financial, and program management

                       Page 5                                                       GAO/T-AIMD-97-91
decisions, and include criteria to be applied in considering whether to
undertake a particular information systems investment.

Specifically, the process should provide for (1) identifying information
systems investments that would result in shared benefits or reduced costs
for other government agencies, (2) identifying quantifiable measurements
of benefits and risks of proposed investments, and (3) the means for
senior management to obtain information on the progress of information
systems investments. None of this has yet been done effectively for MTS.

HCFA’s estimates of MTS benefits are based primarily on unsupported
assumptions. For example, officials said that much of the anticipated
programmatic savings would result from automated edits to identify
unnecessary medical services and abusive billing that could result in
excessive payments. They acknowledge, however, that since they have not
yet identified the edits to be included in MTS, resulting savings could differ
substantially from the estimates. Another incorrect assumption is that
without MTS, costs per claim would continually increase between 1993 and
2002. Yet actual contractor cost reports for 1994 through 1996 show a drop
of about 10 percent.

Our second chart illustrates the escalation of MTS costs; the figure on the
left is an estimate, using HCFA data, of total program costs through
complete implementation, while the one on the right is
software-development contract costs only. I want to make clear that the
dates on these figures refer to when the estimates were made.

Both figures do show recent steep increases. In total, estimated MTS costs
have jumped 7-fold in 5 years, from $151 million in 1992 to about $1 billion
today. I should point out that the $1 billion figure includes costs for the
transition to the interim environment and to acquire MTS operating sites.
Many aspects of the overall development effort remain vague; for example,
requirements still have not been defined. Absent this, estimates of total
software-development costs are, of necessity, extremely rough at best.

There are alternatives to spending of this magnitude, and we
believe—especially given the recent escalation of costs—that HCFA has a
responsibility to explore them. Two years ago we urged HCFA to investigate
commercial, off-the-shelf software to help detect billing anomalies; we
understand that this research is continuing. We believe that combined with
administrative savings accruing from the consolidation of systems,
commercial software could allow HCFA to realize substantial savings now.

Page 6                                                       GAO/T-AIMD-97-91
According to HCFA’s estimate, MTS will not be fully operational, at the
earliest, for at least 3 years. During that period, hundreds of billions of
dollars will have been spent on Medicare claims.

As part of the complete MTS system, HCFA plans to establish two MTS
claims-processing sites and a data operations and analysis center. This
decision was made with inadequate analysis in terms of decision criteria,
alternatives analysis, and technical risk analysis. The decision to have two
processing sites was made on the basis of data-storage and
disaster-recovery considerations only. Given the importance of these
steps, our report recommends that the Secretary of HHS withhold funding
for the MTS operating site contracts until an approach has been selected
that is based on these crucial analyses.

Managing a project as an investment also requires strong managerial
oversight; this has not been the case with MTS. Consistent senior-level
involvement in major decisions is still lacking. Many of the critical MTS
investment decisions have been made without the involvement of HCFA’s
executive decision-making body, the MTS management board. HCFA is,
however, making positive changes; it has designated a chief information
officer and has established an investment review board.

To help HCFA minimize unnecessary spending while developing and
implementing MTS, our report recommends that the Secretary of HHS direct
that the HCFA Administrator justify continuation of MTS with valid
cost-benefit and alternatives analyses that include goals for reaching
programmatic savings and that link estimated savings to specific Medicare
claims-processing improvements—and take appropriate action on the
basis of these analyses.

Our report also recommends that the Secretary of HHS assist HCFA by
providing oversight in accordance with legislative provisions in the
Clinger-Cohen, Paperwork Reduction, and Federal Acquisition and
Streamlining Acts. This should include monitoring by HHS’ chief
information officer. The report further recommends that in accordance
with Clinger-Cohen, the Office of Management and Budget (OMB) utilize its
enforcement authority to ensure HCFA’s compliance with the act, including
the cost-justification provision.

Page 7                                                         GAO/T-AIMD-97-91
                       The third major problem we see is that HCFA is not ensuring that sound
Not Following Sound    systems-development practices are followed. Because of this, the agency
Systems-Development    has decreased the chances of controlling the development of systems
Practices Threatens    requirements and software. HCFA has not developed plans critical to
                       systems success, has not managed its schedule well, and has not
Quality, Timeliness,   adequately monitored its contractor’s software-development strategy.
and Cost Containment   Further, because of faulty assumptions on the part of the contractor,
                       estimates of software-development costs are not reliable. Consequently,
                       the risk that such estimates could rise before the project is completed is
                       very real. Finally, HCFA has not implemented a concerted program to
                       minimize risk.

                       Attention to these steps is common to organizations that succeed in
                       acquiring well-performing automated information systems. Not managing
                       in this way significantly increases the threat to overall system quality,
                       timely completion, and reasonable cost expenditures.

                       Our final chart today shows what can happen when such guidelines are
                       not followed. This illustrates how the number of systems requirements
                       changed over time for the first five contract releases of MTS. The lack of
                       symmetry illustrates the enormous volatility in how many and what types
                       of systems requirements are seen as necessary as development
                       progresses—and this after several years of attempting to define what the
                       system will actually do.

                       Deficiencies in several critical systems-development processes provide
                       early warning of weaknesses in the management capability of HCFA itself
                       and of its contractors. These factors all increase risk. Critical risks that
                       remain unmitigated include (1) missing or inadequate plans for three
                       important components of systems development—requirements
                       management, configuration management, and systems integration, (2) the
                       compression of MTS’ development schedule, and (3) the lack of valuable
                       metrics, which are measures of software quality and performance. Taken
                       together, the number and significance of these unmitigated risks, along
                       with several others, raises the question of whether MTS can become the
                       management tool that HCFA expects.

                       An aspect of the MTS schedule that we see as troubling is that individual
                       systems-development phases now overlap to a dangerous degree. Systems
                       are typically constructed in five phases: analysis, design, development,
                       testing and validation, and implementation. When, for example, testing
                       and validation begins before development has been completed, or

                       Page 8                                                       GAO/T-AIMD-97-91
    implementation begins before the end of testing, the resulting overlap can
    clearly cause problems. These steps were meant to be predominantly
    sequential because each phase’s success depends, in part, upon adequate
    progress in the previous phase. If a contractor advances too far into a
    succeeding systems-development phase before sufficient progress has
    been made in the previous phases, the risk of technical problems increases
    significantly. The current HCFA schedule for MTS shows concurrency in all
    five phases between September 1997 and September 1998, and overlap is
    also present in the schedules for each planned release, such as managed

    To help ensure the success of MTS, our report recommends that the
    Secretary of HHS require that the HCFA Administrator, before proceeding
    further with MTS development, direct and remain accountable for

•   completing and implementing plans that are critical to effective systems
•   requiring an independent evaluation of the MTS contractor’s software-
    development capability prior to beginning that phase;
•   completing a new and integrated MTS program schedule for the entire
    initiative, including the interim, and resources and costs for each task; it
    should also minimize overlap in the systems-development phases; and
•   mitigating critical risks by designating an official accountable for risk
    management, and ensuring that this individual implements a process that
    will, among other elements, identify and quantify significant risks,
    establish time frames for assessing status and for mitigation, and develop
    measures for assessing mitigation effectiveness.

    Finally, we believe that closer oversight by both HHS and OMB is necessary
    to ensure that MTS or any alternative system is developed along the lines
    that we are recommending. In particular, we see HHS as a critical player in
    assisting HCFA and in monitoring its actions. For its part, OMB is authorized
    under Clinger-Cohen7 to take enforcement actions to ensure that HCFA
    complies with the law’s provisions, including the mandate to justify major
    information technology projects with sound, investment-based analyses.

    In summary, HCFA is proceeding with a project that has serious managerial
    and technical weaknesses. In order to bring Medicare claims processing
    into the next century with confidence, we believe that HCFA must manage
    as an investment any information technology it seeks to acquire. This
    means performing the analyses necessary to predict the kind of return the

     Section 5113 (b)(5).

    Page 9                                                       GAO/T-AIMD-97-91
investment is likely to provide, short-term and long-term—in a fiscal as
well as technical sense. HCFA then has an obligation to manage such a
challenge through the use of sound systems-development practices.

We are encouraged that in commenting on a draft of the report being
released today, both HHS and OMB have recognized the problems we have
identified and agreed with all of our recommendations for addressing
them. However, these recommendations must be effectively implemented
in order for a project such as MTS to be successful.

This concludes my statement. I would be happy to respond to any
questions you or other Members of the Subcommittees may have at this

Page 10                                                     GAO/T-AIMD-97-91
Page 11   GAO/T-AIMD-97-91
Attachment I

Related GAO Products

               Medicare Transaction System: Success Depends Upon Correcting Critical
               Managerial and Technical Weaknesses (GAO/AIMD-97-78, May 16, 1997).

               Year 2000 Computing Crisis: Strong Leadership Today Needed To Prevent
               Future Disruption of Government Services (GAO/T-AIMD-97-51, Feb. 24, 1997).

               Medicare: Millions Can be Saved by Screening Claims for Overused
               Services (GAO/HEHS-96-49, Jan. 30, 1996).

               Medicare Transaction System: Strengthened Management and Sound
               Development Approach Critical to Success (GAO/T-AIMD-96-12, Nov. 16, 1995).

               Medicare: Antifraud Technology Offers Significant Opportunity To Reduce
               Health Care Fraud (GAO/AIMD-95-77, Aug. 11, 1995).

               Medicare Claims: Commercial Technology Could Save Billions Lost to
               Billing Abuse (GAO/AIMD-95-135, May 5, 1995).

               Medicare: New Claims Processing System Benefits and Acquisition Risks
               (GAO/HEHS/AIMD-94-79, Jan. 25, 1994).

               Page 12                                                     GAO/T-AIMD-97-91
Attachment II

HCFA Strategy for Transition to MTS

    GAO         HCFA Strategy for Transition to MTS

                From:                                                                        To:
                9 separate claims-processing                                                 A single part A and a single part B
                systems at about 45 sites                                                    claims-processing system at about 20 sites

                          A1                B1                                                        A
                                                      B1                                                              B
                 B4             A2                                                      B1                    A
                                            B5                A3                                                  B
                                                                        A3                                                        A
                      A2               A2                                          B6             A                                       B
                                                      A3                                                                  A
                               B2                                                                         B
                                            B4                               B6                                   B                   B
                                                                   B3                                                         B
                                                                              B3                                      B               B

                From:                                                                        To:
                A single part A and a single part B                                          The Medicare Transaction
                claims-processing system at about 20 sites                                   System at 2 sites

                      A                                                            B

                                            B                                B

                                                      B                       B

                                                                        Page 13                                                               GAO/T-AIMD-97-91
Attachment III

Medicare Transaction System: Escalating

   GAO                      Medicare Transaction System:
                            Escalating Costs

                        Total Estimated Costs                                Software Development
                                                                                 Contract Costs
   1100      Dollars in millions                             100   Dollars in millions

   1000                                                       90
    900                                                       80

    200                                                       20

    100                                                       10

      0                                                        0

          4/92                     12/93             11/96         1/94                                7/96 9/96

                                           Page 14                                            GAO/T-AIMD-97-91
Attachment IV

Volatility of MTS Requirements

     GAO                                 Volatility of MTS Requirements

      Release 1 (Managed Care) requirements                                                             Release 2 (Common Working File) Requirements [FEE FOR SERVICE]                              Release 3 (Financial Server) requirements [FEE FOR SERVICE]
      1,660                                                                                             900                                                                                         845

      1,600                                                                                             800
      1,560                                                                                                                                                                                         825

      1,540                                                                                             700
                                                                                                        650                                                                                         815

      1,480                                                                                             600                                                                                         810
                                                                                                                                                                                                          9/96          10/96           11/96            12/96           1/97   2/97
              9/96         10/96           11/96            12/96              1/97          2/97             9/96         10/96          11/96           12/96         1/97          2/97
                                                                                                                                                                                                                                    Contractor's monthly status report
                                       Contractor's monthly status report                                                            Contractor's Monthly Status Report

     Release 4 (Carrier Processing) requirements [FEE FOR SERVICE]                                      Release 5 (Intermediary Processing) requirements [FEE FOR SERVICE]                          Release 6 (Encounter Data) requirements [FEE FOR SERVICE]

     880                                                                                                860                                                                                         900

     860                                                                                                                                                                                            850
                                                                                                                                                                                                                             To Be Determined
     800                                                                                                760
     780                                                                                                740

                                                                                                        720                                                                                         650
                                                                                                        700                                                                                         600
     740                                                                                                      9/96           10/96          11/96              12/96           1/97          2/97
           9/96         10/96           11/96          12/96            1/97          2/97                                               Contractor's monthly status report                                                        Contractor's monthly status report
                                   Contractor's monthly status report
                                                                                                                                                                                                    NOTE: Scale above [600-900] for purposes of illustration only; numbers of
                                                                                                                                                                                                          requirements for this release are not yet available.

(511220)                                                                                            Page 15                                                                                                                                            GAO/T-AIMD-97-91
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