Connect for Health Colorado (C4HCO) sits midway between a government agency and a startup. As a government agency it purpose was defined to create an individual and small group marketplace for health insurance. As a startup it still had to find a “product market” fit or a method for actually creating the marketplaces and then once finding a product market fit scaling that method to reduce costs or increase the marketplace.
I can be argued that C4HCO has found a product market fit for individual health insurance but the recently released operating report doesn’t provide a good indication that C4HCO knows how this was done or how it will scale. Furthermore the operating report doesn’t provide a clear prioritization of the remaining “startup” tasks. Will C4HCO be focusing on scaling the individual marketplace? Does C4HCO believe that it has achieved product market fit in the individual insurance market? How does small group fit into all of this? Does C4HCO have an overall business model to organize all of these questions?
The most general reason for suspecting there is no business model is the lack of linkage between inputs and outputs. In many cases the operational plan reads that this group is blocked or inefficient. There is then a general outline of how to fix the issue but no sense of which fix is the most important or what a successful fix would look like.
For example, if the Technology and Operational Support Systems, Improve Functionality and Usability List is given in priority order, then the highest priority is the development of a shared eligibility system with Medicaid. This may make sense but how does it meet the customer focused goal of the organization? By C4HCOs own admission, the self service channel is negligible, so how will the shared eligibility service impact the current channels that are actually used? Furthermore, given that C4HCO and HCPF have been working for over year to create this service, this strategy seems like a high risk bet. What does it need to achieve to become a high risk/high reward bet?
Similarly the list of the technology items places a much lower priority on some items than the individual operational areas would imply. For example, there is no mention of linking the appeals case management with the main exchange system. Similarly the Self Service sales channel is the largest subsection of the Sales section but it appears eighth on the technology prioritization (Implement continual adjustments and improvements to shopping, payment and enrollment functions on both SHOP and individual portals). Moreover there are technology systems mentioned in the operational system that are not included in the technology section, namely the mobile app.
The laundry list of metrics at the end of the document also supports that C4HCO doesn’t fully understand how inputs will map to outputs. If the key technology priority is to implement a shared eligibility system how many of the operational metrics does that impact? What operational metric is most important and why?
Even some basic modeling of the known facts doesn’t appear to be reflected in the operational plan. For example, if we assume as a worse case scenario that the current eligibility process is in place for the 2015 plan year and this causes every member to make a contact with the current average handle time, almost 40% of the total Customer Service Center availability would be taken up just retaining the membership that enrolled through January 15th1. While this may be worse case scenario why isn’t any mention made of the potential impacts of a huge retention push?
One of the things that make this lack of a business model more tolerable is the need to focus on improving feedback loops and creating a learning process. However, what this actually entails doesn’t appear to have percolated through the entire organization. This starts at the most basic level. The technology section states that customization will be minimized but how can a quick feedback loop be created without customization unless the platform already enables that through configuration management? If it is a configuration why isn’t it be changed already?
These questions about the establishment of a rapid learning environment then percolate up to the next layer. Are fixed cost contracts and Commercial Off the Shelf (COTS) software, the right answer? If C4HCO fundamental needs to become a learning organization to deliver on the sustainability promises can it do so without becoming a software company? Is it possible to outsource a government service role (COTS technology for enrollment) but not a learning where change is constant?
Even without becoming a software company, C4HCO still seems to be struggling with transforming towards an agile learning organization. For example, change management is a high priority in the customer service and operational section but if the organization is learning and adapting constantly how can change be managed? Similarly if C4HCO is in constant change to maximize learning that is key to sustainability, how is that imported to contractors who perform the work?
Similarly the tools and techniques outlined for becoming a learning organization seem to be relatively naive. Many organizations give up on surveys during the scaling phase since focusing on actual data prevents building a faster horse and focuses on the real problems individuals have interacting with the organization. Similarly C4HCO doesn’t seem to have a good handle on what data exists and is easily actionable, what data exists but isn’t actionable, and what data just can’t be reconstructed.
The overall operational plan lays out an organization that is still struggling to speak as a uniform coherent whole. This is understandable as C4HCO has almost overnight rocketed from start-up to scaling organization but at the same time important questions seem unanswered. C4HCO is clearly committed to becoming a sustainable organization but how exactly will that happen? Will it operate like a government service setting a budget and then seeking to maximize enrollments given that budget? Will it act more like a business making targeted investments that may temporarily cause a loss but generate long term outcomes? Does C4HCO really understand what modern agile learning organizations look like and does it have a goal to become one?
1 The modeling supporting this statement can be found here.