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This presentation explores the continuing evolution of Health Insurance Exchanges (HIXs) and Health Information Exchanges (HIEs) in the United States. It discusses the implementation challenges, lessons learned, and the progress made towards the vision of these tech solutions.
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WRIA 2016 Meeting, Wailea Maui HIHealth Insurance Exchangeand Health Information Exchange– Tech Promises Revisited L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM The University of Louisiana at LafayetteJanuary, 2016
Abstract • In the United States, two tech solutions emerged in 2009 and in 2010 to address information challenges in healthcare and in the health insurance marketplace. • The American Recovery and Reinvestment Act of 2009 (ARRA) included funding for state-level Health Information Exchanges (HIEs), imbedded in provisions collectively known as Health Information Technology for Economic and Clinical Health (HITECH). • The Patient Protection and Affordable Care Act of 2010) (PPACA, or simply ACA) included the establishment of state-level Health Insurance Exchanges (originally HIEs, but eventually HIXs) to serve as electronic marketplaces for the purchase of health insurance, as well as for the qualification of incentives for its purchase. • Initial implementation of HIEs and HIXs were not without incident, but in more recent times improved efficiencies and economies of scale are being reported. • Has the promise of technology been achieved? • This presentation will be a follow-up to prior work discussed at WRIA in 2012 and in 2014, and will explore the continuing evolution of HIEs and HIXs. • Lessons learned will be highlighted, both about the respective technologies involved and about the risks of making promises about technology deployment.
Outline of This Presentation • HIE (Health Information Exchange) - Experience to Date • HIX (Health Insurance Exchange) “Marketplace” - Experience to Date • Mission Accomplished? - Or Merely Some Progress toward the Vision?
1. HIE (Health Information Exchange) – Experience to Date Healthcare has two underlying processes: a. provision of care b. gathering of information to facilitate provision of care in the future
Health Information Exchange (HIE) • A “Health Information Exchange” is an online mechanism whereby clinical, financial, and administrative information can be securely exchanged among patients, physicians, hospitals, other professional and institutional healthcare providers, public health agencies, regulators, and payors. • In the United States, the electronic transactions were well documented in the Administration Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and have been further refined in the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH). • HITECH, a component of the American Recovery and Reinvestment Act of 2009 (ARRA), funded the creation of State Health Information Exchanges on a state-by-state basis and mandated interconnection of these through the application of Nationwide Health Information Network (NwHIN) standards for inter-HIE exchange.
Health Information Exchange (HIE) (sources) • DHHS ONCHIT (created in 2004) Office of the National Coordinator for Health Information Technology (ONCHIT) Federal Health IT Strategic Plan, updated for 2011-2015 and for 2015-2020. • ARRA / HITECH (2009) American Recovery and Reinvestment Act (ARRA) (“the Stimulus Act”) incorporated the $20B Health Information Technology for Economic and Clinical Health (HITECH) Act, seeking “to improve American health care delivery and patient care through an unprecedented investment in health information technology.” • HITECH and HIE HITECH authorized State Health Information Exchange Cooperative Agreements. • LDHH / LHCQF Louisiana Department of Health and Hospitals & Louisiana Health Care Quality Form (LHCQF) – LaHIE Strategic & Operational Plans published in 2010.
2. HIX (Health Insurance Exchange) “Marketplace” – Experience To Date Health Insurance has two underlying processes: a. mitigation of risk for the insured b. gathering of information to facilitate mitigation of risk in the future
Health Insurance Exchange (HIX) • In the United States, the Patient Protection and Affordable Care Act of 2010 (PPACA) entered into a new phase of its implementation on October 1, 2013, with the launch of “Health Insurance Exchanges.” • Health Insurance Exchanges are intended to serve as fully online health insurance marketplaces where individuals and small businesses may select and purchase health insurance. • HIEs will be operated on a state-by-state basis, either by each state independently or by the federal government if a state should chose to opt out of the costs of managing its HIE. In the text of PPACA, references to the “exchange” concept appear 333 times, and the concept is alternatively termed “Health Insurance Exchange,” “Health Benefit Exchange,” “American Health Benefit Exchange,” “Small Business Health Options Program (SHOP) Exchange,” “Data Exchange,” or simply “State Exchange.”
Health Insurance Exchange (HIX) (continued) • More formally, PPACA amended Section 2791(d) of the Public Health Service Act (42 U.S.C. 300gg–91(d)) to add the following definition: “The term ‘Exchange’ means an American Health Benefit Exchange established under section 1311 of the Patient Protection and Affordable Care Act.” In 12 pages, Section 1311 details requirements and functions of a State Exchange, including 11 specific functions to be performed by the online system. Such exchanges were originally dubbed with the acronym “HIE,” but more recently “HIX” has been used to avoid confusion with “Health Information Exchange” (another federally promoted concept). • More commonly, HIXs are referred to as “the Marketplace”.
State Health Insurance Exchange adapted from
Health Insurance Exchange (sources) • PPACA (2010) Patient Protection and Affordable Care Act (PPACA) (“Obamacare”) • Louisiana Governor’s Office - opted to not expand Medicaid - opted to use Federal HIX rather than create own • Louisiana Department of Insurance - certifies HIX insurance carriers & products - educates consumers about open enrollment • Navigators for a Healthy Louisiana (http://lahealthcarenav.com/) - supported under contract to US-DHHS/CMS - provides assistance for consumer use of HIX
What an Applicant-Patient wants to know(how does PPACA affect me and my choices of Providers) • What is the monthly cost of the Healthplan’s premiums? • How long has the Healthplan been in business? How viable is the company? How stable will my premiums be over time? • Can I still see my regular doctors? Will it cost more to see my regular doctors? • Are my current medications in the formulary? Will it cost more to get my current medications? • Must I have prior approval to see a specialist? approval from my regular doctor? approval from the healthplan? • Must I file my own claims? Will I get statements showing total costs and total out-of-pocket expenses? • Is there a co-pay required for routine visits? an annual deductible to meet? • Is there an annual or lifetime maximum benefit? [PPACA prohibits maxima for “essential health benefits” renewals after 12-31-2013]
2015 Marketplace Carriers: 5, excluding LHCoop dba BCBSLA X https://www.ldi.la.gov/onlineservices/TopTwentyPremiums/
2014: 246 Carriers had Individual A&H2015: only 5 Carriers in HIX/Marketplace
Rising Premiums Louisiana is one of five states where the rate review process for plans sold in the exchange is conducted by HHS rather than state regulators. https://www.ldi.la.gov/onlineservices/HealthRates/
Louisiana Did Not Expand Medicaid Eligibility, Yet Its Enrollment Grew
Louisiana’s Uninsured [CPS = Current Population Survey]
Effects of PPACA Implementation http://obamacarefacts.com/sign-ups/obamacare-enrollment-numbers/
The decline in the uninsured is not solely due to plans sold on the exchange; expanded Medicaid and CHIPenrollments were a large part of it, and many new individual plans were sold directly by the insurer or throughbrokers (off the exchanges). The threat of individual mandate penalties may also have increased enrollmentin employer plans. However, when we compare the decline in the uninsured with exchange enrollments, wefind a remarkable correlation suggesting that the wave of interest in signing up for insurance also drove thesealternatives. http://obamacarefacts.com/sign-ups/obamacare-enrollment-numbers/
Louisiana: 2014 Open Enrollmentfor 2015 Coverage Among those using the Marketplace: • 89% qualified for tax credit averaging $319/month • 63% obtained coverage for $100/month or less after tax credits • Enrollments did decline significantly by March 31st and again by June 30th
3. Mission Accomplished?- Or Merely Some Progress toward the Vision? "We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.“ Roy Amara (1925-2007), past-president of Institute for the Future, an independent, non-profit research organization whose mission is “to develop the foresight required to reveal the insights that allow for strategic action” based on local and global trends
What we still want to know(Exchange effectiveness and PPACA compliance metrics) • How many Applicants have visited the Health Insurance Exchange? non-duplicated individuals? • How many Applicants have applied for coverage with each specific Healthplan? non-duplicated applications? • How many Applicants have been approved for coverage with each specific Healthplan? Applicants and individual persons to be covered? • How many Small Businesses have visited/applied/been/approved? Small Businesses and individual persons? • What fraction of previously uninsured individuals will now have coverage? • How many dollars in initial premiums committed/paid by Applicants? • How many dollars in initial premiums committed by federal grants or aids? • What complaints, misrepresentation, violations, etc. have occurred as a result of the Health Insurance Exchange?
This analysis suggests that ... • Benefits may accrue in various distinct areas and in varying degrees to an HIE’s diverse participants. • Certain participants may have no direct interest whatsoever in any but a very few specific HIE functionalities. • Participants who receive HIE transmissions are the principal beneficiaries of the exchange – receiver receives “value” only if they perceive utility. • If an unsolicited request for information arrives, the receiving participant is obliged to respond – a new burden or “cost-of-doing-business” in the electronic age. • Some unsolicited transmissions may be requests for services – “orders” – and the receiver has an opportunity to benefit by turning the order into collectible revenue. • Under-contributing functionalities may still find a long-term niche, especially when these co-exist with other functionalities that can subsidize their continuance. • An HIE “succeeds” when it offers the proper mix of functionalities that can strike a successful balance of “value” for “value” exchange among its participants. • An HIX/Marketplace “succeeds” when it results in consumer enrollment in a health insurance plan. A higher level of success is achieved when the enrollment persists for at least one year. • With HITECH-funded HIEs just having come on-stream in 2012, and PPACA-funded HIX/Marketplaces just having come on-stream in 2013, there is still a significant opportunity for researchers to further develop and test HIE & HIX evaluation techniques, and to influence the enhancement of future deployments.
Questions, Comments,or Suggestions? caillouet@louisiana.edu ferguson@louisiana.edu Learn more at http://lchi.louisiana.edu
