WRIA 2014 Meeting, Napa CAEvaluating Information Exchangefor Effective Risk Managementin Healthcare L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM The University of Louisiana at LafayetteJanuary, 2014
Abstract • The healthcare delivery sector and the health insurance industry seem destined to collide once again as voluntary HIEs are launching and as mandated HIEs are coming on-stream. • But when is an HIE not an HIE? When one is a HealthInformationExchange and one is a HealthInsuranceExchange. • One is vital in maintaining health and critical to managing clinical risk in the delivery of healthcare services, while the other is hoped to aid individuals and small businesses in managing economic risks in daily life. • Evaluating the effectiveness of each, separately, offers a significant research challenge. • Creating and monitoring effective relationships between the two may be the future of risk management in healthcare.
Outline of This Presentation • Healthcare and Health Insurance are Information Intensive Industries • Information Technology Applications (especially HIEs) are Essential Enablers for Implementation of Health Insurance Reforms • HIE = Health Information Exchange (ARRA/HITECH 2009) • HIE = Health Insurance Exchange [HIX, HIEx]; [HIM = Health Insurance Marketplace (Marketplace)] [AHBE= American Health Benefit Exchange (PPACA 2010)] • Experience To Date • Measuring Success of HIEs
1.“Healthcare and Health Insurance Are Information Intensive Industries” Healthcare has two underlying processes: a. provision of care b. gathering of information to facilitate provision of care in the future 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
Healthcare & Health Insurance Information Pathways Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services PHOs Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. IPAs * Us! ASO TPAs Network & Care Mgrs. *Us! = Patients, Employees, Citizens, Enrollees, Members, Covered Lives, Consumers, Marginal Units, Populations Credit Bureaus Claims Assistance Financial Services Insurers
2.“Information Technology Applications (especially HIEs) are Essential Enablers for Implementation of Health Insurance Reforms” The U. S. federal “plan is to propose Health Information Exchange and interoperability requirements … so that patient information follows patients to the point of care and informs critical health decisions.”
Healthcare Information: Order from Chaos? Equip. Mfrs. Peer Review Orgs. Federal & State Gov’t. Hospitals Data Services Suppliers Fiscal Inter- mediaries Employers, Unions, & Assns. Drug Mfrs. Physicians Pharm. Benefit Mgrs. ASO TPAs Network & Care Mgrs. Credit Bureaus Claims Assistance Financial Services Color Key: Clinical (specific) Clinical (summary) Financial Administrative Patients Insurers
The Future’s Just Not the Same Anymore!attributed to Yogi Berra Meaningful Use? Healthcare Reform? Health Insurance Reform? Coordinated Care Networks? Accountable Care Organizations? National Health Information Infrastructure? HIPAA? / ARRA? / HITECH? PPACA? / (repeal?) ???
Health Information Exchange • 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 are well documented in the Administration Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and have been refined in the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH). • HITECH, an embedded component of the American Recovery and Reinvestment Act of 2009 (ARRA, or “”The Stimulus Bill”), 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 (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 – 80pp. (http://healthit.hhs.gov/portal/server.pt/community/fed_health_it_strategic_plan/1211/home/15583) • 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.” (http://healthit.hhs.gov/portal/server.pt?open=512&objID=1487&mode=2) • HITECH and HIE HITECH authorized State Health Information Exchange Cooperative Agreements (http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=11113&cached=true) • LDHH / LHCQF Louisiana Department of Health and Hospitals & Louisiana Health Care Quality Form (LHCQF) – LaHIE Strategic & Operational Plans published in 2010 – 164pp. (http://lhcqf.org/images/stories/LaHIE%20State%20Plan.pdf.)
Health Insurance Exchange • 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 974-page text of PPACA (available at http://www.hhs.gov/healthcare/rights/law/index.html), 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 (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).
Health Insurance Exchange (sources) • PPACA (2010) Patient Protection and Affordable Care Act (PPACA) (“Obamacare”) (http://www.ncsl.org/documents/health/ppaca-consolidated.pdf) – 974pp. • Louisiana Department of Insurance (http://www.ldi.louisiana.gov/) • Louisiana Healthcare Reform Resource Center -- for Consumers (http://www.ldi.state.la.us/HealthCareReform.html -- for Producers (http://www.ldi.state.la.us/MarketplaceTraining.html)
HIE-HIE Connections? Eligibility Co-Pay Collection Coverage Levels Prior-Authorization Changes Enrollment Enrollment
HIE-HIE Communications Payors Insurers Healthplans Healthcare Providers Patients and Families
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]
What a Provider wants to know (how does PPACA affect me and what compliance issues loom) • How will I know which Patient is eligible under which Healthplan? • May a Patient be rejected on the basis of their choice of Healthplan? [e.g., a Healthplan in which I do not participate] • How will I know which services are covered by a particular Patient’s Healthplan? • How will I know which medications are including in a Healthplan’s formulary? • Must I seek approval from the Healthplan prior to ordering tests, performing procedures, prescribing medications, or referring the Patient out to other Providers? How do I go about seeking such approvals? • What must I collect as a co-pay from any particular Patient? • How will I get paid by a Patients’ Healthplan for services rendered to that Patient? on a prepaid per capita basis? on a fee-for-service basis, using a negotiated fee schedule?
What a Healthplan wants to know(who are the Applicants and what underwriting options still exist) • Does the Applicant have pre-existing medical conditions that might disqualify them for coverage? [PPACA prohibits!] • Does the Applicant have behavioral risk factors that might alter their premium? [PPACA allows (e.g., smoking)] • May an Applicant be rejected on certain specific criteria other than a pre-existing condition or a risk factor?[e.g., Healthplan lacks certain services that Applicant-Patient may need] • Does the Applicant agree to all terms associated with the healthplan? • Has the Applicant prepaid the required initial premium? • Will the Applicant’s premium be supported by federal grants or aids? • What Provider(s) will Applicant choose?
What the Regulators 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?
3. Experience To Date Donabedian’s Indicators: Structure – Result of Federal (primarily) and State Funding Process – If you built it, will they come? Outcomes – Too soon to tell!
The HIE & the HIE in Louisiana • The Louisiana Health Care Quality Forum (LHCQF), the State-Designated Entity in Louisiana, has used HITECH funding to create the Louisiana Health Information Exchange (LaHIE), which has just passed the second anniversary of its launch. LaHIE Now Includes More Than 500K Unique Patient Records> The Louisiana Health Information Exchange (LaHIE) now features more than 560,000 unique patient records.> “For those patients, it means their physicians have greater, more timely access to their health records. As we continue our efforts to onboard more hospitals and practices to LaHIE, that number will grow exponentially in the coming months.” Cindy Munn, LHCQF Executive Director > To date, 33 hospitals and clinics are live with LaHIE, and 68 are actively onboarding. The exchange has participation agreements with more than 170 hospitals, providers, clinics, school-based health centers, home health agencies and other health care companies across the state. • The State of Louisiana has opted out of managing its ownHealth Insurance Exchange at least for now, which under the terms of PPACA requires the federal government to operate the online marketplace in Louisiana. • It is too early to judge the effectivenesseither of the HIE or of the HIE (HIX, HIeX, HIM, ABHE)in Louisiana, but it is not too late to create an evaluation plan!