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Evolution or Devolution? The Impact of Health Insurance Exchange and Health Information Exchange

This presentation analyzes the impact of Health Insurance Exchanges (HIXs) and Health Information Exchanges (HIEs) on the exchange of healthcare information and the marketing of individual health insurance. It provides updated insights into the political and business landscape driving changes in the healthcare and health insurance sectors.

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Evolution or Devolution? The Impact of Health Insurance Exchange and Health Information Exchange

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  1. WRIA 2018 Meeting, Las Vegas NVHealth Insurance Exchangeand Health Information Exchange– Evolution or Devolution? L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM The University of Louisiana at LafayetteJanuary, 2018

  2. 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. • Questions remain: • Have HIEs significantly altered methods of exchange of healthcare information? • Have HIXs significantly changed the way individual health insurance is marketed? • This presentation will follow-up on prior discussions at WRIA in 2012, in 2014, in 2016, and in 2017 and will provide updated insights into the political and business landscape that is driving (and is driven by) changes in the healthcare delivery and health insurance sectors. Against a background of continuing volatility in the political climate in Washington, the prospects for consolidation or erosion of prior gains in health insurance coverage in the United States will be considered.

  3. Outline of This Presentation • Have HIEs significantly altered methods of exchange of healthcare information? • Have HIXs significantly changed the way individual health insurance is marketed? • Laying the ground work for future evaluations of lasting impacts

  4. 1. Have HIEs significantly altered methods of exchange of healthcare information? Healthcare has two underlying processes: a. provision of care b. gathering of information to facilitate provision of care in the future

  5. Health Information Exchange • HIE status • LaHIE • Core Services • Key Features • Benefits • Hospitals and Affiliated Clinics • LaHIE Participation (2011-2017) chart(s) • LRHP (2011-2015) – HIE and health information • Connecting PHIS & HIEOs • HIE future • NEJMarticle

  6. 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.

  7. 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 funded the CMS EHR Incentive Program (“Meaningful Use”),and the State Health Information Exchange (HIE) Cooperative Agreements. • LDHH / LHCQF (Louisiana’s State-Designated Entity) Louisiana Dept. of Health & Hospitals & Louisiana Health Care Quality Forum • Louisiana Health Information Exchange (LaHIE) Initial Strategic & Operational Plan published in August 2010 Operations began in November 2011 Updated Strategic & Operational Plan published in June 2012 – the current plan

  8. LaHIE Design Schematic

  9. LaHIE Core Functionality i. Enterprise Master Patient Index – across all LaHIE participants ii. Provider Registry – Louisiana physicians with their local ID’s iii. User Identity Management/Authentication - secure, role-based access iv. Audit Module – HIPAA compliance tracking v. Consent Management Module – tracking patients’ consent selection vi. Clinical Data Repository – storing a sub-set of a patient’s record vii. Clinical Portal – access to web-based summary of patients’ records viii. Direct Secure Messaging –send authenticated encrypted health information ix. Public Health Reporting –facilitate required public health x. Event Notification – providers notified when events occur for their patients xi. Exchange of Data – facilitate exchange of patient data between EHRs xii. Medicaid Eligibility – view Medicaid Eligibility

  10. LaHIE Statistics

  11. ONC Health IT Dashboard

  12. Louisiana HIE & Interoperability

  13. Future of Health IT

  14. 1. Have HIEs significantly altered methods of exchange of healthcare information?Yes, and No.Although large health organizations embraced HIE standards to communicate within their “systems”, independent practitioners have been slower to adopt.Federal incentives (“carrots”) are expected to turn to penalties (“sticks”) for non-compliers.Financial viability of HIEs depends on their becoming a routine “cost of doing business” in healthcare.

  15. 2. Have HIXs significantly changed the way individual health insurance is marketed? 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

  16. 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 have been 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.”

  17. 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”.

  18. Health Insurance Exchange (sources) • PPACA (2010) Patient Protection and Affordable Care Act (PPACA) (“Obamacare”) • Louisiana Governor’s Office - opted first to not expand Medicaid; later did - 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

  19. Federal HIX/Marketplace

  20. HIX / Marketplace Core Functionality • Aiding consumers in discovering their eligibility for Federal health insurance premium subsidies. • Aiding consumers in discovering for ACA-compliant health insurance plans that match their coverage needs and budgets. • Aiding consumers in discovering healthplan particulars, including • 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] • Aiding consumers in applying for ACA-compliant health insurance plans.

  21. State Health Insurance Exchange adapted from

  22. United States’ Uninsured (2008-13) https://www.americashealthrankings.org/explore/2016-annual-report/measure/HealthInsurance/state/LA

  23. United States’ Uninsured (2014-17) https://www.americashealthrankings.org/explore/2016-annual-report/measure/HealthInsurance/state/LA

  24. Louisiana’s Uninsured Percentage of the population that does not have health insurance privately, through their employer, or through a government program(2-year average) [U.S. Census Bureau Current Population Survey & American Community Survey data] PPACA Passage > HIX Implementation > https://www.americashealthrankings.org/explore/2016-annual-report/measure/HealthInsurance/state/LA

  25. Louisiana Health Insurance Carriers 2013: 246 Carriers offered Individual A&H 2015: only 5 Carriers in HIX/Marketplace2016: only 4 Carriers in HIX/Marketplace 2017: only 3 Carriers in HIX/Marketplace HIX “marketplace”facilitated premiumsubsidy calculation,but replaced brokers’ role. ACA “individual mandate”provisions increasedparticipation by theformerly uninsured,but “coverage mandates”decreased participation bycarriers.

  26. Louisiana HIX (Marketplace):Status • 2018 enrollment (111,373)down due to rumor of ACAdemise? • 2017 enrollment (143,577)down due toMedicaid expansionin July 2016, ordered bynew Democrat governor,elected Nov 2015 • 2016 enrollment (214,148) http://www.ldh.la.gov/HealthyLaDashboard/

  27. Louisiana HIX (Marketplace):Status • Open enrollment for 2018 • Advertising andnavigator budgetscut 92% • Shorter HIX window(Nov 1-Dec 15, 2017) • All plans to beeffective Jan 1, 2018;no option to delay asin past years https://www.washingtonpost.com/national/health-science/hhs-slashes-funding-to-some-aca-navigator-groups-by-more-than-60-percent/2017/09/14/729c394c-9957-11e7-b569-3360011663b4_story.html?utm_term=.c207dfdceba

  28. Louisiana HIX (Marketplace):Status • Act 63 of 2017 (HB407)aids Brokers,hard hit by HIX;can now set,charge fees

  29. Louisiana Plan Comparison – Single, Male, 50 (2018)

  30. HIX 2017 (for 2018 coverage):Louisiana & Elsewhere • Carriers declining • Choices declining • Premiums increasing • Deductibles decreasing!? • Out-of-Pocket maxima increasing • Concerns about ACA repeal

  31. HIX 2017 (for 2018 coverage):Carriers Declining

  32. HIX 2017 (for 2018 coverage):Choices Declining

  33. HIX 2017 (for 2018 coverage):Premiums Increasing

  34. HIX 2017 (for 2018 coverage):Average Deductible Decreasing!?

  35. HIX 2017 (for 2018 coverage):Average OOP Maxima Increasing

  36. Concerns about ACA Repeal • After Trump’s inauguration in January 2017, ACA appeared destined for repeal … • No more Health Insurance Exchanges? • No more Medicaid expansion? • No funding to advertise Open Enrollment! … but was not repealed by start of 2018 Open Enrollment • Trump’s HHS-Secretary Tom Price MD favored … • Fixed tax credits -- people buy own insurance on private market -- starts at $1,200/year, rises with age, but isn't adjusted for income. • Expansion of health savings accounts, which allow people to save money before taxes to pay for health care. • People with existing medical conditions couldn't be denied coverage as long as they had continuous insurance for 18 months prior to selecting a new policy. If they didn't, they could be denied coverage for that condition for up to 18 months after buying a new plan. • Limits amount companies can deduct from taxes for employee health insurance expenses … to discourage companies from offering overly generous insurance benefits. Companies deduct up to $20,000 for a family health insurance plan and $8,000 for an individual. • States get federal money to create “high-risk pools” for people with existing medical conditions who can't get market insurance. … but he served only 7 months, resigning in “private jet scandal” • Former drug company exec & HHS-Secretary-designate Alex Azar … • Would execute law should it stay in place, but agrees with lawmakers who want to change it. • Favors same goals as Democrats who support  ACA—lower costs and increased access to care—but wants to take different paths to achieve those goals.  • Does not take issue with GOP plans to repeal the individual mandate through its tax plan. • Has strong support for the ACA's goals of payment reform and the transition to value-based care. • Improving care coordination and integration is central to his goals at HHS.

  37. Concerns about ACA Repeal • HIX future • “Front-Door”ACA repeal & replace? • Eliminate individual mandate? • Eliminate premium subsidiesfor qualifying individuals? • Eliminate subsidies to carriers foroffering ACA-compliant plans? • “Back-Door” riders to Tax Cuts& Jobs Act legislation? • Ends the individualmandate, by reducingthe penalty for beinguninsured to $0? • Will this eliminateindividual subsidiesand thus eliminatethe HIX Marketplace?

  38. 2. Have HIXs significantly changed the way individual health insurance is marketed?Yes, but maybe not in the future.PPACA created HIX/Marketplace, to link to individual mandate premium support eligibility data at CMS & IRS.Repeal of key provisions of PPACA, if only through tax reform, would end individual mandate and premium supports, eliminating need for HIX.

  39. 3. Laying the ground work for future evaluationsof lasting impacts "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

  40. Future Evaluations • Objective – industry data • Uninsured Americans • Carriers, healthplans, and brokers in individual market(s) • Health insurance costs • Health care costs • Subjective – polling data • Public opinion • 2018 Congressional mid-term election results

  41. Questions, Comments,or Suggestions? caillouet@louisiana.edu ferguson@louisiana.edu

  42. Louisiana Plan Comparison – Single, 50+ (2014)

  43. Louisiana Plan Comparison – Single, Male, 50 (2016)

  44. Louisiana Plan Comparison – Single, Male, 50 (2017)

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