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WRIA 2017 Meeting, Santa Barbara CA Health Insurance Exchange and Health Information Exchange – Lasting Impacts. L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM The University of Louisiana at Lafayette January, 2017. Abstract.
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WRIA 2017 Meeting, Santa Barbara CAHealth Insurance Exchangeand Health Information Exchange– Lasting Impacts L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM The University of Louisiana at LafayetteJanuary, 2017
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, and in 2016 and lay the ground work for future evaluations.
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
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
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 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
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
1. Have HIEs significantly altered methods of exchange of healthcare information?Yes, and No.Federal health care laws & regulations have forced the issue.Momentum is strong,but sustainability is not guaranteed.
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
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.”
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”.
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
State Health Insurance Exchange adapted from
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.
Effects of PPACA Implementation http://obamacarefacts.com/sign-ups/obamacare-enrollment-numbers/
Louisiana’s Uninsured [CPS = Current Population Survey]
When Louisiana finally expanded Medicaid, Enrollment Grew by 351,000 (after Jul-16)
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/
Not the only declining statistic … 2014: 246 Carriers had Individual A&H2016: only 5 Carriers in HIX/Marketplace2017: only 4 Carriers in HIX/Marketplace
Louisiana: 19 Rate Reviews for 2017 https://www.ldi.la.gov/onlineservices/HealthRates/
HIX 2017: Louisiana & Elsewhere • Choices declining • Premiums increasing • Deductibles increasing • Out-of-Pocket maxima increasing • “Gap Insurance” making a comeback • Concerns about possible discontinuation of ACA
Outlook for “TrumpCare” • ACA appears destined for repeal • No more Health Insurance Exchanges • No more Medicaid expansion • HHS-Secretary-designate Tom Price said to favor … • Fixed tax credits so people can buy their own insurance on the private market. The credit starts at $1,200 a year and 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 under Price's plan as long as they had continuous insurance for 18 months prior to selecting a new policy. If they didn't, then they could be denied coverage for that condition for up to 18 months after buying a new plan. • Limits to the amount of money companies can deduct from their taxes for employee health insurance expenses … to discourage companies from offering overly generous insurance benefits to their workers. Companies can deduct up to $20,000 for a family health insurance plan and $8,000 for an individual. • States would get federal money to create “high-risk pools” for people with existing medical conditions who can't get affordable health insurance on the private market.
2. Have HIXs significantly changed the way individual health insurance is marketed?Yes, and No.Federal health insurance laws & regulations have forced the issue,but sustainability is not guaranteed.
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
Questions, Comments,or Suggestions? caillouet@louisiana.edu ferguson@louisiana.edu
