Lessons health insurance exchanges can learn from HIEs
Health Insurance Exchanges (HIXs) are not unlike Health Information Exchanges (HIEs) in one important regard: They too will need to integrate and manage large amounts of complex data. As HIX administrators and staff begin to prepare for what is to come, they almost certainly will find themselves facing the same infrastructure and data harmonization issues HIEs have begun to surmount.
Analyst group Gartner recently published a report on HIXs and their role in healthcare reform. With the expected increase in the number of insured patients, HIXs aim to provide an online forum that patients will be able to leverage for selecting their health plans. The HIXs will then transfer the patients’ eligibility information to the specific payers. The Centers for Medicare & Medicaid Services (CMS) is requiring all states to submit their HIX blueprints by November 16, 2012. This is a necessary step for launching state-based exchanges and participating in federal-state exchanges.
While a number of states were waiting to see how the Supreme Court ruled on the Patient Protection and Affordable Care Act (PPACA) before beginning or continuing plans to create a HIX, the June 2012 court ruling and the looming compliance deadlines have created a great need for healthcare IT tools and systems capable of quickly moving large volumes of disparate data.
The November blueprint deadline and the mere 12 months then allowed for implementation along with myriad challenges. Yet as of August 2012, only 15 states had established state-based HIXs and were in the process of building the infrastructure to offer the service; another 16 states were evaluating their options or planning for an exchange. Other states were either relying on a federal HIX to provide services, creating a federal-state partnership, or had not yet taken any significant steps to plan an HIX.
As was the case with previous exchange models, integration will be a primary challenge for HIXs due to the disparate IT systems used by the participating payers. After the data is integrated, HIXs will need to use it for analysis and decision making. Payers will be faced with the same integration needs as they manage information from various HIXs.
Ultimately, collaboration between HIXs and payers will be pivotal for managing large volumes of data in order to offer health insurance services that are targeted for individual and company recipients. Fortunately, HIXs and payers can both benefit from lessons learned by e-marketplaces and HIEs.
During the dot-com era of the late 1990s and early 2000s, industry-specific electronic marketplaces called e-marketplaces brought corporate buyers and sellers together in an online setting that had great intentions of simplifying global sourcing via the Internet. Examples included automotive and plastics exchanges, among many others. These early e-marketplaces were ahead of their time and served as some of the first models of cloud computing by providing connections among many participants in the middle of cyberspace.
Unfortunately, most of the more than 300 e-marketplaces that once existed have since dissolved as a result of business models that did not support the expenses involved. Those that have survived, however, today stands as models of proficiency in integration and data management, and have provided HIEs with a viable operational example.
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Some successful HIEs have also turned to the cloud to face the challenges of infrastructure, integration and data management. While some HIEs have approached their task with the belief that “if you build it, they will come,” this rather simplistic view seldom bears out. Instead, the HIEs most likely to survive are those that offer services with value-added benefits that not only retain original customers, but also attract new ones. The speed, ease, cost-effectiveness and utility of cloud-based solutions provide the ability to offer those value-added services.
The most critical challenges for HIX development and implementation at the present time include:
- Infrastructure costs: One common problem for HIXs is the high cost of the infrastructure required to collect, transmit, store and share data. Hardware, software, data centers, and employees to staff the service typically require a significant portion of an HIX budget. This leaves little money to purchase the applications that allow actual use of the data. In other words, by the time a HIX gets to the useful applications, the money is gone.
- Staff expertise: The level of knowledge and skill required to integrate IT systems, then aggregate and harmonize data from a wide range of disparate sources is not readily available — as many HIEs have learned. To properly integrate systems and manage data in-house, each HIX will need a staff of dedicated experts.
- Value-added applications: Just as HIEs need to provide applications that are beneficial to paying customers, HIXs must provide user-friendly interfaces that offer easy access and accurate, usable information to consumers and payers in the exchange. The speed at which consumers and payers can get information and the quality of links to data within the system are essential to success. Even if an application is well-designed, it means nothing if it is not sourced by substantial data.
- Fast-approaching deadlines: The short time frame for submission of HIX blueprints to CMS is followed by a tight 12-month turn to implement the HIX. Meeting these deadlines from scratch and without outside resources is realistic only for those states that have been working on development of a HIX since the initial passage of the PPACA. Others will want to consider partnership options.
The good news is that each of these issues can be addressed by taking advantage of existing cloud-based technology platforms and services capable of enabling HIX compliance by January 2014.
States can bypass both the investment in infrastructure and the time required to build it by using platforms already developed by third-party specialists. For a monthly fee, an organization has access to the infrastructure paid for, built by, and supported by the third party — as opposed to the significant capital expense to build and maintain its own.
Third-party specialists can also offer expertise on everything from technical questions to issues such as consent management. For example, many HIEs initially required consent for every patient whose information was managed by the HIE. Now, consent management has evolved to an “opt-out” default in many instances. With the benefit of a specialist’s experience, a HIX administrator can shorten the time required for implementation and produce a better product for users —which ultimately translates into better service for patients and payers alike.
If HIX administrators learn one lesson from e-marketplaces and HIEs, it should be to look for innovative solutions to their challenges. One such solution is to take advantage of cloud-based integration and data management platforms that already exist. Rather than re-inventing the wheel, this option allows HIXs to expediently focus on their true mission: To match patients with payers and extend health insurance coverage to all Americans.
Gary Palgon is the vice president of healthcare solutions for Liaison Healthcare, which provides healthcare organizations with innovative solutions to complex integration and data management needs.
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