Tag Archive for Health

Health Insurance Exchanges: Benefits, Challenges, Lessons

On Thursday, Jan. 10, Government Technology hosted its first TweetChat: Innovation in Focus – States and Health Insurance Exchanges.

The chat, held on Twitter using the hashtag #GTonHIX, included industry experts John Sweeney, IBM’s senior product manager for the Curam solution, and Dan Schuyler, director for Leavitt Partners’ health insurance exchange practice, to answer questions about state health insurance exchanges (HIX).

An HIX is a government-regulated, standardized marketplace for the purchase of health insurance, and the Obama administration mandates that each state have one. States may choose to create and run their own HIX, or they can opt out and have the federal government create their exchange for them.

States had to declare whether they were running their own exchange by Dec. 14, 2012. And according to the National Conference of State Legislatures, as of Jan. 4, 2013, 19 states, including the District of Columbia, submitted blueprints for HIXs to the U.S. Department of Health and Human Services, which must approve the plans. Under the mandate, all insurance exchanges must be fully operational by Jan. 1, 2014. 

As the deadline looms, states may have pressing questions about what needs to happen by 2014. Here are some of the discussion highlights:

1.    What are the benefits for both states and their citizens in building these exchanges?

2.    Are there any lessons learned from states that have implemented or are in the process of implementing an exchange?

3.    What are the technical challenges the states face in implementing HIXs?

4.    How different will the HIXs be across states?

5.    How can states maximize the cost benefits of implementing these HIXs?

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Utah’s Health Insurance Exchange in Limbo

Since the Affordable Care Act became law in 2010, states have known they would have a choice about whether to run their own health insurance exchanges or let the federal government do it for them. But with only eight months left before those online marketplaces are expected to open to the public, Utah hasn’t made up its mind.

Utah is one of several Republican-led states weighing an eleventh-hour decision about whether to set up a state-run exchange. But it is a special case because it is one of only two states, the other being Massachusetts, that already has a functioning insurance exchange. In both states, the exchange was the brainchild of a Republican governor eager to promote free market competition.  But once the concept became integral to the success of President Obama’s federal health law, Utah and many other Republican-dominated states resisted it.

The Obama administration has a strong interest in convincing red states to establish their own, tailor-made insurance exchanges keyed to their particular needs. To that end, the U.S. Department of Health and Human Services has vowed to give states as much leeway as possible. Utah is a test of that commitment.

As soon as the federal health law was enacted, Democratic governors jumped at the opportunity to set up their own exchanges, which are expected to serve 30 million Americans. Their states have received millions in federal grants to create the online marketplaces and call centers where individuals and small businesses will be able to choose between competing insurance plans that meet federal coverage standards.  Individuals also will be able to sign up for federal insurance premium tax credits and enroll in Medicaid through the exchanges.

GOP governors put off the decision on whether to launch state-run exchanges in hopes that either the Supreme Court would strike down the health law or Republican Mitt Romney — ironically, the Massachusetts governor who championed the exchange in that state — would become president and repeal it. Once those possibilities evaporated, most Republican governors decided to let Washington run their exchanges. A handful of states, some headed by Republicans and others by Democrats, elected to create joint state-federal exchanges.

Utah’s Republican Governor Gary Herbert asked Washington right after the elections to accept his existing state exchange as compliant with the federal health law — pretty much as is.  In response, Utah received “conditional” approval from the U.S. Department of Health and Human Services last week. But the conditions include changes to Utah’s exchange that state officials say the governor may not be prepared to make.

That leaves Utah’s decision about whether to run an exchange up in the air. But even if the governor were in full agreement with Washington, he would need final approval from the state legislature, which meets January 28.

So far, Utah lawmakers have been solidly against a state-run exchange. In fact, a law was enacted in 2010 preventing the state from seeking any federal money for the project.  And despite the governor’s recent request for the flexibility to convert its existing exchange into a health law-compliant exchange, many in the legislature still oppose the idea.

One influential lawmaker, however, has an alternative. Republican Representative Jim Dunnigan, the  chair of Utah’s Health System Reform Task Force, says it’s clear the federal government isn’t going to give Utah the leeway it needs to run its own exchange. Instead, the state should maintain its existing small business exchange and let the federal government build a new site for consumers.

One thing working in Utah’s favor, at least from Herbert’s point of view, is that the state’s existing exchange has been a success. It includes 140 health insurance plans and has sold coverage to 326 small businesses employing 7,890 individuals. The site uses what it calls a “defined contribution” approach that allows employers to decide how much they want to contribute to their employees’ health insurance and then select a list of policies employees can choose from.

Of the companies served by the exchange, 67 percent had no prior coverage for their employees, and 92 percent renewed their policies after the first year. The exchange is working with 789 insurance brokers across the state to expand the number of businesses it serves, according to the governor’s office.

But the site has its critics. Unlike the one in Massachusetts, the Utah exchange — now called Avenue H — does not vet insurance policies or negotiate for the lowest prices. Built in 2009, the website was designed to let all insurance carriers offer their policies to small businesses as a way to promote competition.

As a result, critics say, many small businesses that have visited the site find the policies too expensive and look elsewhere. Utah has about 60,000 businesses with fewer than 500 employees, according to the U.S. Small Business Administration. Covering 326 businesses after two years of operation is hardly an achievement, they add.

So far, Avenue H does not offer comparison shopping for individuals, but Herbert says the state always planned to extend the service to consumers. In fact, the plan also envisioned a tool that would allow people to pull together funding from various sources —which could include federal tax credits — to purchase their policies.

Since November, Herbert and the Obama administration have been swapping letters about whether Avenue H will pass muster under the health law.  If Washington agrees to approve Avenue H in its current form, Herbert has said he would join three other Republican-led states, Idaho, Nevada and New Mexico, in creating a state-run exchange.

“I want the Utah exchange to survive and thrive as we originally envisioned it,” Herbert wrote to President Obama ;ast month. “In fact, I hope it becomes a model for other states to use as a platform for their own versions regarding health care reform.” In subsequent letters, Herbert outlined his plans for expanding Avenue H to serve individuals and larger businesses.

HHS Secretary Kathleen Sebelius promptly replied to his letter, promising that her staff would work with the state to expand its existing exchange. Herbert thanked her, but made it clear what the state would and would not do to comply with the health law. Within days, Sebelius gave the Utah exchange a conditional stamp of approval. The state is expected to give HHS more details on its plans on February 1.

The problem for Utah is that the agency’s approval came with a long to-do list. “That wasn’t what we wanted to hear,” says the governor’s exchange chief, Patty Conner. “We wanted to hear that they would approve the exchange that we have. I think we have a different definition of flexible.”

Conner says she and her staff are committed to dramatically expanding Avenue H according to their own plans, not the check lists and timelines forwarded by HHS. She says she’s confident the site will be ready to receive consumers by October 1, and will provide most of the services outlined in the federal health law. She intends to use a seamless software patch to link Avenue H to federal premium credits and Medicaid forms.

Behind the scenes, officials in the governor’s office say they’re mystified by Washington’s approval letter. “Utah’s position on our state health exchange has not changed and it will not change,” wrote deputy staff chief Ally Isom in an official response. “Of course we’ll review the HHS announcement and determine if the conditions are acceptable or reasonable for our state exchange — and that includes sitting down with legislators — but there is nothing about Utah’s path that changes as a result of today’s announcement.”

Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Identity Management: A New Way to Fight Health Care Fraud, Waste and Abuse

December 26, 2012 By Clint Fuhrman, National Director of Government Health Care Programs, LexisNexis Risk Solutions

Government health-care fraud, waste and abuse has been a major news story for the past year — and with good reason.

In 2010, the U.S. federal government issued $125 billion in “improper payments,” defined as overpayments, underpayments, inadequately documented payments and fraud. While there are many contributing factors, government agencies don’t always know who they’re dealing with, which can result in the wrong individuals receiving and/or providing benefits. Identity theft is the fastest growing crime in the U.S., and with 30 billion connected devices in use, it can be very difficult to ensure that personal information is kept private. 

When it comes to moving services online to streamline processes, reduce costs and increase convenience and efficiency, government has seized the moment. Unfortunately, the functionality that yields these benefits is what creates challenges for maintaining the integrity of the system.

That said, it is possible to leverage the Internet to its fullest potential, while mitigating negative outcomes. Take the Florida Department of Children and Families, which implemented online self-service portals to augment traditional channels. This move enabled the agency to improve its error rate to -0.5 percent, the best in the nation, while achieving a 250 percent boost in productivity. In fact, 95 percent of clients utilize the online system. Certainly these numbers are impressive, but how are they achieved?

The answer is a robust identity proofing management. Government agencies must invest in identity verification and authentication at the front-end of benefit administration. The right identity-proofing strategy must be anchored by robust master data management and rules-based solutions, as well as comprehensive identity management. This type of rigorous identity management involves two processes:

Verifying, through electronic or manual means, that an individual is who they say they are; andAuthenticating that identity through knowledge-based mechanisms, i.e. questions that only they can answer.

Employing this type of system enables government agencies to mitigate fraud, reduce improper payments, increase service delivery and efficiency, and address privacy concerns.  

Identity management requirements will vary from agency to agency depending on the mission. There is no one-size-fits-all strategy. The mission of a federal agency that provides disaster relief services is to ensure efficiency delivery of benefit payments to residents who have been displaced. This must be done while meeting strict regulatory requirements for timely payments, and maintaining processes that prevent fraud and improper payments. An agency has specific identity proofing requirements – functionality that is speedy and the ability to answer questions related to property ownership. In addition, in this scenario, the information needed at the beginning of the relationship, a simple “Who are you?” is different than the information required downstream, “Were benefits received?”

We can contrast the above scenario to the case of an agency providing retirement benefits. In this scenario, identity proofing is designed to improve customer service over repeat visits. Instead of requiring a user to repeat the same steps very time they log on, a “data minimization” process will be utilized so that the system only asks what it needs to know to facilitate the transaction. The first time an individual registers with an online retirement system, he/she will be asked to provide his/her name and ID number, and upon registering, will answer several knowledge-based authentication questions. During subsequent visits, interactions will be “fast-tracked” since the individual’s identity has already been proven. The system will perform an invisible check to confirm his/her identity using two-factor authentication, thus requiring less effort from the user while increasing efficiencies.

Regardless of the scenario, there are four technology fundamentals that should be encompassed by any comprehensive identity management solution: 

In the identity management process, data that is broad and deep is key to maximum results. The accuracy with which you can verify that individuals are who they say they are, and the percentage of the population that can be accurately verified, depends in part on the amount and variety of data your identity management system can access. Consider what you could do with data far beyond standard demographic information and what can be gleaned from a credit bureau check. Best-in-class solutions tap billions of public records that allow them to verify hundreds of millions of individuals and provide more interesting data better suited to knowledge-based authentication, such as the model of a car the consumer owned during a certain year. 

While data is necessary to create a robust identity management system, it is only meaningful if it can be leveraged to provide insights. It is essential to have the ability to link familial relationships to the identity of an individual that they have verified. In general, an identity proofing solution should be able to:

Locate data relevant to the identity being presented by your constituent;Match it with current constituent inputs, such as answers to knowledge-based questions, a voice or fingerprint, or a one-time pattern-based PIN;Normalize and fuse data to eliminate redundancies and improve consistency and efficiency for better real-time performance; andFilter and organization information into a multifaceted view that provides what you need to know for a particular transaction with confidence.

Analytics can provide further insight into data by detecting patterns of behavior, such as suspicious patterns of identity verification failure indicative of fraud or data integrity problems. Analytics can also be used to quantify identity risk by scoring the level of identity fraud risk associated with a particular transaction. The score will be given when your system’s rules and thresholds trigger an action; for benefits claims, these decisions would include things like accept, needs review, refuse, etc. This type of scoring provides an objective, consistent and reputable way of making complex decisions in a high volume scenario. By configuring rules within your identity management solutions, you enable it to make intelligent, dynamic decisions based on the information present and the level of risk you are willing to undertake.

Today’s business environment demands that organizations that engage in identity-reliant transactions ensure the security of the critical information that they collect. In addition to a high level of security, organizations also need an equal degree of flexibility to support a wide variety of organizational platforms and end-user devices. To accomplish this goal, it is best to choose an identity management solution that can provide services across various operational systems, channels and devices. They will also support many different ways for identities to be asserted, verified and authenticated, and can apply the appropriate degree of security based on the type of transaction. 

Due to the number of constituents they deal with on a daily basis, government agencies need to ensure that they are following best practices for identity proofing and using the most advanced solutions available to them. In addition, identities are often viewed at one point in time, but it is critical that agencies stay apprised of any changes to an individual’s status that may change his or her eligibility for benefits. Individuals will continue to try to perpetrate fraud and a robust identity proofing system is the best line of defense.

Clint Fuhrman is the National Director of Government Health Care Programs for LexisNexis Risk Solutions. Fuhrman joined LexisNexis in 2009 after serving as Deputy Secretary of the Florida Agency for Health Care Administration, where he helped direct agency strategy and operations in the areas of legislative affairs, communications, Medicaid policy, and health information technology.

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Broadband Health Care Fund Launched by FCC

The FCC has announced the creation of a new fund to upgrade health care broadband services — that will ultimately be used to reform and modernize its universal service program for health care.

According to the FCC, this fund — the Healthcare Connect Fund — is intended to reform existing health-care service programs, improve broadband access and lower patient costs. It will help expand rural health-care providers’ access to high-bandwidth connections necessary for telemedicine by doing a few things: encouraging collaboration between smaller health-care providers and urban medical centers, and supporting the purchases of broadband services and upgrades to higher speed services. 

The FCC’s existing Rural Health Care program was established by the 1996 Telecommunications Act, and was not effectively structured to expand the reach of broadband health-care networks, according to the FCC.

So in 2006, the FCC launched its Rural Health Care Pilot Program to learn how to more effectively support these networks, and it now funds approximately 50 active pilots across the nation. In a recent report, the FCC highlighted lessons learned from these pilots, including a group of health-care providers in the Midwest that saved $1.2 million in patient electronic intensive care unit services.  

And a new pilot program will also be established to assess expanding broadband health-care networks to skilled nursing facilities.

Participants will have to contribute 35 percent of the costs, but will be afforded access to lower rates through group buying. A maximum of $50 million will be available over three years to pilot program applicants.

With the efficiencies that providers will gain through this fund, the overall cost of broadband healthcare networks could be cut in half, the FCC said in a press release. Past pilot programs revealed savings of $18 million in one South Carolina Medicaid program. Another pilot revealed savings of $1.2 million by providers in the Midwest that used electronic services in their intensive care units.

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FCC Health Care Initiatives Gain Momentum

The Federal Communications Commission (FCC) is getting its health care initiatives organized. Through the creation of a new website and a recruitment for a new position, Director of Health Care Initiatives, the FCC will attempt to meet recommendations made by a mobile Health Task Force.

According to an official FCC blog post, the Director of Healthcare Initiatives will promote communications technologies that improve health care programs, facilitate medical facilities’ access to wireless spectrum, and ensure open connectivity for health care facilities. The director will also be responsible for launching a pilot program to explore the possibility of expanding health care networks to skilled nursing facilities. The announcement comes days after the announcement of a new fund dedicated to overhauling broadband services for health care.

The new FCC official will work closely with the mobile Health Task Force, and federal agencies including Health and Human Services, the Food and Drug Administration, and the National Telecommunications and Information Administration.

The FCC’s new website will provide a central hub for all of the agency’s health care related projects. “By recruiting a Director of Health Care Initiatives and launching the FCC Health website, we hope to accomplish even more, with greater coordination within the agency, more community engagement, and more efficient collaboration with our external partners,” the FCC announcement reads.

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