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A Snapshot as Deadlines Approach


The federal health law [PP-ACA] gives states the option of creating health insurance exchanges [HIEs] through which residents can purchase coverage.

Now, with a November 16 deadline for states to declare their readiness to build an exchange, most states are expected to let the feds take over by default–only 15 states, and the District of Columbia, have created a health insurance exchange thus far.


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22 Responses

  1. HIEs

    In the big sky country, an HIE has big ideas for data analysis. For example, HealthShare Montana’s team wants to do more than exchange data.


    They want to take data from clinical, claims, Census and other datasets and ask big questions about illness, treatment and public health.

    Dr. David Edward Marcinko MBA


  2. HIEs

    States get 3 more weeks for health information exchange plans.


    Ann Miller RN MHA


  3. Poop, by any other name, still stinks!

    In an effort to connect with more consumers and potentially sway some lawmakers, HHS has embraced the word “marketplace” in its communications of health insurance exchanges [HIEs].




  4. Consumer alert

    Tim – The new health care markets [HIEs] are on the way.




  5. Delayed

    Did you know that Obamacare’s HIEs are now delayed until 2015 [cheese]. Costs and logistics are rising.



  6. Stupid HHS ideas

    Unlimited campaign donations from the HIT industry purchase stupid ideas from HHS

    Last week, we learned that “Healthcare systems’ transitions from paper records to electronic ones are causing harm and in so many serious ways, providers are only now beginning to understand the scope.” (“HIT Errors ‘Tip of the Iceberg,’ Says ECRI” by Cheryl Clark, for HealthLeaders Media, April 5, 2013).


    Three days later, we learned that “One of the policy changes HHS is considering is to require that health care organizations engage in electronic HIE in order to participate in Medicare. That is, HHS is considering making electronic HIE one of the Medicare Conditions of Participation (CoPs).” (“Requiring Electronic HIE as a Condition of Participation in Medicare” by Helen R. Pfister and Susan R. Ingargiola, Manatt Health Solutions, April 8, 2013).


    Full speed ahead!



  7. What are health Exchanges and do I have to buy health insurance through them?

    A health insurance Exchange is essentially a one-stop health insurance marketplace. Exchanges are not issuers of health insurance. Rather, they contract with insurance companies who then make their insurance coverage available for examination and purchase through the Exchange. In essence, Exchanges are designed to bring buyers and sellers of health insurance together, with the goal of increasing access to affordable coverage.

    The Patient Protection and Affordable Care Act does not require that anyone buy coverage through an Exchange. However, beginning in 2014, each state will have one Exchange for individuals and one for small businesses (or they may combine them). States have the option of running their own state-based Exchange or partnering with the federal government to operate a federally facilitated Exchange. States not making a choice default to a federally run Exchange.

    Through an Exchange, you can compare private health plans based on coverage options, deductibles, and cost; get direct answers to questions about coverage options and eligibility for tax credits, cost-sharing reductions, or subsidies; and obtain information on a provider’s claims payment policies and practices, denied claims history, and payment policy for out-of-network benefits.

    Policies sold through an Exchange must meet certain requirements. Exchange policies can’t impose lifetime limits on the dollar value of coverage, nor may plans place annual limits on the dollar value of coverage. Insurance must also be “guaranteed renewable” and can only be cancelled in cases of fraud. And Exchanges can only offer qualified health plans that cover essential benefits.

    In order to be eligible to participate in an individual Exchange:

    •You must be a U.S. citizen, national, or noncitizen lawfully present in the United States
    •You cannot be incarcerated
    •You must meet applicable state residency standards

    Dr. David Edward Marcinko MBA


  8. HIE Delays

    Small business HIE participation has just been delayed a month until November 1st 2013, but without a shorter enrollment window.

    Is a delay for the individual mandate forthcoming?

    Hope Rachel Hetico RN MHA CMP™


  9. As HealthCare.gov Rebounds, New Glitches Hit Medicaid Enrollments

    Enrollees who don’t qualify for Medicaid are being told they do, and processing delays could keep some who are eligible for Medicaid out of the program in early 2014.


    Ann Miller RN MHA


  10. Is the future of HIE private?

    Whether public health information exchanges will survive after federal funding has been a lingering question.


    While no survey is enough to seal the fate of public HIEs, the results of new one ought to raise a few eyebrows — and maybe spur change.



  11. Projected Health Insurance Exchange Enrollment for Subsidized Individually Purchased Coverage (Millions of Nonelderly People)

    1. 2014 – 05
    2. 2015 – 11
    3. 2016 – 19
    4. 2017 – 20
    5. 2018 – 20
    6. 2019 – 20
    7. 2020 – 20
    8. 2021 – 20
    9. 2022 – 19
    10. 2023 – 19
    11. 2024 – 19

    Source: Congressional Budget Office [CBO]


  12. Most Medical Groups Are in ACA Exchanges and Dislike It

    Group practices are participating in new insurance plans created by healthcare reform by and large, but they are grumbling about it, mostly because of administrative hassles and narrow provider networks, according to a new survey by the Medical Group Management Association (MGMA).

    Almost 77% of MGMA members have agreed to be network providers in one or more private insurance plans sold through state marketplaces, or exchanges, under the Affordable Care Act (ACA). The leading reason for signing up, cited by 58% of participants, was to remain competitive in their local market.

    But, what do group practices expect to gain from the ACA exchanges? Not much, according to the survey, released on May 20. Fifty-nine percent of all practices, participating or not, said the exchanges will have either an unfavorable (44.3%) or very unfavorable (15.1%) effect on them. Only 13.8% of the 700-plus groups polled predicted a favorable or very favorable effect.

    Source: Robert Lowes, Medscape News [5/27/14]


  13. Health Insurance Exchanges Impact Patient Enrollment

    The first installment of this four-part Health Capital Topics series describes the operational challenges that federal and state government agencies faced during the 2014 Health Insurance Marketplace Enrollment period. The 2014 enrollment period concluded March 31, 2014, with over 8 million U.S. citizens purchasing health insurance through an online interface.

    During the 2014 enrollment period, the online interface, commonly referred to as the Marketplace, was managed by state and federal government agencies, which faced numerous technical difficulties and glitches. These challenges may be recognized and resolved when improving the Marketplace prior to the 2015 enrollment period, which begins November 2014.


    Robert James Cimasi MHA CVA CMP


  14. Exchanges and the Affordable Care Act: By The Numbers

    According to the Kaiser Family Foundation, Centers for Medicare and Medicaid Services, and the Robert Wood Johnson Foundation:

    • 2.5 million people have signed up for the exchanges during 2014. (as of Dec. 12, 2014).
    • 6.7 million who signed up during 2013 on the state and federal health insurance exchanges.
    • $0 – amount of new funding appropriated by congress in its latest budget to implement the ACA.
    • 37 states are using the federally facilitated health insurance exchange.
    • 28 states have expanded Medicaid.
    • 41 million people did not have health insurance in 2013.
    • 31 million people did not have health insurance in 2014.

    Source: NBC


  15. Private Exchange ACOs Emerge as Next Generation ACO Model

    Public health insurance exchanges [HIEs], created by a provision of the Patient Protection and Affordable Care Act (ACA), have received considerable attention as health insurance coverage has been expanded to cover previously uninsured individuals.

    These public health insurance exchanges alone are expected to provide coverage to approximately 13 million individuals in 2015, a significant increase over the average coverage of individuals by exchanges in 2014, of approximately 7 million individuals. Private exchanges are also grabbing the attention of consumers, with enrollment in private exchanges expected to equal the enrollment in public exchanges as early as 2017.

    Consequently, both public and private payors are devising innovative strategies, such as partnering with Accountable Care Organizations (ACOs), to capitalize on the increasing demand for affordable health insurance plans, which offer the consumer a range of health insurance plan options.

    This article will discuss these new private exchange ACO models, as well as the driving factors behind the increased interest from consumers in choosing private exchanges over public exchanges.


    Robert James Cimasi MHA AVA CMP™



  16. UnitedHealth May Withdraw From ACA Exchanges in 2017

    The nation’s largest health insurer, UnitedHealth Group, said that it is retreating from efforts to attract customers for the coming year in insurance exchanges created under the Affordable Care Act — and may withdraw from the marketplaces altogether in 2017.

    UnitedHealth executives attributed the abrupt change of course to what they called “higher risks and more difficulties” in selling coverage through the exchanges in a way that is profitable. The company is the first major insurer to say it might leave the exchanges, raising questions about the stability of the marketplaces that now provide a path to insurance for 10 million Americans.

    Source: Amy Goldstein and Carolyn Y. Johnson, Washington Post [11/19/15]


  17. Clinically Integrated Networks

    While scientists are in general agreement about how evolution works, there are several somewhat different theories for exactly how it proceeds. One theory put forth by the late Stephen Jay Gould is called “Punctuated Equilibrium,” and it essentially means that evolutionary changes proceed rather slowly in stable environments, disrupted – or punctuated – by bursts of massive changes in response to substantial environmental changes. Mutations that could not thrive in the earlier environment do so in the new one, though some prove more long-lasting than others. That’s what we’re seeing right now as the federal government changes the healthcare environment.

    Clinically integrated networks initiatives are mutating all over the place, as are private payer organizations. Each showing some similar features, but each having its own distinctive forms and functions, partly in response to the external environment, both local and national, and partly in response to their existing capabilities and cultures. Examples of differing factors include such things as health system employed physicians vs. independent physicians or groups; rewarding health system executives for making high margins and high utilization vs. rewarding for reducing costs; private payers creating reward-based payment models vs. reward and risk-based; health systems competing with payers vs. partnering with them vs. contracting with them; health system regional dominance vs. regional competition; and so forth. In reality, none of these are actually “vs.” situations; they are more of a balance between such factors.

    If the environment has an impact on health system clinical integration, there is also a feedback loop just as in biologic evolution: as they evolve, they have an impact on their environments as well. We are seeing that as well, but it remains far too early to describe it in any way that will not be different within a year or two. Mutation: the engine that powers change. Gotta love it.

    Peter R. Kongstvedt MD, FACP
    [Principal, P.R. Kongstvedt Company, LLC]


  18. CINs

    The question around the state and impact of CINs is one of HUGE importance. That said, my short answer is “We really don’t know.” The CIN movement has been stealthier than the development of B1 bombers.

    The promulgation of CINs was initiated and promoted by the Federal Trade Commission guidance in the mid-1990s. The CIN construct was the government’s response to the industry’s spawning of “financially” Integrated Delivery Systems in the early 1990s. The intent was to provide antitrust guidance by allowing clinically beneficial integration initiatives across provider organizations while discouraging veiled anti-competitive practices.

    As of 2008 there were only a handful of CIN initiatives in the US; by 2013 the Advisory Board reported that there were some 500 CINs in existence. Who/what are they? Don’t know — I’ve never actually seen a list of CIN initiatives.

    Contrast the dearth of information about CINs with the plethora of information and discussions around ACOs. ACOs have been widely reported on in excruciating detail. I’d imagine there’s a fair amount of overlap between a list of ACOs and a list of CINs — but that’s conjecture. A few CINs have been above the radar — Advocate in Chicago is the poster child example of a visible, successful, aggressive CIN.

    The structure of CINs has been highly regulated. Ideally, CINs would be driven primarily by clinicians seeking to promote integrated patient care and secondarily by business executives focused on creating effective partnerships and alliances. Yet, the creation and guidance of CINs has been driven and controlled by lawyers and compliance officers.

    Vince Kuraitis
    [Principal, Better Health Technologies, LLC]


  19. UnitedHealth Will Drop Out of Most ACA Exchanges

    UnitedHealth Group CEO Stephen Hemsley said recently that the health insurance and services conglomerate will pull out of most of its Affordable Care Act marketplaces. But the company won’t bail on the exchanges completely and will sell individual plans in a “handful” of states. “We cannot broadly serve it on an effective and sustained basis,” Hemsley told analysts and investors on a conference call. UnitedHealth has fully or partially exited five states so far—Arkansas, Georgia, Louisiana, Michigan, and Oklahoma, according to various news reports.

    The company sold plans in 34 states for this policy year and did not disclose which states it will stay in. Insurers that sell plans through the federal HealthCare.gov portal have until May 11 to file rates for 2017 plans. UnitedHealth recorded an additional $125 million loss on its individual ACA plans, meaning the company’s total ACA losses for 2015 and 2016 will exceed $1 billion. UnitedHealth signed up many sicker-than-expected members, ending the first quarter with 795,000 public exchange enrollees, which is only a fraction of the ACA’s individual market.

    Source: Bob Herman, Modern Healthcare [4/19/16]


  20. 62% of Exchange Plans Will Be HMOs in 2017

    McKinsey & Company recently released an analysis of 2017 exchange plan designs across the U.S. Here are some key findings from the report:

    • HMOs will comprise 62% of all plans for 2017.
    • 68% of consumers will have access to competitively priced managed plans only.
    • The lowest-price silver plan premium will increase 9% for managed plans in 2017.
    • 82% of consumers will have access to both managed and unmanaged plans in 2017.
    • For unmanaged plans, the lowest-price silver plan premium increase will be 18%.
    • 97% of national plans will be managed in 2017, up from 62% in 2014.

    Source: McKinsey & Company, August 2016


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