Health Insurance Exchanges

One of the biggest issues that came up during last year’s raging debate on the need to overhaul health care was the idea of government run health care insurance exchanges. Since the passage of the health care bill, this topic has seemed to lose focus in the media. However, I noticed in an article in The New York Times titled: “Health Care Overhaul Depends on States’ Insurance Exchanges”  (by Robert Pear; Published: October 23, 2010) that reminded me of how much of an impact these exchanges could/ will have on the success of the health care overhaul. Also, from an IT perspective, I was (am) interested in the technical aspects of how exactly these exchanges will work. I should also note that under national health reform, states must have a health exchange in place by January 1, 2014 – so this is something that states are either planning and/ or have a solution in place.

What is a State Insurance Exchange?

I had a hard time finding an official definition of a “State Insurance Exchange”; but here’s a definition that seemed to make the most sense to me – it’s from a 2008 study by the Minnesota Department of Health titled, accurately enough “Health Insurance Exchange Study”: 

“The basic idea of a health insurance exchange is similar to the concept of a stock exchange or farmers market – an exchange serves as a market clearinghouse, but not as a regulator or purchaser.3 It functions as a single place where people can go to find out about their health insurance options, and improves market competition among health plans by providing more complete and understandable access to information about the products and pricing available in the market.”

Why does an Exchange matter?

In my mind the most simplistic way to understand why this matters to the success of the health care overhaul, is to think about the cause and effect of a law stating that everyone needs to have health insurance. That is to say, that in order to realistically require some level of health insurance for everyone there has to be a organized (maybe controlled?) way for people to obtain that insurance, at a cost they can afford (or be subsided by the government) – and there has to be a way to provide enough data about the options so people can make an informed choice. And, of course for any of this to work you have to create a “market place”, as stated in the definition above, in which insurance companies not only compete but also activity participate in, maybe even be required to participate in.

How they work... and the IT side of things

There is a great graphic in The New Your Times article sited above that shows generally how Health Insurance Exchanges work, however like many other articles it does not describe any of the specific technical details of how an exchange works. That said, here are my general comments on what I did see or assumed:

·         First, the obvious - health exchanges are web based solutions. I could not find one example of a state exchange that was not web based.

·         For a visual of what the user interface of an exchange might look like I looked at the U.S fed. Employee’s site: http://www.opm.gov/insure/health/search/plansearch.aspx and the Massachusetts state’s “HealthConnector” https://www.mahealthconnector.org/portal/site/connector/

·         Both of the above are your basic web portal, with tools, information. I had tried to find someone working on more of a next generation web app style exchange (think iPhone app) but didn’t find anything

·         I couldn’t find any specific info on how the insurance companies communicate with the exchange – meaning are they using a specific standard (HL7?) and are they using the normal web service model / XML to exchange data. I’m assuming that this model is in use, but I didn’t see this detailed out anywhere.

·         I also tried to answer a general question I had as to if there was some link into a user’s patient health record system (PHR) and if there was any way for a tool, through the PHR to do routine searches of the exchange to determine if there was possibly better options for the patient – both cost and general insurance options. My thought was that it would be good if there was a way, say every 6 months to have an app update a patient’s PHR info with any changes in the exchange. So when the patient logged in they could determine if they wanted to make a change. Anyway, this does not exist (or else I couldn’t find it).

Please tell me what you know…

Please comment on any additional info you may have to the above; I would love to find more technical information on how the exchanges will work – especially how other entities communicate with them, what standards are used, and if these exchanges are just between insurance companies and the state or if the exchanges will also allow other tools/ apps to exist and be used by patients – or be tied into a patient’s PHR.