The Health Insurance Exchange NPRM

Last week, Health and Human Services issued an important notice of proposed rulemaking (NPRM) about Health Insurance Exchanges.

What are Health Insurance Exchanges?

They are state-based competitive marketplaces where individuals and small businesses are able to purchase affordable private health insurance.  As Secretary Sebellius noted

"Health Insurance Exchanges offer Americans competition, choice, and clout. Insurance companies will compete for business on a transparent, level playing field, driving down costs; and Exchanges will give individuals and small businesses the same purchasing power as big businesses and a choice of plans to fit their needs.”

Health Insurance Exchanges are abbreviated HIX rather than HIE, reducing confusion with Health Information Exchanges.

The IT portion of the NPRM is interesting - Section 1311(c)(5) requires the Secretary to make available to all states a model HIX web application developed by HHS.

This is not intended to be a single central website for the US.  Instead, there will be a set of common web tools available to all states to support health insurance exchange websites.  My understanding is that the infrastructure will be service oriented so that states can create their own user experience but leverage complex business logic and administrative tools developed for all.

Massachusetts is part of a six state New England consortium that was awarded an innovation grant of $35.5M to in February 2011 to build a New England HIX by December 2012.  For details, see their website.  The New England team believes HIX has many components that are common and hence can be developed just once for the region/country.   At the moment, HIX has a strong policy directive, appropriate funding, excellent leadership, and multi-stakeholder governance - many of the key elements in my Recipe for Success.

Are there lessons learned from Healthcare Information Exchange (HIE)?

At the moment, HIE has less of a strong policy directive (Meaningful Use Stage 1 only requires a single test of HIE), funding is limited considering the scope of work necessary to connect every provider/payer/patient, the domain is highly complex creating a shortage of excellent leaders, and governance is still evolving.  

CareSpark, one of the early HIEs recently closed it doors because it lacked significant adoption and a sustainable business model.

A lesson learned from the HIX effort is that HIE needs a urgency to implement the technology and an audience that wants to adopt it.

Are there common components that could be developed just once?

Yes  -  gateways provided by a Health Information Services Provider (HISP), provider directories, certificate management, a standard for transfer of care summaries, and consent guidance that empowers the develop of local consent frameworks.  

Hence, the work by the Direct project, the Summer Camp of the HIT Standards Committee, and the projects of the Standards and Interoperability Framework.

It will be more difficult to create national components that can be repurposed locally because of the heterogeneity of use cases for HIE in every locality.   Thus, HIX, which provides uniform functionality across states does not precisely provide a model for HIE, but in the next year all the use case work, the standards work and the policy work (meaningful use stage 2) will converge so that HIE will have as many "recipe for success" factors as HIX has today.