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Health IT underpins wide swaths of the recently passed health reform law, but nowhere is it implied more prominently than in the legislation's requirement that states set up health insurance exchanges.
President Obama in March signed the Patient Protection and Affordable Health Care Act and companion Reconciliation Act of 2010 into law. The legislation calls for establishing exchanges by 2014 to enable small businesses and people lacking an employer- provided plan to purchase coverage.
State exchange programs will use an Internet portal to direct insurance shoppers to health plans and provide them a means to evaluate private plans available through the exchange. The portals will also determine whether users are eligible to purchase insurance via the exchange.
Health IT experts believe the exchanges face complex integration challenges. Erica Drazen, managing partner of emerging practices with CSC's Healthcare Group, said an exchange portal will be "way more complicated" than the typical Web-based information hub.
"You need links to all the insurers," she said. "Ideally, you want people to be able to compare products and then sign up for insurance on the Web site. It's not just an information portal, it's got to be a transaction portal."
The difficulty of the integration challenge will rise with the number of links to private insurers and other parties. But multi-source eligibility determination will add another level of intricacy to the job.
Medicaid is a case in point: Determining Medicaid or Medicare eligibility"which would disqualify a client from using the exchange"will call for interaction with state Medicaid systems, which can be clunky at best, according to Bobbie Wilbur, co-director of Social Interest Solutions, a non-profit organization that applies technology to improve access to health and social services.
"You have to look at how the exchange technology is going to support a variety of Medicaid systems out there," she said. "The states have a lot to do to get ready for 2014."
Reinventing the wheel
The broader difficulty, however, might be keeping costs under control as 50 states roll out exchanges and portals. "It would make no sense to have every state go out and try to start this from scratch," Wilbur said. "It would be just cost prohibitive."
Wilbur suggested that the federal government set up a model exchange that states could adapt. At the very least, the law calls for the Department of Health & Human Services to develop a "model template" portal that will be offered to the state exchanges. Alternatively, a state such as Massachusetts, which already has an insurance exchange, could facilitate the transfer of that technology to other states.
Even so, states would do well to coordinate their insurance exchanges with their ongoing efforts to launch in-state health information exchanges. The HIE and insurance exchanges might be funded from separate program streams"ARRA backs HIEs"but should be coordinated.
"As you look at the [health reform] law and look also at the stimulus dollars, the successful states are going to look at those two things together," said Kerry Weems, senior vice president and general manager of health solutions at Vangent, an information management and outsourcing firm that specializes in healthcare.
To do so, states should aim to create an architecture in which health insurance exchange and the health information exchange can talk to one another. "If they create those separately, in my view, they are going to make a big mistake," said Weems.
Other IT Influences
Beyond insurance exchanges, the healthcare reform law gives IT a role in longterm care. In the legislation, HHS is authorized to award grants to long-term care centers to defray the cost of acquiring electronic health records systems and hardware such as handheld computers. The grants, totaling $67.5 million over a four-year period, can also be used to upgrade software and hardware to "enable e-prescribing."
CSC's Drazen suggested that the grants might have been included to compensate for the absence of those facilities in the economic stimulus package. Weems said the amount of money, a small outlay compared with ARRA's hospital and physician funding, indicates the dollars are intended to fund pilot projects.
Either way, long-term care facilities are substantially behind hospitals in EHR adoption, Weems said. "It's probably one of those gaps we are going to see in the continuity of care as you go from hospitals to rehabilitation facilities, which also may be long-term care facilities," he said.
Another IT angle in the health reform law involves accountable care organizations (ACO). The law encourages the creation of ACOs, which seek to pull together primary care providers, specialists and hospitals to coordinate patient care and reduce costs. "ACOs harbor hidden requirements for IT that are pretty substantial," Drazen said. "They will live and die based on their ability to connect information and manage care across settings."
It makes sense to link health information exchanges into the ACO process, Wilbur said, noting that sharing patient information among doctors and hospitals will improve care and reduce inefficiency" the expense of running duplicative tests, for example.
Part of the motivation behind ACOs stems from a desire to deploy a valuebased reimbursement system. If reimbursement emerges as the main problem ACOs seek to solve, the resulting work will occur at the Centers for Medicare and Medicaid Services. Weems said CMS could end up tweaking its existing payment system to accommodate ACOs.