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As the CEO of Pulse8, John Criswell works with health insurance exchanges and long-term care facilities on big data and analytics, which gives him a purview into the back-end integration required for states and the federal government to setup HIXs. Yet, he’s optimistic that the gvoernment will meet the October 1, 2013 deadline.
Government Health IT Editor Tom Sullivan spoke with Criswell about the complexity of standing up HIXs, how the exchanges might fare come October, and the overarching opportunities that both HIX and health information exchanges will create as they amass mammoth data sets.
Q: When it comes to the back-end data integration of standing up an HIX, linking payers into the so-called marketplaces' online retail store front, that sounds like an IT nightmare. Is that work as difficult as it seems? Are the payers willing or merely obliging with the law?
A: It is complex. It is difficult. I think you’ll see different things from payers. My sense is that among the commercial population of payers they are very interested in participating. Historically, when you look back on things we’ve had to stand up like Medicaid, there are many, many challenges and Medicaid did not have full participation on day one but, over time, we’ve seen a pretty significant growth in Medicaid services. And now things are happening that are positively impacting the change of Medicaid, this being one: the new commercial health insurance marketplaces. Payers are willing, they are eager, they are learning. I believe the Department of Health and Human Services has a series coming up on the technology component around the edge servers and the infrastructure to support things like risk-adjustment. But it is complex, it is difficult and I think we’re going to see a lot of challenges over the next several months as this thing begins to go live.
Q: There's a growing collective of people basically saying there's not an ice-cube's chance that the marketplaces will be ready for even the first deadline in October of this year. HHS is sticking firm that they will. How do you envision this all playing out in October and beyond?
A: I’m very optimistic. I was able to listen to a senior leader at HHS [last] week and I walked away feeling more confident than I felt before. From my perspective we need to get down to ‘what is it we’re trying to accomplish?’ What we’re trying to do is get Americans health insurance. I think if we keep that in mind, we can accomplish this. But it is extremely big and we can’t ignore that. This is not something that can kind of race across the calendar and then we end up having to say ‘Folks, this is not going live on time.’ This is not going to be a perfect system that goes live for enrollment in October, but there are going to be improvements over time, every quarter. I do believe that if a deadline is missed, regardless of when it’s set, the next deadline is going to be missed. And you’re probably familiar with ICD-10 implementation. That’s just processes and workflows. ICD-10 is not, in my opinion, mission-critical. Insurance exchanges and Medicaid expansion are mission-critical. Now, they didn’t get cancelled and knowing that we’re trying to get insurance for people who need it, this is much more significant. Again, I heard HHS speak and it was a wonderful presentation and I felt much more confident about the federal side of things moving the exchanges forward.
Q: The HIX and Medicaid expansion are definitely mission-critical to achieving what the ACA intends to achieve and there’s at least some risk that if the federal government does not get the exchanges stood up and more people insured, then it will be that much easier for a different administration to undo the law – if that is the next President’s intent.
A: My sense, Tom, is I think we’re going to see enrollment in October. And there are going to be bumps. But I think it’s going to go live and people will enroll. On January 1, 2014, benefits are going to be eligible, people are going to be seeing their doctors, using this system, with insurance. And as things move along it will get better, smoother. Whether it’s Medicare, Medicaid, or the health benefits marketplaces, yes there are lots of things different about the marketplace, but the essential healthcare delivery systems, you and your provider, that interaction between patient and provider is not changing today.
Q: As things shake out, it appears that about half the states will opt for the federal exchange. What are the implications?
A: Over time, I think we’ll see states eager to take over this responsibility, and that might be 2 or 3 years into the future. That’s what I anticipate seeing.
Q: Once the exchanges are set up, what is the overarching opportunity to run analytics against that patient and payer data? How can that data be harnessed to both improve care and bend the cost curve?
A: From a data perspective, in respect to HIPAA, there are a lot of opportunities to improve care overall. When I look at, say, analytics and bending the cost curve, this has the greatest potential in the history of healthcare in our country. For the very first time we’re going to be able to analyze disease trajectories and pathways that are well beyond our current imagination. I don't think we can fully dream of what we can do. We really don’t know what this is going to look like as we pull all of this data together. To draw a parallel, it’s like taking what the Internet did to general knowledge — when I look back, as a child my parents bought me the World Book of Knowledge — I look at it very much like that. And you’re probably familiar with Encarta and the conversations with Microsoft happening way back in the 90’s, I think we’re really talking about is giving payers access to as much information as possible becoming the new norm. There’s natural concern around PHI and HIPAA but there’s lots of opportunity. Imagine having data concurrently for 10 years of the same member population de-identified or 100 million people, imagine what you can do with that data. It’s really powerful stuff to analyze treatments, facilities, providers, geography, all of those things that can allow us to improve care. When you can do that, I think we’ll have the ability to contain costs and improve quality.
Q: Now, are you talking just HIX data or also HIE data?
A: Both HIX and HIE. On the HIE side, those models are going to empower providers to have a much more robust data set. Today, when you visit your doctor, the doc only knows, in most case, what you are telling him or her. In that environment, they don't have full visibility. In tomorrow’s environment they can have full visibility to your specialist visits, to your emergency department visits, to the fact that doctors have prescribed you five medications and you didn’t fill one. If you choose not to fill a prescription, what does that say about the relationship between you and your doctor?
Q: It says plenty…
A: I think it does and I don’t think we can dream big enough. We have to dream very big and there’s significant opportunity that is best served between the provider and the patient and getting the provider the information he or she needs is critical to the cost curve and the outcomes improvement.
Q: And as you mentioned, the historical data on millions of people will be very powerful. How do you envision providers using it?
A: There are a lot of data sets that exist today. There are Medicare data sets, commercial data sets, but the challenge is that it’s not a concurrent history of one individual, there are still disparities within their own data set. What I look at is being able to connect a member as he or she moves throughout the healthcare system because they will move and whenever that occurs you begin to lose sight of that person. If I were to project ten years into the future, after the exchanges go live, after HIEs are live, we now have the ability to look at numbers over this period and we can analyze and understand much more deeply how things are operating and that will help us rip out costs that are unnecessary and improve quality and outcomes. We take two people who have undertaken different treatment plans, for instance, and determine the most appropriate trajectory.
Q: What state exchanges are you working with and what are the unique things they are doing?
A: In the dialogue that we’ve had with the States, Massachusetts is the most mature and the only state that’s received provisional approval to run its own risk-adjustment methodology at the moment, so that’s certainly unique. Maryland’s Health Connection and Be Covered Texas, those are two examples where education updates, guidance via text, email updates, any citizen can enter their information and get updates, a sense of what’s going on. When you move to the payers, Florida Blue has extensive retail centers. Emblem Health has Care Cafes that connect members for social services, food, transportation, they’re doing fun things like Wii Fit, there’s an interactive health risk assessment that you can take. We’re starting to see the beginning of how payers are migrating to a retail mindset. Along those lines as we think about HIPAA and PHI there are a lot of regulatory compliance matters and it’s really complex, but there’s significant opportunity to use data and analytics to help people live independent healthy lives. And as we think about ACOs and PCMHs the ability to drive information to a provider so they know what’s happening with a patient across the healthcare delivery system can help us improve the efficacy of interventions, research, create best practices. Doctors want to provide the best care. They’re an extremely thoughtful, intelligent, competitive group and by giving information to them, showing how they are benchmarking against their peers, we will improve the community. I see lots of collaborative models developing out of this that drive opportunities to educate providers in a way that’s never happened before.
Q: Those collaborative models, are you talking about ACOs?
A: I think many of the ACOs today are engaged in the Medicare performance model and what you will see is a migration to the health insurance marketplace. I can imagine that ACOs today around the country are evaluating whether or not to become a qualified health plan on the marketplace. I can see that happening. When that happens, it will drive more options for consumers.
Podcast: The ACA at 3