Maine co-op gets loan from ACA-based federal program.

There is a report this week that a non-profit group in Lewiston has received a $62 million loan as part of the ACA-defined program for setting up health insurance co-ops. The CEO, Kevin Lewis, comes from ten years at Maine Primary Care Association, an industry group of care providers focused on the "health care safety net". The cynical eye might see this as health care providers putting their heads together to figure out how to deal with the uninsured who show up at their doors. They have an ambitious schedule of developing their offerings and supporting infrastructure by 2014.

It should be noted that this doesn't seem to be a HIX, per se, but just a non-profit insurance company that will get subsidies for it's qualifying participants' premiums. Basically a private sector replacement of Dirigo Choice.

Enterprise Vendors

This is supposed to be a blog about technology so I think I'll take a quick survey (by no means comprehensive). As we get futher along we'll look at some of the technical specifications put forth by the government but for today let's see what's on the ground. With hundreds of millions of dollars in play, it is no surprise that many large and medium software vendors are putting forth their take on Heath Insurance Exchange software.

Oracle

Building around it's SOA infrastructure now called Fusion Middleware, Oracle is a little light on details around what they will provide out of the box but they stick with their industry best practice architecture of including a rules engine to go with their ESB. Their professional services group is usually pretty adept at fitting their technology stack into enterprise problem spaces, but the story has been a bit muddled since their Sun merger/acquisition. They do have a high-profile customer in this space of Oregon, one of the earliest and most enthusiastic states in the HIX field.

Microsoft

Redmond is always happy to throw things against the wall to see what sticks and woe be to those left holding the bag handed to them just months before by wild-eyed "technology evangelists". In this case, it seems they are at least leveraging the mature/venerable Biztalk platform they seem somewhat committed to, packaged with a CRM product that will really need to be shoe-horned to fit into the space in question here. While they do have some partners with expertise within this space that comes with challenges of it's own. For instance, the recent acquisition of Extend Health calls into question the availability some of the technology and industry expertise that partner brought to the table with it's Medicaid Exchange tool suite. At the end of the day, Microsoft's big play in the health care field, HealthVault, is on life support (see: throw things against the wall and see what sticks) and really is only tangentially relevant to the HIX space.

eHealth

From the health insurance industry-specific vendors we find set of tools that speak to a more ground-up approach rather than the top-down vision presented by the enterprise vendors. eHealth provides tools for health insurance carriers, agents and brokers to be able to collaborate on quoting, acquisition and servicing of group and individual business. Since a HIX conceptually is just a competitive bidding market place (similar to what plays out today in agencies and brokerages) with an additional layer of medicaid integration, tax credit calculation and reporting capabilities (amongst others) they seem well positioned to at least participate in the process. Many of their capabilities are "cloud-based" SaaS (Software as a Service) which does usually support rapid adoption and flexibility at the cost of vendor lock-in. The bottom line is that there is no complete solution here but some of the major components needed for carrier integration are.

In the next post we'll pick apart some of the technical specs being published by the feds.

Is DirigoChoice a Health Insurance Exchange (HIX)?

Around in various incarnations for more than a decade, DirigoChoice is Maine's best effort to date on expanding health care coverage to it's small businesses and individuals who would have problems accessing health insurance otherwise. The plans offered by current provider Harvard Pilgrim (I guess the "choice" part of "DirigoChoice is a bit of a misnomer) have relatively high deductibles (from $1500-$2750) and include state-supplied subsidies for qualifying entities.

Chronically underfunded for it's mandate, DirigoChoice's subsidies are currently capitalized through a 2.14% surcharge on insurance claims. This has replaced past funding measures including regressive "sin taxes" (repealed by voter initiative) and the original (and controversial) tax on health insurance providers.

Is DirigoChoice a Health Insurance Exchange (HIX) as defined by the Affordable Care Act (ACA)? Not as far as I can tell, though it certainly provides a solid jumping off place. How would DirigoChoice need to change to evolve into a HIX? Some initial thoughts:

• Expand the supporting IT systems to allow other insurance carriers to offer their products on the DirigoChoice chassis.
• Modify the premium subsidy mechanism (and eliminate the existing claim surcharge process) to align with the ACA funding model.
• Integrate more tightly with the MaineCare mechanisms to provide a more seamless continuum for servicing low- and middle-income customers.

In it's current configuration, DirigoCare is aligned with the spirit of the ACA (providing health coverage to constituents that otherwise could not access it) and puts Maine on much better footing than many other states. The decade of wrangling the insurance industry, DHA and state legislature has gone through has provided those involved with innumerable lessons and many of the policy fights have subsequently been hammered out. While most states (who haven't embarked upon the public-private collaboration of providing expanded health coverage) are being handed a pre-packaged policy by the ACA, Maine is in the enviable position of having deep experience with such policy at all levels of our leadership. The hope is that this will play out to deliver the most efficient and cost-effective system in the country and the coverage extended to Maine citizens will be the best possible across the spectrum.

MaineCare

As background, we look to some of the existing programs which Maine has in place. The first is Maine's Medicaid implementation known as MaineCare, which provided some level of coverage to almost half a million Mainers in 2010. A good overview of how MaineCare fits into the landscape of health care in Maine was produced in 2005 and is still largely relevant. From a HIX perspective, it is important to realize that a broad spectrum of services well beyond the scope of health insurance (long term care, disability coverage, etc) in encompassed in MaineCare.

The boundary between private insurers and the Medicaid infrastructure has been expanding year over year and particularly in Maine. This is one area we look to as the foundational aspect of any future Maine HIX. There is a strong history of public-private collaboration in delivering subsidized group and individual health insurance products to Mainers, meaning that any HIX implementation will not be "green field" development in any sense.

The next post will look at DirigoChoice, which builds on MaineCare and is even closer to a HIX-compliant offering.

Introduction

I'm starting this blog as a venue for exploration of this interesting topic as it develops over the next eighteen months. As a technologist with experience in the insurance industry and resident of Maine, the mandate for Health Insurance Exchanges (HIX) in the federal PPACA (ObamaCare) legislation is both interesting and confusing - hence the deeper dive. A great primer/overview for what the federal legislation actually is showed up on Reddit lately as "What exactly is Obamacare and what did it change?" in the "Explain like I'm 5" subreddit.

I will say up front that while I have personal beliefs and opinions on ObamaCare and other topics, I will keep the conversation to the facts and refrain from politicizing the dialogue (monologue?). By focusing on the technology around HIX compliance, hopefully this will not be overly onerous.

Finally, as of this writing, it would seem the points to be made are largely moot as Maine has indicated it will not be establishing it's own state-based HIX. The assumption is that the Federally-Facilitated Exchange (FFE) will be leveraged in Maine on the January 2013 deadline. This may change in the future (making this a fascinating topic!) but it would appear that much of the discussion around a Maine HIX is largely academic at this point.