1 Establishig State Health Isurace Exchages A Review of Critical Issues, Opportuities ad Risks Cotributors: Thomas C. Lerche, Natioal Practice Leader, Health Care Philip A. Peterso, FSA, Natioal Practice Leader, State ad Local Govermet Michael H. Taggart, FSA, Natioal Practice Leader, Healthcare Data Aalytics
3 Backgroud State-based Health Isurace Exchages ( Exchages ) have the potetial to trasform the health isurace market for idividuals ad small busiesses ad, loger term, large employers. If correctly desiged ad successfully implemeted, they offer may advatages: expaded competitio for health isurace programs, improved trasparecy of health care quality metrics, icreased use ad value of welless programs, ad expaded optios for cosumers i their health plas. Desigig, implemetig, ad operatig a Exchage is a challegig udertakig, however. Numerous issues ad risks must first be addressed. This paper highlights a few of the most critical. Key Cosideratios Certai states (Massachusetts ad Utah) have already formed Isurace Exchages, ad others are actively explorig the possibility, i part based o ideas discussed i framig atioal health care reform ad i respose to state-level cocers. We believe there are three key areas for states to cosider before takig actio to establish a Exchage: 1. Develop a value propositio for establishig a Exchage 2. Determie critical success factors for a Exchage 3. Establish a structure for Exchage creatio, maagemet, ad goverace 1. Develop a Value Propositio for Establishig a Exchage While the health care reform movemet will drive state actio, the questio remais as to how states should pla ad costruct their Exchages i order to best serve potetial customers ad satisfy the forthcomig regulatios. We believe that the value for states i creatig a Exchage icludes the followig: A more competitive health care isurace market for participats This is a compellig log-term reaso to establish a Exchage, but oly if it ca gather ad retai a sigificat market share. If erollmet is large ad stable, the Exchage should be able to leverage that to drive iovatio ad more competitive premiums that will improve the value ad affordability of health isurace for the etire state. A well-operated Exchage could deliver substatially greater value tha ay idividual members or employers could obtai idepedetly. Reduced admiistrative expeses ad processes For employers, particularly small employers, ad health isurers, a Exchage provides a great opportuity to reduce admiistrative costs. At the broadest level, the cost reductios may come from: Admiistrative fees charged by health isurers, such as marketig expeses, ew policy issue expeses, ad ogoig admiistratio. There also are opportuities to egotiate reduced sales fees (icludig broker commissios), further reducig costs for policies. Iteral time spet by small employers o admiistrative processes, icludig beefit pla erollmet, employee commuicatios, mothly billig process, aual regulatory filig requiremets, etc. Establishig State Health Isurace Exchages 3
4 Sice small employers are traditioally the egie of job growth, implemetig a Exchage could make the state more attractive to the busiess commuity by stabilizig the cost of employee health coverage ad the admiistrative burde of sposorig coverage. Employers would be more likely to add ew employees if their idirect busiess costs of health isurace coverage were lower. Iovatio i health care maagemet We believe that Exchage formatio will ecessarily speed the covergece of health care delivery toward a itegrated platform. The curret health care area cotais multiple types of vedors: health isurers, pharmacy beefit maagers, utilizatio review firms, disease maagemet/ welless ad employee assistace program (EAP) providers, data warehousig compaies, home health care firms ad others, each operatig idepedetly uder traditioal health plas. There is a cosiderable degree of iefficiecy ad waste i this approach. With a Exchage, these elemets of health care delivery ca be collected ad coordiated more effectively, leadig to improved uderstadig of isurace ad health maagemet programs, better access ad efficiet use of program services, ad a more kowledgeable membership that ca access health care services efficietly. Sice 60% of the costs of employer-based health coverage are drive by medical claims from lifestyle-related ad chroic diseases, Exchages provide a great way to ecourage iovative welless ad prevetio programs, which will moderate premium icreases over time. More effective distributio chaels for beefit optios Exchages ca be effective distributio chaels for a wide rage of health care services ad isurace products. Examples iclude optios i life isurace, acillary health services, disability, volutary beefits, persoal lies, etc. I additio, approved products ad services that are cogruous with the theme of healthy lifestyle ehacemet (e.g., utritio ad exercise products/services) could reiforce the proper use of core offerigs. A Exchage s ability to offer its membership products ad services through a sigle poit of access ca both reduce the purchase costs of all beefit plas ad facilitate improved oversight. Improved service delivery A Exchage s ability to stadardize core programs ad cosolidate delivery through a sigle delivery poit/portal makes it easier to advocate ad resolve member disputes ad appeals associated with isurace programs. Appeals outcomes ca be documeted o a stadard basis across all members, allowig participatig health isurers ad other health care orgaizatios to adopt similar admiistrative processes ad reduce overall expeses. 2. Determie Critical Success Factors for a Exchage While there are umerous elemets that eed to be preset for a state-based Exchage to be completely successful, we believe that ay state cosiderig a Exchage should cocetrate o the followig critical factors to promote log-term success. Erollmet ad coverage Market share, as determied by the total umber of members erolled ad covered through the Exchage, is perhaps the most critical success factor. The Exchage must first attract ad maitai a critical mass of participats (both employers ad idividuals). Secodly, it must grow that membership cosistetly over time. Like may ew techologies, Exchages have high startup costs to deploy the ifrastructure but low margial costs for addig ew members. The ability to leverage cost advatage is thus highly depedet o erollmet. The decreasig costs associated with a growig membership will i tur help uderwrite other programs that the Exchage may wat to add to attract ew members. 4 Ao Cosultig
5 Market dyamics are likely to create a mometum effect, e.g., the Exchage that attracts the greatest iitial iterest ad geerates the largest iitial erollmet is likely to experiece a spiral of success; awareess feeds ew iterest ad membership. Of course, all elemets that drive cosumer satisfactio will eed to be preset from the start to maitai high program retetio. Health isurer/service provider participatio The Exchage should be desiged to attract a sufficiet umber of high-quality health isurer participats. Health isurers/service providers eed to uderstad how the Exchage affects the markets i which they do busiess ad the rules that apply to marketig ad sellig the busiess. They will wat to uderstad the Exchage-dictated coditios uder which they will be boud cotractually ad how that affects pricig. Health isurers/service providers will eed to be assured that the uderwritig ad admiistrative rules of the Exchage provide them with a fair opportuity to obtai profitable erollmet. For health isurers, the uderwritig ad erollmet rules are critical, as health isurers will be cocered about the risk of adverse selectio. Uderwritig rules for member selectio must provide a reasoable assurace that health isurers will ot be exposed to high selectio costs. Depedig o the extet to which ope competitio is permitted amog Exchages, health isurers will be cocered about premium rates ad how they vary amog uderwritig groups ad over time. Risk poolig ad isurace rate stability Oe of the most critical steps i settig up a Exchage is to esure that isurace carriers or brokers do ot adversely select agaist it. A Ao study of private isurace exchages foud that adverse selectio ca quickly lead to market failure. States ca take the followig steps to guard agaist selectio problems: 1. Establish the Exchage as the exclusive market for idividual ad small group isurace. This would costitute a sigle risk pool for the etire state, effectively precludig the potetial for adverse selectio. 2. Require all isurace carriers to participate i a statewide high-risk pool. This would reduce the likelihood that ay particular isurace carrier would be disproportioately hit by adverse selectio. Spreadig the impact of high-cost claims across all isurace carriers would improve the stability of isurace premiums across all isurace carriers ad allow the Exchage to focus o achievig its atural competitive advatages, superior cosumer service, ad lower admiistrative fees. 3. Alog with use of a high-risk pool, the state ca cosider redistributig the risk usig the cocepts of reisurace/stop-loss risk, therefore brigig greater rate stability to the Exchage. If the majority of busiess comes from idividuals ad small groups, it is especially importat to costruct a risk redistributio model for high-cost claims to protect Exchage members. Admiistrative platform ad processes The admiistrative systems ad processes must be able to maage the volume ad complexity of the Exchage trasactios. They also must set the foudatio for maitaiig relatively low operatig costs. The complexity of trasactios ad the umber of data iterfaces i a Exchage will dictate the eed for robust systems. Exchages ca potetially serve as the cetral hub aroud which all health trasactios are itegrated. For istace, states will wat to look at their curret use of electroic medical records (EMR) techology i both the private sector ad public plas (e.g., Medicaid, CHIPS) ad make decisios o three frots. Establishig State Health Isurace Exchages 5
6 1. Whether it is realistic to expect to make use of EMRs i a Exchage eviromet over the short-term 2. Whether/how existig platforms ca support the developmet of ad use of EMR techology ad bolster the Exchage s value 3. Which cliical ad other prerequisites eed to be i place to trasitio successfully to the use of EMR Buildig streamlied admiistrative processes is likely to be the key factor i maagig operatig costs. To be successful, the Exchage eeds to deliver most of the capabilities of a traditioal employer beefit departmet at a far lower cost. The way to meet this objective is to automate the vast majority of trasactios through the Exchage s techology platform, where the trasactio costs are a fractio of traditioal paper ad people processes. Give that most small to mid-market busiesses have limited iteral admiistratio capabilities, the Exchage eeds to establish a stadard process for a very wide rage of admiistrative tasks. Exchages should allow the itegratio of all types of services, icludig: Sharig of eligibility data for service provisio, billig, ad reportig/disclosure Warehousig of cliical data for assessig risk more accurately i order to maage costs ad member health Deliverig services to employees through a sigle access poit, usig call ceter ad portal techology. This sigle poit of access for all vedors is a critical factor i deliverig large employer health pla maagemet strategies to smaller employers Exchages also ca have a impact o other techologies eeded to improve the health care system. May hospital ad physicia providers believe that policymakers should ecourage the evolutio of EMR techology to iclude capabilities that support care coordiatio. If the Exchage becomes the cosumer s health home, it ca help expad acceptace of EMR techology. 3. Establish a Structure for Exchage Creatio, Maagemet, ad Goverace Exchage Structure, Operatio ad Charterig Curret law/regulatio, as well as the likelihood of ewly adopted state policy, will shape how Exchages are orgaized. Each state will create a regulatory framework for buildig ad operatig Exchages to reflect the realities of curret policy ad practice ad the political eviromet. The followig areas must be addressed. Desig, develop, ad implemet a effective goverace ad maagemet system at the Exchage leadership level. This icludes: Optimal structural formatio Executive roles ad resposibilities Policies ad stadards for decisio-makig Goverace, moitorig, ad cotrol processes Cosumer decisio-makig tools ad methods 6 Ao Cosultig
7 Implemetig these steps requires a uderstadig of several factors. The state ad federal regulatory climate ad where chages should/ca take place to accommodate Exchages The markets i which health care purchasig takes place (i.e., retail, public plas, ucompesated care) The makeup of the isurace ad health care orgaizatios that are likely to participate i the Exchage, how the service areas of these orgaizatios alig with the targeted member populatios, the health risks associated with those member groups, ad the ability of isurers to deliver a quality cotiuum of locally-based care (core medical, metal/behavioral health maagemet, case maagemet EAP, etc.) A foudatio for maitaiig Exchage risk pools to create a competitive market ad a self-sustaiig fiacial structure for both health isurers ad health care providers A admiistrative ad operatioal aalysis regardig the state s ability ad desire to self-admiister the Exchage as a state etity or whether to focus o establishig the regulatory stadards of the Exchage ad orgaize a private etity to operate it Public policy relatig to competitio through the Exchage. For example, will Exchages be allowed to egotiate directly with health isurers, or will they be limited to a price taker role, acceptig whatever rates are proposed by the health isurers Public policy decisios ad regulatory requiremets o Exchages beig owed/operated privately or as part of the public domai The ability to offer programs through a Exchage to iclude coverage optios such as core detal or visio or employee paid optios A positio o whether Exchage membership will be limited to citizes of the state or whether to parter with adjacet states Oce these ad other issues are cosidered, the state will eed a process to determie the best way to establish the Exchage withi the state s directio ad budget. Ecoomic aalysis ad testig of prelimiary models ca the occur, with the goal of idetifyig the best operatig model for the Exchage, with perhaps a pilot to stress-test the model. Support defiitio, aligmet, ad commuicatio of strategic priorities to all parties, icludig recruitig ad aligig key participats i the Exchage. These iclude: Federal agecies (HHS, Departmet of Labor, etc.) State agecies (Departmet of Isurace, Departmet of Commerce, etc.) Markets/health isurers Health care ad disease advocacy groups Vedors/health isurers Establishig State Health Isurace Exchages 7
8 Employers Potetial members Policy ad market experts (health policy, actuarial, cosumer advocacy ad educatio, etc.) Idetify ad defie critical likages betwee the regulatory structure ad the Exchage maagemet, icludig: Legal status Requiremets for licesig, reportig ad disclosure, marketig, distributio, pricig, cotractig, etc. Operatioal structure Requiremets for egotiatig ad cotractig with vedors (health isurers ad health care providers), developig ad sellig multiple product lies sesitized to differet audieces (e.g., culturallybased medical care), fiacial stewardship (product/marketplace viability profitability, etc.), IT ifrastructure ad grids (use/proliferatio of EMR, etc.) Maagemet structure Requiremets for executive authority, lies of accoutability, decisio-makig, ad likage of Exchage busiess strategy to ext-dow levels through traslatio of strategic precepts to clear accoutabilities ad expectatios Exchage Marketplace Exclusivity ad Choice Regulatios yet to be issued uder the ew atioal health care reform law may allow idividuals ad small employers to cotiue to purchase health isurace outside of the Exchage. Assumig states develop their ow approaches, they will eed to address the market implicatios of dictatig exclusivity i usig Exchages or allowig member choice betwee multiple Exchages ad/or traditioal isurace sources. I states with Exchages, experiece has show that whe participatio is volutary, the isurace programs offered are vulerable to adverse selectio. This ca drive up the cost of isurace ad ultimately cause the Exchage to fail. Sice successful isurace programs ivolve poolig of health risks, it is ecessary to develop strategies to prevet adverse selectio. States may also wat to create affordable pla desigs ad etwork plas to allow lower icome residets to purchase Exchage policies that fit their family budgets. Despite certai provisios aimed at miimizig adverse selectio, if eough isurers decide to opt out of the Exchage ad cotiue to sell health isurace directly, the Exchage could fail to gai sufficiet membership ad eter a death spiral. The state also may wat to facilitate formig accoutable-care orgaizatios i which groups of hospitals ad physicias that improve patiet quality of care are allowed to retai a portio of the savigs. These providerled etities ca serve as a additioal pla optio i the Exchage beyod traditioal health isurace plas. To miimize the risk of adverse selectio, states will eed to develop Exchage policies to esure the cotiued participatio of all (or almost all) of those health isurers operatig i the state. 8 Ao Cosultig
9 Exchage Isurace Regulatio ad Compliace States will eed to establish appropriate Exchage rules ad whether federal madates apply with a variety of regulatory requiremets. Some regulatios, such as certifyig that health plas meet the applicable coverage requiremets, could be hadled directly by the Exchage or by the state Isurace Departmet. Other requiremets, such as risk adjustmet programs for determiig pricig models, could be admiistered separately by the states. Prior to startup, the states will eed to acquire the expertise to maage the actuarial ad certificatio duties required uder the reform legislatio. Exchage Commuicatio ad Educatio Commuicatig the Exchage s purpose ad value to the state s eligible populatio will be a major challege. States will eed to use multiple commuicatio chaels ad elist the support of a wide rage of commuity ad public orgaizatios to reach the full rage of idividuals ad busiesses impacted. Gaiig ad maitaiig erollmet is critical to log-term success. Give the high fixed cost of implemetig the Exchage ad the relatively low trasactio cost to eroll ew participats, gaiig sigificat erollmet is key to havig eough operatig icome to be self-sustaiig. Therefore, without sufficiet erollmet, states may be forced to provide uplaed additioal fudig. The states will be challeged to fid creative ways to educate the public ad market their Exchage. Cosumer protectio ad advocacy groups will eed to operate at uprecedeted levels. While existig law ca serve as a foudatio, cosumer protectio relatig to health iformatio privacy ad discrimiatio, combied with robust appeals processes, must be ehaced. Exchage Admiistrative Complexity The admiistrative cosideratios of choosig ad erollig i a health isurace pla are already complex ad cofusig to cosumers. Exchages will eed to reduce this complexity ad offer cosumers a easier way to obtai health isurace. Admiistrative processes eed to be mapped i all areas of Exchage activity as well as iterfaces with outside etities (e.g., the federal govermet). Key compoets iclude: A comprehesive IT strategy to assess the state s curret capabilities while prioritizig eeds that caot be met, all withi budget. Eforcig strict requiremets aroud IT is the sigle most importat fiscal factor i avoidig ruaway costs Determiig the eligibility status (icludig eligibility for member subsidies) for idividuals will be challegig. Public plas such as Medicaid ca testify to the difficulty of obtaiig timely ad accurate iformatio o pla eligibility, especially whe such factors as icome, assets, ad family status are costatly chagig. Give the high levels of employee turover amog may small employers, keepig track of eligibility ad participatio is sigificat work I additio to data itegratio with isurers, itegratig record-keepig capabilities with multiple state agecies ad programs (Medicaid, CHIP, etc.) o a real-time basis Maagig various federal requiremets such as miimum essetial coverage ad qualified health plas Establishig State Health Isurace Exchages 9
10 Lookig at best practices ad lessos leared from states such as Massachusetts ad Utah, which have previously desiged ad implemeted state-based Exchages While the potetial beefits from a successful Exchage are sigificat, states will eed to pla ad implemet these programs carefully. Recommeded Next Steps We believe the merits of availig more Americas of quality, affordable health care ca be achieved through state-based Exchages. At the same time, the work of establishig these Exchages is complex. We recommed the followig steps for ay state explorig the possibility of creatig a Exchage. 1. Select a idividual to lead the effort. Ideally, he or she should have workig kowledge of the state s isurace markets, have the capacity to call o ad orgaize resources from aroud the coutry, ad be able to lead a coalitio of differet parties i the costructio effort. The leader should be directly accoutable to the state s goveror. 2. Build a Exchage Advisory Workig Group (EAWG) represetig parties throughout the state who have a vested iterest i the Exchage s success. Members should be seasoed leaders i their respective fields ad be able to make the time commitmet to esure a optimal solutio. They should come from the followig areas: - State govermet Isurace Commissioer s office, Health & Huma Services, Iformatio Techology, Attorey Geeral s office, Treasurer s office - State health isurers (e.g., state AHIP chapter) - Hospital ad physicia providers - Care maagemet providers (e.g., case maagemet, utilizatio review, EAP, chroic care maagemet, pharmacy beefit maagers) - Cosumer advocacy experts state govermet ad respected private groups - Selected employer professioal/trade associatios The perso selected to lead the Exchage effort would chair the EAWG. 3. Iitiate a feasibility study to explore ad resolve the issues outlied i this paper. The EAWG should lead it ad ultimately produce a work product that icludes: - Settig goals ad objectives - Collectig all ecessary ad available data for curret ad future state aalysis - Uderstadig, aalyzig, ad edorsig the value propositio for creatig a Exchage - Assessig the state s ability to create the proper coditios for achievig the critical success factors idetified i this paper - Assumig the EAWG recommeds movig forward with creatio of a Exchage, costructig a prelimiary baselie model represetig approaches to Exchage creatio, maagemet, ad goverace The feasibility study would be submitted to the goveror for his/her review ad approval, ad possibly to the legislature for charterig ad fudig. Next steps would iclude actual costructio of the Exchage. 10 Ao Cosultig
11 Exhibit 1 The followig flowchart depicts Ao s uderstadig of how potetial Exchage members will be directed through the process of qualifyig ad choosig their Exchage. State Health Isurace Exchage High Level Process Map Buyers Exchage Market Exchage Maagemet Subsidy / Pla Selectio Eligibility Coverage Optios Billig Exchage billig Data reportig ad aalytics Employer data Health pla sectio Uisured/Employee Selects isurace optio Website log-i Determie eligibility Calculate subsidy Acillary beefit pla selectio Public Programs Member Decisio support Erollmet Customer Service Welless Sellers Procuremet State selects participatig plas Isurers Federal Govermet selects isurer Federal Govermet State selects participatig plas *PMPM Per member per moth **Firms with <100 employees ***Firms with >100 employees Source: Ao Govermet Affairs team, H&B practice, team aalysis For more iformatio o establishig state health isurace exchages, cotact Tom Lerche at or Establishig State Health Isurace Exchages 11
12 About Ao Cosultig Ao Cosultig is amog the top global huma capital cosultig firms, with more tha 6,300 professioals i 229 offices i 98 coutries worldwide. The firm works with orgaizatios to improve busiess performace ad shape the workplace of the future through employee beefits, talet maagemet ad rewards strategies ad solutios. Ao Cosultig was amed the best employee beefit cosultig firm by the readers of Busiess Isurace magazie i 2006, 2007, 2008 ad For more iformatio o Ao Cosultig, please visit Copyright Ao Cosultig 2010
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