States try to innovate with health exchanges

Kelly Kennedy, USA TODAY

1:01AM EST November 10. 2012 – States should use their creation of health insurance exchanges required by the 2010 health care law to create prevention programs aimed at promoting long-term savings, expert say, but state officials argue that those “wish lists” might have to wait so states can meet their deadlines.

“To do something different, I sure wish we had an extra year,” said Howard “Rocky” King, executive director of Cover Oregon, Oregon’s health insurance exchange. “Our first priority is to come up with something that works.”

That means states such as Oregon hope to build the foundation of their exchangesfirst and then add the extras over the next few years.

“States could play a huge, important role in prevention and care coordination,” said Ken Thorpe, head of Emory University’s health policy department. “But if we’re looking at yesterday’s benefits, we’ll get yesterday’s problems. We need to pull costs out of the system.”

Otherwise, more people will be covered through the 2010 health care law, also known as the Affordable Care Act, but premiums will continue to go up, Thorpe said.

Rather than focusing purely on making insurance available, states could build evidence-based prevention and lifestyle-change options into the plans. Theycould insist that their insurers pay teams of hospitals, primary-care physicians, home health care professionals and hospice providers a set price to care for a consumer, rather than pay by the injection, scan or visit.

Without such changes, Thorpe said, health care costs will keep rising.

So far, Thorpe said, California has done the most to promote innovation in itshealth care exchange.

Health exchanges are state- or federally run websites that allow consumers to choose a health plan, as well as to compare benefits and costs of each plan. Some states will allow all insurers to participate; others have asked insurers to bid to participate; and some states are creating a list of requirements insurers must meet to participate.

Peter Lee, California Health Benefit Exchange’s executive director, said that insurance has “been a game of avoiding sick people” to keep insurers’ costs low. Now insurers must take everyone, and that means keeping chronically ill people stable and trying to prevent people from becoming sick in the first place.

In part, California can push for change because there are so many players: 33 health plans submitted bids to be part of the health exchange.

“The exchange has asked the plans not just for the lowest cost on Day One, but the lowest costs over the long term,” Lee said. “Our board said one of our values is to be a catalyst for change.”

California officials wanted health plans to show how they pay for and reward primary care, provide better care for the chronically ill and build in preventive services, Lee said.

Not every state is moving this direction. C.J. Bawden, spokesman for the SilverState (Nevada) Health Insurance Exchange, said their main goal is to take as little money from the federal government as possible by outsourcing much of the technology of their exchange to Xerox, rather than building from the ground up.

“A lot of states want to build it from the ground up and keep it in-house,” Bawden said. “We came out with a good business plan.”

Everyone with plans that meet federal and state requirements may participate in whatBawden called a “free-market” approach. “We’re trying to facilitate without doing a lot of market disruption,” he said.

Washington, D.C., exchange officials are waiting to hear what the plans will come up with, but they included preventive services, health club memberships and coordinated care included in the plans on their wish list.

Mohammad Akhter, the chairman of the exchange, said Washington’s main innovation wasthat exchange board members are experts in medicine and education and not politicians.

“We expect more innovations because of that,” he said. Negotiating possibilities with insurers is difficult until everyone knows just how manypeople are enrolled in the exchanges, Oregon’s King said.

Oregon officials have asked that each carrier offer several plans, so that they’ll end up with 10 or so carriers with five or six possibilities each for the smallgroup market. That way, someone who knows she probably won’t need a lot of time with the doctor can choose a high-deductible plan.

In the meantime, the state is testing out new care models in their Medicaid and state health programs to see what works to keep costs down, King said. These things include preventive-care programs, as well as making sure doctors arepaid to keep people healthy, rather than through a fee-for- service program.

In Rhode Island, only four carriers exist, but officials still hope to set up different products than were available before. They’ll be negotiating with the insurers over the next month.

Christine Ferguson, Rhode Island’s director of the health benefit exchange, said the plans will be able to do more with a higher concentration of people.

The state hopes to build the exchange, collect data about what works and what doesn’t, and then re-evaluate. For example, do cancer screenings and immunizations affect the number of days people go to work or children go toschool?

“So we’re looking at improvement,” she said. “The exchange is a catalyst to move the debate to reform.”