It's been some time since I last wrote a column. A three-and-a-half week trip to India did not help matters. But before I was on my hiatus I was honestly starting to think that there was not much left to write about in the health care industry. After all, everything that could be written about ICD-10 was already written--and then some. Health insurance exchanges were almost as hot as the background gamma radiation spreading across the universe, and writing about mandated exchanges (yes, somebody coined the word “HIX” for them, finally) was sure to invite the wrath of someone, depending upon which side of the fence they stood. So basically, unless you wanted to write about a topic as exciting as “claim pend rules,” you were pretty much done.

I guess I should have had more faith in our industry. I came back State-side and lo and behold there is a whole new can of worms opening up. First thing I read on my return is that grants worth $241 million had been doled out to seven states as early innovators of HIX. Wow! Close to a quarter-billion to figure out the best approach to adopt exchanges geared toward the less fortunate … one doesn’t need to go far to see the irony there. That’s a topic for a later date (at least one silver lining I can see is that my writer’s block is gone).

What interested me even more was the fact that distribution of dollars was quite divergent ... Oklahoma got almost $55 million whereas Maryland (my poor home state) received only $6.5 million. So I looked closely at the grant applications and something really stuck out: it’s clearly evident that states are looking at highly diverse models, ranging from a Corolla (no insult intended to that ubiquitous warrior of the U.S. roads) all the way up to a state-of-the-art Cadillac (I am assuming Caddies are still the benchmark for luxury?). What struck me further was how the Oklahoma model was trying to pull the clinical and financial aspects together rather than simply focusing on the eligibility and enrollment aspects. Kudos. I, myself have been toying with the idea that there is significant convergence between health information exchanges and HIXs--and here I was staring at a model trying to provide proof of that pudding.

What's the single biggest criticism we've heard about HIXs? Adverse selections. We surely cannot expect a poor sap to make a decision about their health care insurance just like they make decisions about their car insurance, mortgage, kid’s college or, for that matter, choosing between McDonalds or Subway. So how do we avoid adverse selections? Leverage the clinical information about the person that is hopefully readily available in a local HIE or a delivery systems’s data warehouse, or maybe even a public clinical repository such as HealthVault or GoogleHealth.

I see a convergence here. A plan recommendation based on the clinical history of the prospective member. Is that a novel concept? Not really. Other industries do similar analyses all the time when, for example, they decide what kind of loan a person is eligible for based on his/her credit score. It will not eliminate adverse selections completely but sure as heck will reduce the probability. Something is always better than nothing. There are many scenarios where HIEs can significantly improve HIX operations, such as reveal the quality of the docs in a plan’s network so patients can choose one plan over another, or use predictive modeling to assess future medical requirements before someone decides the plan best-fit to support their future needs, etc..

Let’s flip it around and look at what HIXs can do for HIEs. Imagine a world (and here I go philosophical) where a patient can see a 360-degree view of all their medical needs and visits. How about a dashboard that can provide them on one line the date of service, the diagnosis, the procedure ordered, the allergic reactions if any that were considered, the charge from the doctor to the insurance, the payment made by the plan, the share that Medicaid/Medicare/private insurer paid, the patient’s share, the HSA/FSA account that was debited, and on top of it all a replenishment of the tax-deferred account automatically from the pre-specified checking account, once the tax-deferred account falls below a pre-defined critical level. Now, that’s Utopia … and of course some of the data has to come from an HIX (the financial information) rather than a traditional HIE.

I have a strong hunch that that cost of implementing HIXs and HIEs separately is significantly higher compared with doing them as a joint exercise and leveraging the same platform. Over the next few weeks I'll try to build a financial model for a typical small state HIE and HIX rolled into one and see how accurate my hunch is. I’ll share the results in this space (provided my numbers add up). Meanwhile, food for thought: is it really HIE and HIX, or could it possibly be HIEX? (That’s the best acronym I could come up with. I’m really bad at this.)

Rajiv Sabharwal is the chief solution architect in the Healthcare and Life Sciences unit at Infosys Technologies LTD. He can be reached at Rajiv_Sabharwal01@infosys.com.

 

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