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NYU professor Thomas Nagel is most well known for his 1974 essay “What is it Like to Be a Bat?” That is an exciting read for anyone, but especially for people in consulting and sales/marketing, who are always trained to think from the perspective of our target audience. That is the reason, that we can frequently see our own sales organization negotiating sometimes on what our product/solution should do, and sometimes on what we should charge for it. That is also the reason that we make sales.

To be able to think like your customer is an important skill for anyone to have – whether we consider a nurse delivering a flu vaccination to a child, or a hotel cleaner preparing the room for the arrival of a guest, or a solutions architect preparing to deliver a piece of software.

So then, what does a CEO or a CIO at a carrier organization think about?

Well, there are always tactical decisions to make. This is typically the “how” of the business. Things such as vendor selection, team structure, review of operations, etc. Most of the CEO’s team is charged with owning, planning and executing those tactical, repeating decisions.

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What are the common roles & challenges for brokers recruited as Navigators/Assisters?
As a navigator or assister, a broker should be able to:
•    Establish exchange eligibility of the individual, employer, etc.
•    Provide information about different Qualified Health Plans (QHPs)
•    Offer information about premium tax credit eligibility
•    Offer direct enrollment options
•    Execute cost-sharing calculations
•    Identify people or businesses eligible for premium assistance
•    Communicate across linguistic and cultural mix that an exchange caters
•    Offer clarity regarding cost structure of different metal plans—bronze, silver, gold and platinum
•    Advise consumers about primary, secondary insurance coverage options or ancillary health plans to create a comprehensive coverage portfolio
•    Help the state exchange manage its risk pool

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Brokers have played a significant role in how health insurance is sold and bought in the U.S. However, with the arrival of the health insurance exchanges, brokers can expect their traditional role to undergo a major change.

Getting Started: Exchanges Create Navigator & Assister Roles for Brokers
The ACA seeks to address a traditional problem that has plagued consumers when buying health insurance plans—understanding what they are purchasing. This is why the ACA mandated a comprehensive SBC (Summary of Benefits and Coverage) for every health plan. This ensures that consumers have access to comprehensive information about every aspect of the proposed coverage. However, consumers often need personalized guidance to understand the intricacies of health coverage. Traditionally producers, i.e. agents and brokers, handled such concerns. The ACA wanted to replicate the producers’ role, albeit make it more accountable and exhaustive. Further, considering that the exchanges will offer a totally new buying experience, first-time consumers are likely to need more assistance. This is why federal mandates insist that state health care exchanges train and recruit customer assistance specialists in the form of Navigators & Assisters.

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It seems almost surreal when a connection between health plans and social gaming is proposed. However, there is a definite and growing interest among payers in the customer engagement capabilities of social gaming. There is emerging proof that social gaming can be used as a cost effective tool for better care management and for keeping patients away from emergency rooms.

First Steps—Tracing Social Gaming’s Entry into Healthcare IT
A few years ago, the use of social gaming in healthcare technology was considered a fad. Things changed when Aetna began testing social gaming’s utility in 2011—at a time when healthcare reforms were beginning and the present day emphasis on improving overall quality of care had yet to emerge. However, Aetna proceeded with this initiative. Using behavioral science principles, the gaming application was able to inspire some people to adopt healthier lifestyle habits. Aetna continued its journey with an interactive brain testing program that helped its players combat stress.

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There have been a lot of opinions expressed about how the payer’s margin will be squeezed in the reformed health insurance market. This discussion focuses its attention on dealing with the situation, i.e. preparing a business strategy for survival in the new Exchange market.

1. Get Smart About It: There is Life for Plans off the Exchange
Restrictions imposed by the ACA are here to stay but a smart payer can still dig out profits by reading between the lines. For instance, the Healthcare Law stipulates that health insurance products sold on and off the federal/state health care exchanges should put forth the same range of premiums, out-of-pocket expenses, etc. However, the ACA doesn’t stipulate that standalone products sold on the exchange need to be retailed in the same format in the non-exchange market.

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With the goal of making the new healthcare system work for everyone, the PPACA as amended by the Health Care and Education Reconciliation Act created a requirement called Share Responsibility. This is applicable to individuals, insurance companies, medical device companies, medical providers, pharmaceutical companies, employers and the government. On January 30, 2013, the HHS and IRS released a Final Rule and two Proposed Rules related to the individual part of Shared Responsibility.

Shared Responsibility for Individuals
This requirement was put into effect with the perspective of making health insurance feasible for consumers and the payers in the long run. By making a basic type of coverage necessary, health care benefits of individuals and subscriber volumes for insurers are addressed simultaneously. Individuals should maintain a Minimum Essential Coverage (MEC) or be ready to be penalized where the penalties will be levied as Shared Responsibility Payment.

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This is the first of a 2-part discussion that explores the role Healthcare Analytics can play in the era of Health Reforms.  Here, we discuss the contemporary realm of Analytics and the challenges to its usage.

Pharmaceutical companies are perhaps the most seasoned users of Analytics in the healthcare market since detailed analysis is central to their efforts in drug research and clinical trials. Other healthcare entities like payers, provider organizations and government agencies haven’t adopted Analytics as enthusiastically. However, this scenario might change rather soon. With State Exchanges set to redefine the health insurance marketplace, most healthcare organizations have understood that they can either adapt to the reforms or perish. As 2013 progresses, healthcare businesses are realizing that they need to squeeze more out of every dollar spent, limit wastage of resources and eliminate fraudulent practices to achieve profitability-cum-compliance. This translates into many operational and administrative changes. Healthcare Analytics can make this transformation less challenging.

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On December 7, 2012 the U.S. Department of Health and Human Services (HHS) released a proposed rule that advises States to consider broker compensation as a parameter when issuing Quality Health Plan (QHP) certifications to health plans that are keen to market their health products at the Federally Facilitated Exchanges (FFEs) and Federally Facilitated-SHOP Exchanges (FF-SHOPs). The Government believes that the proposed rule would help synchronize and regulate the State’s local Exchange and non-Exchange insurance markets.

The rule proposes that a QHP certification, granted by a FFE and/or a FF–SHOP, should be issued to health plans on the condition that they pay equivalent broker compensation for QHPs sold through the federal exchanges and similar plans offered outside the exchange markets. While this may appear to be another restraining federal mandate, the ruling may really prove to be a blessing in disguise!

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It would be appropriate to say that 2012 was the Year of Health Insurance Exchanges in the U.S, with the State-Federal Partnership Exchanges and Federally Facilitated Exchanges (FFEs) taking center stage in the new healthcare reform developments. The year 2013 also shows signs of continuing in the same vein as last year. As a result, the hCentive team is diving deeper into the Partnership Exchange model to understand what this model entails and the flexibilities States’ will enjoy under this arrangement.

The combined efforts of the States and the U.S. Department of Health and Human Services (HHS) under the partnership model can help in establishing States’ exchanges and can lay the groundwork for a future transition to completely state-based exchanges. As of January 3, 2013, six U.S. States—Arkansas, Delaware, Illinois, Iowa, North Carolina, and West Virginia—have applied for State-Federal Partnership Exchange and 20 states have received approval for their State-based exchange design. The remaining U.S. states have additional leeway only until February 15, 2013 if they chose to apply for a State-Partnership Exchange.

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The year 2012 proved to be an eventful period for the U.S. health insurance industry. The Affordable Care Act (ACA) continued to charge ahead amid widespread controversies—including a ruling by the Supreme Court—and became infused with a fresh lease of life when President Obama won a second term in office. With last year witnessing the rise of private health exchanges, payer-provider mergers, Accountable Care Organizations, 2013 is now poised to see some important developments and new trends in the U.S. healthcare sector. Some of the landmark changes that are sure to gain prominence in 2013 include:

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