While states such as Oregon and Nevada continue to struggle with technology glitches in their state-run health insurance exchanges, Kentucky's Kynect exchange ranks among those hailed as successes.
The system, which combined enrollment in government programs such as Medicaid and shopping for private health insurance, was serving about 2,400 Kentuckians a day during February, and the pace only picked up in March as the open-enrollment deadline neared. More than 321,000 Kentuckians have enrolled through Kynect, approximately 75 percent of whom did not have insurance previously.
FierceHealthIT spoke with Kynect's technical leader, Chris Clark (pictured), technology program manager at the Office of Administration and Technology Services in the Kentucky Cabinet for Health and Family Services, about the factors leading to its success.
FierceHealthIT: Tell me how Kentucky got started on this project.
Clark: The Cabinet, upon passage of the Affordable Care Act, started moving toward complying with the law. There were sessions among stakeholders to see what the interest was in the Commonwealth in terms of key decisions--one of the first ones was whether to try to go with the state-based exchange or go through the federally facilitated exchange.
There was some serious discussion with insurers, hospitals and providers. The overwhelming response was that the state wanted to do a state-based exchange because no one understands the local health of the state better than Kentuckians. It was felt there was more flexibility with a state-based exchanged and there would be more of what the Commonwealth would need if we stood up our own exchange. That was broadly supported by the insurance companies, the agent community and the provider community as well.
Immediately on the heels of deciding we wanted to build a state-based exchange, the Commonwealth started holding JAD (joint application design) sessions to start mapping out the requirements of what a state-based exchange would need to do--what the functions would be. That culminated in over 1,200 requirements that ultimately were part of a request for proposals issued by the Commonwealth. From that RFP process, we selected a vendor, Deloitte.
FierceHealthIT: Were you getting guidance from the feds?
Clark: Yes. There's the law itself, then over the course of the past two years, as we were designing the exchange, there's been a series of regulations and guidance coming down from Washington on what this component of the law means, what you need to do to comply, what the law is on this area… here's what any exchange needs to do to accommodate the law.
FierceHealthIT: What do you consider the keys to Kynect's success?
Clark: One of the first key ones was establishing the office of the exchange as a state agency. We had a very tight timeline to get this important work done. As a state agency, we're able to take advantage of the state's accounting systems, policies and procedures that included all of the Commonwealth's procurement practices. Setting it up as a state agency under the Cabinet for Health and Family Services got us moving immediately.
The other advantage of that is that the majority of our business partners are within this Cabinet structure and all of us report to the same Cabinet secretary. I'm talking about the exchange, the Department of Medicaid Services and our Department for Community-Based Services, which is our caseworkers in the 120 counties across the state. That helped unite us immediately under a common vision. We also work closely with the Department of Insurance, which works with insurance companies and agents.
We engaged our stakeholders early and often. Beginning in December 2012, we started meeting minimally every month with each of the insurance companies. We did our planning with the insurance companies; we did not plan it, then [present it to them.] We're still working that closely with the insurance companies.
FierceHealthIT: Tell me about your team. Did you have the skills in place to do this?
Clark: I think what's neat is if you look at the Cabinet's track record for implementing these complex eligibility systems over decades, our track record is very good. It's a very experienced group we have here from the state side. Some of the people on my team are the same ones who built our current Medicaid-eligibility system.
I had a team of about 70 Commonwealth staff and Deloitte had well over 100 people on this project. Between the two of us, we had well over 200 people working on this, easily. I think we did some smart things in the design of the system as well.
FierceHealthIT: Tell me about those [designs in the system].
Clark: One thing we tried to recognize early on was that we'd have a broad range of individuals who would come to the exchange. That might be someone who was Medicaid-eligible to someone who would want to buy health insurance without any financial assistance. So we tried to have a balance in our design to appeal to that broad customer base.
The other smart thing is that we allowed individuals to browse and plan without registering or submitting an application. So it's very easy to come to Kynect and look at the plans offered and understand what's available.
The other cool thing is we allowed an individual or family to do a preliminary screening by capturing just a few pieces of basic information like the size of your household, the ages--this is anonymous--and income. With that, we were able to make a pretty good determination of potential eligibility. So within five minutes, you'd have a pretty good idea who in your household might be eligible for Medicaid or financial assistance with the health plans.
There's essentially a single application for [government program] eligibility or healthcare coverage. In addition to building the exchange, we also stood up a completely new integrated eligibility system… Different members of the household can be eligible for different [government] programs… So within one system, we've got all the business rules it takes to determine eligibility for a household, then we have all the exchange components to shop and enroll in private health insurance and to send that information to the insurance companies. So we can take all that information from one application, then take the family shopping for the plans appropriate for their eligibility. I think that's worked really well.
FierceHealthIT: What technical issues turned out to be trickier than you expected?
Clark: For all of our planning, design, development and testing, the night before Oct. 1, there was still a lingering question, which was, "Will anyone show up?" That question was answered pretty quickly on the morning of Oct. 1. We had so many people coming to the exchange wanting to set up accounts--and I should tell you that in designing the system, we leveraged already existing components for certain functions. One of those was the account-creation function. We had to modify it to comply with the Affordable Care Act. But it was that system that on Oct. 1 became a little overwhelmed with the volume of people that came to the exchange, and we were able to address that by adding servers. The architecture was such that it was running on the Java Virtual Machine, so it was pretty easy to do. And we've not really had any technical problems since.
FierceHealthIT: The Healthcare.gov site was criticized for having too little testing. Tell me about the testing you did.
Clark: From July to September, we were really head-down in testing. Deloitte did its own testing and we did ours. We wanted to test the user experience, so we had business users, people from the Medicaid office and our case workers testing it. We also engaged the insurance companies to make sure we had good test cycles on the enrollment. We involved them in defining the transaction rules. So we had broad participation in testing.
FierceHealthIT: What's happening with the exchange going forward?
Clark: Even with the end of open enrollment for qualified plans, Medicaid enrollment is year-round--Kentucky did vote to expand Medicaid. Small-business enrollment is year-round, so in those respects it will be business as usual.
Editor's note: This interview has been condensed and edited for clarity.