Federal officials, state representatives, nonprofit organizers, and uninsured individuals alike waited with baited breath for the October 1st rollout of public health insurance exchanges under the Affordable Care Act. Now that we’ve let out that collective breath, let’s look back on the first month and learn what it meant for the states.

All 34 states with exchanges run by the federal government faced challenges as the website, Healthcare.gov, was plagued by technical issues relating to higher traffic than anticipated. States running their own exchanges, on the whole, had more success in enrolling people in plans. Enrollment numbers continue to creep upwards as technical issues are resolved and more Americans enroll online, over the phone or in person. 

The State Exchange Table continues to provide the latest information on carrier participation and plan rates.

Latest Developments:

State Run Exchanges and Partnerships -

California: As of October 8th, 28,000 people had enrolled through Covered California, the state’s health insurance exchange, via the online portal, over the phone, and in person. Program executive director Peter Lee predicts that 500,000 to 700,000 Californians will enroll with subsidies by the March 31 end of open enrollment.

Covered California has removed a much-hyped online tool that would have allowed people to search by zip code for doctors available through plans in their area. Program representatives cited technical glitches as the reason for removing the tool.

Outreach efforts continue with state officials stating they plan to train and certify 20,000 enrollment counselors and 12,000 insurance agents. Only a small fraction of those already trained have received official approval, often leaving healthcare consumers to navigate the system alone or be subject to long wait times for over-the-phone assistance.

The diversity of the state has made bilingual outreach the focal point of education campaign efforts. Bilingual ads and door-to-door education campaigns aim to reach hard to access populations. Health clinics are another popular location for outreach. To aid in this effort, Covered California has awarded millions of dollars in grants to organizations helping Latinos and other ethnic groups enroll.

While support is available online and via over the phone helplines, state officials report that 80% of consumers will want in-person help and this has been problematic due to the shortage of enrollment assisters authorized to handle applicants. Of the 16,000 assisters envisioned by the state, only 20% have been trained and authorized.

As many as 700,000 Californians have been informed that their previous coverage plan does not conform with ACA standards and will be cancelled. While approximately a third of these will receive subsidies from the federal government, others will be faced with new plans and in some cases, higher premiums.

The Covered California website has faced some technical issues, but has had considerably more success than the federal site, Healthcare.gov. The state site received 987,000 visitors in the first five days, with high traffic volumes causing pages to load slowly at times.

Covered California chief Peter Lee defended continuing to withhold enrollment data for the state exchange, citing a need to “make sure the numbers are right.” A lack of transparency has been a continuing criticism of both state and federal exchanges. The state has also not released quality ratings on eight of the twelve insurers offered on the exchanges. Exchange officials stated that ratings would be available in October 2015, after examining patient reviews and other data.

Covered California gets help from cities and counties across the state in the form of volunteer outreach efforts. The state exchange has money to authorize community organizations as enrollment assisters, but does not have similar funds for cities or counties.

The Children’s Partnership launched a campaign specifically targeted at reaching uninsured children and their families and enrolling them in health insurance through Covered California.  The ALL IN campaign focuses on outreach and education at schools, afterschool programs, and child care centers.

Colorado: Colorado released its metrics for the first week of its exchange, Connect For Health Colorado, reporting 162,941 unique visitors. Of those visitors, 18,174 created accounts, but only 226 bought plans. State officials attribute this lack of enrollments to technical issues and expect higher numbers by the time open enrollment ends in March 2014.

Exchange CEO Patty Fontneau considers the first week a success, citing visitor numbers as an indication of how much interest there is in the program and insisting that the low enrollment is only a temporary setback. The health exchange board, in the meantime, expressed frustration at the slow enrollment and many wondered how much higher the enrollment numbers would be without all the delays.

USA Today interviewed uninsured Coloradans, in a piece titled “Microcosm of Confusion on Health Law.” While interviewees did mention feeling underinformed about the options available to them, many also expressed hope that the new health care system would help alleviate the stress of being uninsured and save them money.

The Colorado exchange has embraced a new character in encouraging Coloradans to enroll  – the college bro. Ads featuring beer kegs and red cups have one bro asking, “Yo, mom, do I got insurance?” Whether these humorous ads will be successful in encouraging enrollment is yet to be seen.

Connecticut: Almost a third of enrollees in Connecticut’s health exchange are under 35, according to program CEO Kevin Counihan. This is good news since insurance providers depend on high enrollment from younger, healthier people to support more costly care for older enrollees. The state-run exchange, Access Health CT, received 1,157 applications its first week, with the majority split between the silver and gold plan options.

According to state officials, 4,065 individuals have enrolled in private insurance plans on the exchange since October 1st. The state aims to enroll 100,000 people by the end of open enrollment on March 31st.

Many Connecticut residents are having to change plans, as many of their current plans will not be offered under the new system. Major carriers such as Anthem Blue Cross, Cigna, and Aetna are discontinuing existing plans, some for non-compliance with federal standards, and are working to migrate their customers onto new plans with similar benefits.

The state exchange site has been hit with at least five unsuccessful hacker attacks in recent weeks. Security of consumers’ personal health information remains safe and data security remains a major concern for state officials running the exchange. The site faced another setback on October 27th when the federal hub, which verifies individual’s identity to determine eligibility for subsidies, went down for a time.
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With the amount of money being spent on health care in America — and our general enthusiasm for all things mobile — you’d think there would be a huge and successful market for mobile apps that empower consumers to take control of their health and wellness.

But according to a report by the IMS Institute for Healthcare Informatics, of the 40,000+ health care apps now available for download on the U.S. Apple App Store, over 50% of them get downloaded fewer than 500 times.

The report is based on an analysis of these apps and an assessment of the potential value they provide at various stages of a patient’s journey to better health. The study was conducted in June 2013.

So what’s the problem?

According to the IMS report, the following issues are holding us back.

1. There are just too many apps!

Forty thousand apps are available on the App Store alone — with reports of at least another 60,000 available from other sources. Seriously? How can we possibly sort through them and decide which ones might meet our needs… let alone which ones are any good.

The sheer number of apps available suggests that app developers are well aware that if they can strike the right chord with consumers, the potential rewards are great. But so far, few seem to have found that magic formula.

Maybe developers should try asking consumers what we want. And perhaps they should also do a better job working with health care providers to determine what we need.

The payday developers are seeking — and the results consumers and their health care providers are looking for — might very well lie at that intersection.

2. For all of the health apps out there, just 54% have a legitimate health-related function, and therefore have the potential to help us stay healthy or manage existing conditions.

Of the 43,689 apps identified as falling into either the “health and fitness” or “medical” categories in the IMS study, 20,007 were excluded early on from additional analysis because they were not really related to health care. According to the study, examples of those include apps related to beauty or fashion or “apps that use gimmicks with no real health benefits.”

Of the remaining 23,682 apps, 16,275 were for consumers and 7,407 were for health care professionals. Of those for consumers, the majority focus on diet and exercise.

The analysis further showed that two-thirds of the apps available for consumers simply provide information. Smaller subsets give instructions, capture data entered by consumers or have an alert/reminder feature.

In other words, the majority of apps for consumers simply move general information from websites and/or printed materials to our mobile phones — and do little else.

3. We have no way to tell the good apps from the bad apps.

The report notes that another issue is that consumers have few options for guidance on the quality of the various apps available. While physicians see the potential benefits of these, they are wary of recommending them to their patients. They too need information about which ones are helpful and which ones aren’t.

With so many apps available, it’s a sure bet that many, many of them are not very good. The report quotes Dr. Israel Green-Hopkins of Boston Children’s Hospital, saying “…40,000 apps within any store is the definition of poor design, because you know that 90% of them are terrible designs.”

Other reports show that some doctors have recommended apps as helpful tools for their patients – to track pollen counts in allergy season, brush teeth for the recommended amount of time or resist urges when quitting smoking. But physicians warn that these apps are supplements and not replacements for in-office care, with most of their benefit coming from encouraging good behavior, not actually improving health.

For the apps evaluated in this study, the App Stores’s popularity rankings do provide one small measure, but it is ultimately insufficient.

4. The vast majority of these apps are completely disconnected from the rest of our health care providers and systems.

The report notes that over time, health care apps will mature from being self-selected by consumers or physician-recommended on an ad hoc basis to being used systematically in health care delivery as an integrated component of our system. But they are not there yet.

What’s working now

Still, amidst this mass of underperforming apps, it is interesting to note that just five of the 40,000+ apps in the App Store make up a whopping 15% of all downloads.

One of these, Calorie Counter by MyFitnessPal, was the second most popular app in the App Store at the time this analysis was conducted and is the most popular free calorie counter and fitness tracker on Google Play. What does it do? And why is it breaking through?

Positive reviews of the app suggest that its primary strength is its community aspect, which allows users to share their progress, weight-loss goals and calorie counts with friends via social media channels like Facebook and Twitter.

While this might not be appealing to everyone, it has been a powerful differentiator in a sea of competitors. An attractive and intuitive interface also allows it to stand out from the crowd.

Despite these distinctions, the Calorie Counter app simply counts calories and nothing more! And counting calories alone has not been proven to improve overall health.

Bottom line, developers need to build better apps and consumers need better ways to find the good ones.

And the health care community needs to fully embrace mobile apps and integrate them into our health care system — empowering consumers to take charge of their own health.

In the meantime, if you’re using apps to get fit, it’s all about finding what works for you – whether it’s tweeting your latest weight loss milestone or tracking your speed on your morning jog.

[Photo Credit: Jason Howie on Flickr via Creative Commons 2.0]

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