Medicare Compliance & Reimbursement

Health plans push innovations that improve quality, cost and effciency, survey finds.

For a while now, health care commentators have been noting the role health insurers are playing in stimulating and supporting health information technology. But some experts worry that the fast-growing health IT advances could create serious roadblocks when too much variety in IT products makes across-the-board adoption difficult.

Those looking for more concrete details can now see how 38 health insurance companies have implemented more than 40 different health IT advances in a new America's Health Insurance Plans report.

U.S. health insurance plans have established technological innovations that providers and patients use as well as insurers. "Health insurance plans are using IT not only to process claims more efficiently but also to promote evidence-based care, add value to health care services, and empower consumers through access to information and decision tools," says AHIP president and CEO Karen Ignagni.  Such achievements have stemmed from technological advances in case management, e-prescribing, consumer-information tools, claims processing and personal health records, the report notes.
 
But even as the report touts the wide range of initiatives health plans have undertaken, some industry insiders worry that the variety itself could be hampering IT efforts--and argue that the progress the industry has made could move even more rapidly. The health care industry's past efforts to advance technology "were not successful because there was too much variation in the technology, which made it hard to invest," says William Fleming, Pharm.D., vice president of pharmacy and clinical integration at Humana. Pharmacies have made inroads on their end because they can organize around the National Council for Prescription Drug Plans, "but physicians and hospitals don't have the same kind of entity to govern" developments, he laments.

Still, health plans undeniably have been instrumental in forwarding technology use and anticipate continuing to generate and refine products in 2006, according to the report. 

PHRs Especially Valuable In Current Treatment Climate

PHRs hold perhaps the most promise and the most importance for future development, as Hurricane Katrina illuminated the potential disaster of strictly paper-held medical records, the report remarks. The features the report highlights include:

• Member input: Plans cite the need to give control to beneficiaries in constructing their PHRs for better operability and user-friendliness. For example, Empire Blue Cross Blue Shield's PHR My Health Record enables members to complete a health risk assessment when they first log in. Members also have the ultimate say in whether--and which--providers can see their records and which entries remain outside physicians' view. "This will hopefully lead to better decision-making, as members become increasingly engaged in their own care," says Empire Chief Medical Officer Alan Sokolow, M.D.

• Data for consumers: Some plans emphasize giving members information about upcoming treatments, as in CIGNA's Web portal myCIGNA.com, which "estimates employees' total out-of-pocket costs for prescription drugs, in- and out-of-network physician visits, and other services," the plan notes in response to the AHIP survey.

• Physician support: Another feature involves offering health care practitioners material that can assist them with treatment options or other issues. One example is MyGroupHealth from the Seattle-based Group Health Cooperative.  This feature not only analyzes claims data to identify at-risk members and recommend treatments, preventive measures and diagnostic tools, but also sends physicians alerts about alternative prescription drugs for patients who experience adverse reactions to a particular medication.

• Patient guidance: One example of how PHRs can enhance care is the after-visit summary, which both Kaiser Permanente and UnitedHealth Care offer, among others. The summaries help patients remember and follow treatment instructions, the insurers point out.

 The roster of initiatives health plans have slated for 2006 include expanded wellness and disease-management programs (Group Health), "audit trails" that denote who has modified the record and when (United), and enlarged networks for current pilot programs (Kaiser, WellPoint, Health Plan of Nevada--and Blue Cross Blue Shield of Florida and Humana, which are sharing a multi-payer-based initiative).

Medical Care Benefits From Plans' Health IT Push

Health plans have promoted IT productively in arenas other than PHRs, the report reveals. Florida-based Health First, Inc., has developed an electronic intensive care unit program in three participating hospitals. With this product, called VitalWatch, critical-care physicians, nurses and technical support staff can monitor ICU patients at all hours from a remote location. The program achieved substantial results, including a 50 percent reduction in patients experiencing cardiopulmonary arrests and a 16 percent drop in ICU patients' mortality risks, according to Health First.

Tufts Health Plan has worked with medical manufacturer Alere Medical to develop a monitor that members with heart failure can wear. The monitor attaches to a digital scale, and when patients stand on the scale, they respond to specific health-status questions, sending their answers to Alere's database. From there, cardiac nurses examine the data for unusual variations--such as significant weight gain ...quot; and notify treating physicians for follow-up as needed.

E-Prescribing Programs Beginning To Take Hold--And Upcoming Standardization Will Help

Many of the IT initiatives now underway represent joint efforts. A good example is the eRx Collaborative, which Blue Cross Blue Shield of Massachusetts, Neighborhood Health Plan and Tufts Health Plan have formed. The plans intend to mitigate the difficulty physicians face when prescribing for various health networks' members. Technology that the Zix Corporation and DrFirst constructed led to a handheld device that prescribers can use to check patient eligibility and drug history, access formulary information and create or renew prescriptions electronically.

And the Centers for Medicare & Medicaid Services has announced foundational e-prescribing standards for drug plans participating in the Medicare Part D benefit. These standards become mandatory as soon as Part D begins on Jan. 1, 2006.