Execs urged to take a more member-centric view

ANN ARBOR, MICH.- In the past, plans provided electronic explanation of benefits to consumers, which reflected a major customer service innovation. Today, innovations involve enabling consumers to connect their physicians and other care providers with a comprehensive information repository enriched by the data managed by the plan-including medical and drug claims, lab results, and health risk information, industry experts say.

"One trend that we see is health plans providing their members with better access and insight to their own health information," says Bobbi Coluni, director of product innovation, Thomson Healthcare. "We believe the market is moving toward personalized healthcare. Our experience suggests we are moving into the second wave of consumerism, with health plans and employers focused on how to drive behavior change. There is strong evidence that providing personalized information to consumers is one element of successful programs to change behavior."

For example, Coluni says, communication that tells consumers explicitly what preventive care they need based on their own medical conditions, age, risk factors, and past health history is more effective in driving action and sound decisions than generalized preventive care guidelines for all individuals. "Tools that tell consumers explicitly how much they will pay out-of-pocket for a procedure are more helpful than general information on the total charge for the procedure," she adds. "The more personalized and action-oriented the information is, the more effective it will be."

Personal health records (PHRs) are the most important innovation that health plans and employers have introduced to engage consumers with their health and healthcare, according to David Merritt, a project director at the Center for Health Transformation and the (Newt) Gingrich Group. However, he says, to date the adoption rates for PHRs-regardless of who is sponsoring them-is dismal.

"The reason consumers have not flocked to them is because, for the most part, they have failed to solve any real-world problem that consumers face," Merritt continues. "PHRs can be the portal to: cost and quality data on providers and insurers; information on disease management, diet, and exercise; and personal financing, such as managing one's HSA or high-deductible health plan."

There will be increasing consumer adoption as the technology becomes more sophisticated, as valuable features such as online scheduling or physician consultation become more widespread, and as more information becomes available on cost and quality, Merritt says. "Additionally, when payers and physicians can collaborate to provide a truly integrated tool with comprehensive patient information, we will most assuredly see adoption," he says. "State and federal governments are so far behind the private sector that they barely know that PHRs even exist. They have begun to look at leveraging their purchasing power and the personal data they possess, but very few have actually done anything substantive. Tennessee is the only state I'm aware of that is actively working on deploying consumer technology or PHRs."

PLANS AT WORK

Leading health plans are leveraging their data-mining expertise to inform their members via educational information and timely alerts that highlight opportunities to improve care or save money.

"Some plans are incorporating classic CRM capabilities used in other industries into these initiatives, allowing them to monitor and evaluate the impact of their communications and learn more about the consumer," Coluni says. "To support these efforts, member-centric integrated information systems are critical."

Another significant innovation is in re-engineering the payment process to reduce administrative burdens for both payers and providers. This includes tools to inform consumers in advance about their liability and to accommodate payment after service based on an estimate of care that is reconciled later.