Internet-based companies like Healtheon/WebMD have been running rampant across the healthcare marketplace recently, making bold promises to facilitate online transactions and communications between payers and providers through their Web portals. The promise of faster claims processing and less administrative hassle has appealed to physicians, and more are moving their back office operations to the Web.
Conspicuously absent from this discussion of payer-provider connectivity, however, are the payers.
Health plans have been somewhat slow to embrace the Web, hindered by inadequate information technology budgets, worries about the year 2000 bug, and security and regulatory issues. Now, Web-savvy consumers are demanding more online interaction with their health plans, and as federal programs move toward requiring electronic claims submission, more providers will expect private payers to have those capabilities as well.
Payers realize they must establish a Web presence yesterday, but first they must overcome several significant barriers: their own Web inertia; physicians' reluctance to partner with organizations they view as adversaries; and competition from online companies like Healtheon, which have already made significant inroads in the e-health world.
Still, some forward-thinking plans believe the dot-com companies have yet to tap the real potential of the Internet. And some believe plans will define the Internet as a meeting place where payers and providers can conduct business but also share outcomes data, establish best practices and improve outcomes.
"The ultimate goal is not how to automate the steps of the process, the ultimate goal is to redefine the process so it's a better process," says David Pryor, M.D., CIO for Minneapolis-based Allina Health System. Allina, which employs 500 physicians and has a network of 8,000 contracted physicians, runs Medica Health Plan, which covers about 1 million people.
Last month, reports of an online partnership among six of the nation's largest health plans caused a stir in the e-health world and illustrates payers' sense of urgency surrounding the Web. The venture would unite competitors AetnaUSHealthcare, Cigna, WellPoint Health Systems, Oxford Health Plans, Foundation Health Systems and PacifiCare Health Systems and bring them head-to-head with Internet healthcare companies. Although the payers would not confirm the venture, several industry analysts say the project is indeed in the works, and they expect an announcement this month or next.
The coalition could facilitate patient-to-plan and plan-to-physician communications, as well as create many e-commerce opportunities, including claims submission, eligibility verification and electronic funds transfer.
According to the Long Beach, Calif.-based First Consulting Group, the proposed venture would offer much more than most plans currently offer. FCG recently conducted a survey of 27 health plans to determine their e-health goals and objectives and their current and planned capabilities. FCG also analyzed 59 health plan sites to assess their capabilities, quality and effectiveness.
FCG identified five stages of Internet business development:
Stage one: build a Web awareness and presence with customers and employees, primarily by publishing static information;
Stage two: engage the community by providing relevant information and enabling the community to interact with the site and the organization;
Stage three: deploy robust self-service capabilities and online transactions, such as online enrollment, online referral processing and claims submission;
Stage four: integrate the automation of numerous transactions in an effort to automate entire business functions, such as online medical management;
Stage five: transform the entire enterprise through seamlessly integrating all processes through end-to-end Web-based interactions with customers and business partners.
The majority (68%) of the 59 sites assessed are in stage two, while 12% are in stage one and 20% are entering stage three.
"The large health plans are farther out in front than the smaller ones, and the larger ones are getting basic transactions in place that provide for interaction with members and providers," says Mary Franz, managing director of FCG's health plans practice. "But, the really Web-enabled are still limited to eligibility checking, provider directories and maybe referral submissions."
Blue Bell, Penn.-based AetnaUSHealthcare often is lauded as having one of the more advanced sites, yet it is still largely limited to one-way communication.
Patients can choose providers and more than half of the insurer's claims come in electronically, but it is far from the end-stage development to which Franz refers.
Of the health plans FCG surveyed, 70% reported that they have a formal Internet strategy in place, yet only one-third have any staff dedicated to Internet-health initiatives. All the survey respondents ranked connectivity, business processing and information sharing as their highest priorities and said their end goal is to streamline operations through automation. But the plans are a long way from achieving that connectivity: only 25% allow members to change primary care providers on their Web sites; about 20% allow patients to enroll online; and only 30% allow providers to submit authorizations via the Internet.
The accounting firm Ernst & Young last month released its own survey of 74 payers' Internet strategies and Web sites. The Ernst & Young report agrees that while most health plans distribute information and some communicate through their Web sites, few are offering financial or two-way transactions.
Payers are most likely to introduce electronic capabilities that do not alter existing work flow, and few have any two-way transactions that would require the plan to reorganize or alter its existing products or systems, says Peter Kongstvedt, M.D., partner with Ernst & Young's health consulting practice in Washington. For example, while some payers accept claims electronically, any problems or questions about those claims are dealt with over the phone or through the mail.
"The movement of these capabilities is not as easy as people would like to think. Some of what looks like e-commerce is just data that ends up getting printed out," Kongstvedt says.
Only 19% of the sites surveyed by Ernst & Young permit providers to check claims status online, and 11% permit providers to submit claims electronically.
The report also says that size, market penetration and large capital investments are not necessarily required to secure a foothold in e-commerce. In fact, some of the most sophisticated payer Web sites are those of mid-sized regional health plans.
The Web site of Blue Cross and Blue Shield of South Carolina allows patients to check their claims status, how much money they've paid toward their deductible, their out-of-pocket amounts and also to choose a physician. Providers, meanwhile, can check a patient's claim status and inpatient and outpatient authorization.
The insurer covers 1.2 million people and has a network of 8,000 providers. The site was launched last December. To date, 1,000 physician offices have registered, and the volume of hits is increasing 30% a month, says Tom Faulds, president and COO of the company's Blue Cross and Blue Shield Division. The site is not yet conducting two-way transactions, but those nuts and bolts one-way transactions are what physicians are looking for, Faulds says.
"Status of claims, eligibility, co-pays--that is the high volume stuff that people call for today," he says. "A huge number of people are involved in answering the phone calls from physicians' offices. This will facilitate that communication with physician practices and save us money."
While the Blues and other health plans scramble to get up to Internet speed, a number of start-up companies are filling in. Jeff O'Connor, M.D., a Spokane, Wash., family practitioner in solo practice, turned to an Internet-based middleman when the local payers couldn't offer the level of connectivity he was looking for.
O'Connor uses a community-wide intranet built by Bellevue, Wash.-based PointShare to make referrals, check patient eligibility and transmit lab tests and imaging results. O'Connor and the other providers pay a monthly subscription fee of between $40 and $65 for access to the private intranet that links about 60% of Spokane-area doctors, payers that cover about 70% of area patients, a major lab and several hospitals.
O'Connor can check eligibility on about a dozen different payer plans, check whether a given specialist is covered by the patients' plan and communicate with specialists about the patient's condition via secure e-mail. The Web-based referral system allowed O'Connor to eliminate one staff position that was devoted to managing referrals.
The system "enables primary physicians for the first time to close the loop on post-examination care," O'Connor says. "By automating referrals and lab test results, we have taken the (administrative) process out of the way of taking care of the patient."
Renton, Wash.-based Asterion.com also aims to link payers, providers, hospitals and labs in an Internet-based community. For a monthly subscription fee, physicians can check patient eligibility, claims status, treatment guidelines and clinical protocols with multiple payers. Because the system tracks providers' referrals and utilization, the Web site also allows managed-care organizations to measure clinical and financial outcomes on a real-time basis and suggest alternative protocol, if necessary.
The 650-physician San Jose (Calif.) Medical Group, which covers about 120,000 enrollees, began using Asterion.com in March 1999, according to COO Ernie Wallerstein. "Most of the communications with our physicians was via fax machine or telephone. So we were looking for a way to automate those programs, make them more efficient and, if possible, find a way to deliver medical services in a more cost-effective manner," he says.
According to Wallerstein, the group is now able to make 90% of all referrals online at the point of care, and the number of referrals made to out-of-network physicians has been drastically reduced.
Wallerstein says the data reports and utilization review capabilities are most valuable to the group.
"We do utilization management for all those patients, so we require authorization for all elective procedures and referrals to nonemployed physicians. We needed a process to make that less obtrusive to the doctors and patients," he says.
Lebanon, N.H., dermatologist Georgia Tuttle, M.D., fears that type of online access to physicians' practice patterns will make the health plans too powerful.
"From a strategy point of view, data is where the future of medicine will be. The ability to get data and manipulate data to show quality and outcomes will be critical for physicians. If we give that to the managed-care companies and insurance companies, we no longer have control to determine our own futures," says Tuttle, president of the New Hampshire Medical Society.
Tuttle says a local insurer recently put clinical guidelines on its Web site. "Now physicians have to abide by those, and it shifts a lot of burden to the doctor," she says. "We know all the medical information, but now we're being asked to keep track of each insurance company's medical policy. You start trying to keep 35 or 40, or even two or three, in your head, and suddenly, you are worried about things that have nothing to do with the process."
Allina's Pryor says developing Web-based guidelines can actually help providers and points to an Allina pilot project that connects diabetes patients with Allina providers through secure, encrypted e-mail. Patients enter their blood sugars daily and can ask questions of nurses. The program recognizes when a patient's sugar levels are out of whack and automatically suggests preestablished triage strategies, which were created by physicians.
"Doctors get patients with better outcomes and a more efficient use of their time. They're seeing the patients they need to see, while at the same time are able to provide clinical contact in partnership with (the online) patients," Pryor says. "The strategies that are going to be effective in the future are not going to advantage one component of the system at the expense of another. The strategies that are going to be successful will be where the components work together."