From the healthcare carrier's perspective, the logic is simple: Support physician members' ability to access aggregate patient data and use of e-prescribing and e-doctor visits. Physicians use technology to provide improved quality care, business- and patient-related efficiencies. Ultimate ROI: healthier patients and reduced exposure associated with later health-related problems.Long-term results may not be available yet, but carriers have high hopes for programs designed to create incentives for providers that will help create a "healthier" patient base.

A report issued in February by Dublin, Ireland-based Research and Markets notes that insurers will benefit from a trend in widespread adoption of electronic capture of patient data. Alluding to the routine capture of documents and data for both regulatory and business intelligence purposes, the research firm holds that "health care in the clinical setting has resisted this industry-transforming technology for nearly 20 years. The reasons: the lack of user-friendly interfaces for busy health care providers, lack of workflow understanding on the part of vendors, the expense and complexity of implementation and maintenance solutions, and the lack of transparent ROI for providers.

It took results of a 2003 Rand study, which reported that only 55% of U.S. patients receive adequate care, to convince Philadelphia-based Highmark Inc. to create additional incentives for its state-wide, QualityBLUE pay-for-performance program.

In place since 1993, the program has for the past two years given member physicians "points" for using electronic records and other preventive care measures to improve their outcomes.

Points are added together, and if a physician performs better than Highmark's network average, the result is monetary reimbursement. To date, Highmark counts 1,300 physicians and 250 practices among its participating members, and provides physicians who don't score on an upward trend tips to improve performance.

Highmark's e-health collaborative, a $26-million grant, is making technology available to physicians across the state, along with funding-up to $7,000 each to help offset the cost of establishing e-health records and future e-prescribing capabilities.


"We believe it will change the market," claims Dr. Michael Madden, medical director for Medical Performance Management at Highmark, an independent licensee of Blue Cross and Blue Shield.

"The relationship between doctors and insurers needs to evolve. We want to create incentives for physicians to provide better quality care, not just more care. So it makes sense that more and more physicians are moving to the level of information technology that is available," he says.

The carrier has hosted six CME-based seminars to educate physicians on creating technology-based efficiencies and on using its Navinet physicians portal, which helps Highmark monitor claims submissions and verify eligibility and cost for reimbursement.

"Most doctors' offices are small businesses. They may not even be aware of how to focus on changing their processes to do this," notes Madden.

For Dr. Robert Neilsen, Annville Family Medical Center, Annville, Pa., evaluating technology and process went hand in hand. As part of a larger office redesign, the 10-provider, 20,000-patient practice implemented an electronic health records database one year ago at a cost of $200,000.

"From a business perspective, Highmark's 'points' were a powerful incentive to recoup those costs," confirms Neilsen. "But we also felt it was critical to look at our outcome measures," says Neilsen, "and found we needed a benchmark. Partnering with the insurance carrier gives us access to that database of information, so we can examine how we can change our practice using technology to improve healthcare."

The practice evaluated basics such as: How do we collect and share information? How do we communicate in such a way to contribute to a successful outcome? How do we look at obstacles to care? How do we implement best practices?

"In this discovery process we found that e-records narrow the gap with what occurred and what gets documented," says Neilsen. "This lends itself to improvements in provider quality across the board."

Technology lends itself to quality improvements, he adds. "For me, it's the access to aggregate information. You are no longer counting on the patient's recall, but instead have the data in front of you. You can look at the practice population for a certain disease and broaden that out to a national benchmark to see how the patients are doing. It's particularly effective with disease management."

From a business perspective, using a hand-held computer to access and register information on the more than 35 patients seen daily, Neilsen confirms a cost savings of $3 to $4 for each chart and associated lab results that otherwise would have to be pulled manually.


From using the Internet to query diagnostic studies to Neilsen's description of a 90-year-old emergency room patient who was spared three or four invasive procedures because the participating hospital had instant access to his patient's records. "The service improvements are immeasurable," he says.

A survey of 134 World Healthcare Congress registrants (18% of whom were health insurers) conducted in April by Bermuda-based Accenture and New York-based Harris Interactive confirmed that Highmark is not alone in its quest for devising incentives to reduce health-related claims exposure.

In fact, 24% of survey respondents define pay-for-performance initiatives as one of the top three priorities to address quality of care, 13% believe implementation of e-health records is most important to improve quality of care, and 43% say using electronic records and e-prescribing is the way to mitigate the high cost of healthcare.

Highmark is currently working with Neilsen's practice to support Web-enabled doctor visits for patients with non-emergency issues and have a shared target date within the next six months, both parties confirm. And Highmark expects pharmaceutical formularies to be added to its system by this fall.


Although not tied to an official pay-for-performance program, New York-based Empire Blue Cross Blue Shield sees e-health as looming large in its ability to provide improved patient care. The carrier recently completed an 18-month pilot project with RelayHealth Corp., Rochester Hills, Mich., to expand to more than 400,000 HMO members access to RelayHealth's Web-enabled doctor visits.

The plan pays participating physicians $25 for Internet-based consultations. Since last fall, more than 300 physician members of CPPN-the physician/provider managed care organization of Columbia University Medical Center in Manhattan-and 3,000 of its patients have participated in the pilot program.

Both parties use RelayHealth's single, centrally managed database for doctor-patient communications, such as appointment scheduling, lab and test results, e-prescribing and prescription renewals and refills.

Studies revealed that employees were 50% less likely to miss work because they were able to communicate online with their physician via RelayHealth, claim the two companies.

Hartford, Conn.-based Aetna meanwhile, announced coverage of online physician-patient communications for its members in California and Florida through RelayHealth. The carrier will support clinically based doctor-patient consultations, appointment requests, the ability to get referrals, lab and test results, as well as electronic prescriptions and medication refills.

"Aetna believes online health care communication, properly structured for non-emergency conditions, holds great promise," Dr. Charles Cutler, Aetna's national medical director for quality management, told INN.

Members will be responsible for their office visit co-pays, based on their plan design, for the online doctor visit. There is no charge to members for the other communication services, confirms Cutler.

Members can access the service through two entry points: or through their physician's Web site if their doctor participates with RelayHealth.

Cutler says that although online doctor visits do not fully replace telephone consultations or face-to-face office visits, "doctors may find that online, structured communications helps them determine key patient information quickly and may provide a more accurate record."

In addition, he says, patients' details about their conditions are gathered in an organized way and can free office staff and nurses from triaging information, resulting in a more efficient use of office staff.

Like Highmark, Aetna also announced funding support for its e-health initiative, namely, of eHealth-Connecticut, a non-profit public-private partnership through a $25,000 grant. The carrier will also continue to evaluate the e-health launch as it moves forward while gathering information about potential additional markets.

"Decisions will be based, in part, on ensuring appropriate access for members, employer interest and the strength of RelayHealth networks in those areas," says Cutler.


For all health carriers, ensuring appropriate access means a long look at privacy and security issues. Highmark's Madden confirms that the Philadelphia carrier is taking a proactive approach to meeting and exceeding regulatory requirements.

"We know in the next couple of years, Medicare will have the expectation that content of care must be verified electronically," says Madden. "Privacy of patient records is critical, and believe it or not, electronic systems do a much better job assuring patient privacy- because rather than having a paper chart available to anyone in the office, everyone who touches this information is logged and tracked by user ID."

Cutler agrees. "Communication cannot be read en route, deleted, copied or altered," he says.

The RelayHealth service requires a sign-in identification and password and can only be accessed by registered users. Patients using the service can view an audit trail detailing who has accessed their records.

"If, for example, the patients change physicians, they also can terminate their online relationships with a doctor at any time, which prevents access to any medical information communicated via RelayHealth in the future," Cutler adds.

So far, carrier support for e-health initiatives is meeting with positive results.

"These are tight budgetary times," says Annville's Neilsen. "We get squeezed from growing overhead, such as medical malpractice, and now we have a large insurer who will help us redesign our systems, our process of care and more. This is a major step forward in thinking."

Madden prefers to refer to Highmark's pay-for-performance program not as a financial project, but as a quality improvement project. "It's the right thing to do, and ultimately the right thing to do translates into value."

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