Technology & Innovation

Sharing information—the payer’s perspective

October 18, 2010

Global

October 18, 2010

Global
Our Editors

The Economist Intelligence Unit

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In 2001 Humana, a health insurer headquartered in Kentucky with revenues of US$31bn in 2009, was looking into ways of automating its interactions with physicians’ offices. But it faced a quandary.

“We knew it didn’t make sense to try to develop our own system,” says Humana’s chief service and information officer, Bruce Goodman. “After all, there are many insurance companies out there, and we’d never convince a doctor’s office to adopt ours if it meant they would have to then adopt—and learn how to use—numerous others. This was an area where no one company could succeed. Plus, most doctors’ offices are small, so we needed to find a way to drive the technology adoption ourselves.”

So, Humana did what many companies in highly competitive industries usually hate to do: team up with their competitors to create one solution they could all use.

The result was a system called Availity, piloted in the State of Florida with that state’s Blue Cross and Blue Shield organisation. Since that time, Availity has grown rapidly and is now used by over 250,000 physicians in 74,000 practices in 20 states, with many joint-venture partners.

In the paper world, administrators in a doctor’s office fill out forms, sending them to the insurance company and waiting for the insurance company to process them. The insurance company assesses how much of the treatment is covered, generates a statement (called an “Explanation of Benefits”), and sends one copy to the patient and another copy to the physician’s office. Then, the physicians’ office generates its own bill, sends it to the patient and waits for payment.

Individual physicians’ offices lose a lot of money through this approach. “We estimate that only about 40% of what is still owed by patients is actually collected after they leave the office,” says Julie Klapstein, Availity’s CEO.

With Availity—or any similar automated system—all of this is done electronically and on the spot. While the patient is still in the physician’s office, administrators enter all the information via an online portal and get that same information in real time. The physician can then collect payment before the patient even leaves the office, and payments from the insurance company are processed electronically—and much more quickly.

Another huge benefit from Humana’s perspective was the ability to drive many transactions online—and off the phone. “This is huge for us,” explains Mr Goodman, “because the cost of paying someone to answer the phone is about ten times what it costs to deploy technology that does the same thing.”

Mr Goodman adds that other features in the system also enhance clinical outcomes. “For example, because we can see whether a patient has filled a prescription written during a previous visit, or followed up on a specialist referral, we can alert the doctor to possible gaps in care, which he or she can then raise with the patient. This is especially important in the case of chronic conditions such as diabetes or high blood pressure where patients do not always closely follow treatment regimens, and these conditions are the single largest source of cost in our healthcare system.”

The system even has features that, for example, remind a physician treating a diabetic to ensure he has regular foot and eye exams to detect potential disease complications that can be serious for the patient, and also add considerably to the total cost of care. The system will also immediately flash a warning if a medication prescribed has a potential adverse interaction with another drug the patient is taking.

“Any opportunity to identify these issues immediately at the point of care, where the physician is interacting with the patient, has a great potential to improve the overall quality of healthcare and also to lower the cost of providing that care,” says Mr Goodman.

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