1. Consumerism in Healthcare: The Demand to Provide High Quality Information to Healthcare Customers Consumer Driven Healthcare Summit John Mills Washington, DC October 20, 2008

2. 1 Overview About HIP Health Plan and EmblemHealth Consumerism in Healthcare and the Need for Information Information and Tools Available to Consumers –Personal Health Records –Health Risk Assessments –Network Quality Information Employer Wellness Efforts Incentive Programs to Promote Healthy Behavior Conclusions

3. 2 About HIP and EmblemHealth EmblemHealth –HIP and GHI affiliation approved in October 2006 –Combined entity will be known as EmblemHealth on January 1, 2009 Current membership is more than 4 million Serves New York, Connecticut and Massachusetts Product offerings include –HMO and POS –EPO and PPO –CDHP –Government programs –Dental insurance –Pharmacy benefit management

4. 3 Consumerism in Healthcare Consumerism in healthcare demands a greater understanding of plan design and cost information –Health Savings Accounts, Health Reimbursement Accounts and other Consumer Driven Health Plans are a driving force behind it because they require access to both cost and quality information Employers want their employees to be better informed about health care costs, prevention and treatment of illness Emergence of the Internet has made health information more accessible to consumers and it can now be provided in an integrated and user friendly model

5. 4 Consumerism in Healthcare Providing healthcare information –Personal Health Records –Health Risk Assessments –Health Dictionaries Network Quality Information –Hospital Quality Tools Incentives to Change Behavior

6. 5 Personal Health Records Personal Health Record (PHR) –Patient geared tool which generally sits on either the health plan or employer website and provides a medical profile of the member –A set of consumer health related information used by the consumer and any other care or service providers as appropriate –Permits member and health plan to populate it with claims, lab and pharmacy data either manually or through a claims download –Can be thought of as a patient-owned Electronic Medical Record –Establishes personalization and consistency of care

7. 6 Personal Health Records Capabilities Information available in the Personal Health Record

8. 7 Personal Health Records Capabilities Office visits

9. 8 Personal Health Records Capabilities Condition detail from physician visit

10. 9 Personal Health Records Capabilities Track medications

11. 10 Personal Health Records Capabilities Medication details

12. 11 Personal Health Records Capabilities Track medical tests

13. 12 Personal Health Record Capabilities Printable Personal Health Record Summary

14. 13 Personal Health Records Capabilities Opt in for automatic claims download

15. 14 PHR Interoperability Standards Personal Health Records and Electronic Medical Records currently have no data or transmission standards –Every vendor has different fields and collect different data Makes it difficult to transfer PHRs electronically or load information into an Electronic Medical Record –Lack of data and transmission standards is a major hurdle to increasing adoption of PHRs and EMRs

16. 15 PHR Interoperability Standards Industry and government are trying to establish interoperability standards for both PHRs and EMRs –Office of Health Information Technology established to fund healthcare IT projects –RHIOs established to bring payers and providers together to facilitate better IT communication –Industry trade groups have been attempting to develop common data sets and transmission standards

17. 16 PHR Interoperability Standards AHIP established a pilot project where they identified 10 core data elements for the transfer of data between health plans including: –Patient Information –Encounters –Medications –Providers –Facilities

18. 17 PHR Interoperability Standards Eight participating health plans were paired up and asked to transfer 500 records among them Common data elements were provided and plans had to perform translation where necessary Pilot was a success with all plans successfully transmitting the data elements identified

19. 18 Health Risk Assessments Health risk assessments are used by the member to assess their behaviors and determine how those behaviors impact their health This tool helps plans meet the NCQA accreditation requirements Most health plans are using tools which encourage members to complete the assessment –Incentives for completion are sometimes provided The information collected is confidential and can only be used to improve a member’s health through disease management or health coaching services

20. 19 Health Risk Assessments The tool provides information to the health plan to help devise disease management programs for chronic conditions including: –Diabetes –Asthma –Smoking cessation –Obesity Health coaching can help members with or without chronic conditions who are looking to improve their health

21. 20 Health Risk Assessments Assessment questionnaire

22. 21 Health Risk Assessments Results

23. 22 Health Risk Assessments Ways to Improvement your score

24. 23 Network Quality Information Implemented a hospital cost and quality tool (Hospital Comparison Tool) as part of the Health Manager suite. The Hospital Comparison Tool allows members to search hospitals by location and compare them on number of cases, mortality and complication rates, length of stay and cost for a given procedure. The Hospital Comparison Tool is available to members, prospective members on the hipusa.com home page. Consumerism in healthcare necessitates that more information be made available about the price and quality of health services

25. 24 Network Quality Information Choose procedure and location

26. 25 Network Quality Information Select hospitals to compare for procedure

27. 26 Network Quality Information Report on hospital quality for selected procedure

28. 27 Employer Wellness Efforts Many employers are starting to understand that healthier workforces lead to: –Lower health costs –Less absenteeism –Better productivity Employers have started to implement incentives for their workers to live healthier lifestyles –These programs must adhere with Department of Labor and HIPAA non-discrimination rules Employers are permitted to provide financial incentives for as much as 20% of the cost of coverage

29. 28 Employer Wellness Efforts Programs to promote healthier behavior include –Smoking cessation programs –Completion of health risk assessments –Biometric screening for blood pressure, glucose and cholesterol –Health coaching programs drawn up for individuals –Gym memberships and onsite activity programs Rewards programs include –Premium reductions within Department of Labor and HIPAA guidelines –Point programs leading to reward certificates –Funds deposited into either Flexible Spending or Health Savings Accounts

30. 29 Employer Wellness Efforts New York State enacted a law in 2008 permitting health plans to provide wellness programs including financial incentives for participating –Permitted activities include inducements for taking a Health Risk Assessment, participating in a smoking cessation program and joining a gym

31. 30 Employer Wellness Efforts Permitted incentives include –Reimbursement for participation in a wellness program or for a gym membership –Waiver or reduction of co-payments, coinsurance or deductibles for preventive services –Rewards programs such as bonus points programs or gift cards for meeting certain milestones Premium reductions are only available at the group level and can only be provided if a plan can demonstrate that the wellness program improved the overall health of the group –Community rated groups are not eligible for premium reductions

32. 31 Incentive Programs to Promote Healthy Behavior A key success factor for these programs is keeping the goals realistic –Programs with too ambitious objectives tend to fail –Raise the bar when employees begin meeting the goals You want to encourage success but not make it too easy These programs are relatively new –Internal pilots are going on with employee populations and the results will be used to design programs for employer groups

33. 32 Conclusions Consumerism in healthcare is creating demand for more information about healthcare as costs increase and employers become more concerned with the health of their workforces The Internet has created an opportunity to provide information and perform transactions that were too difficult and costly to organize in a paper environment Many health plans have made an initial investment in this area and will expand that investment as interest continues to grow from consumers and employers

34. 33 Questions ?