2005 Technology Issues for Health Insurance

Alignment of IT with business strategy is critical to realizing the value of technology investments. Looking to 2005 and beyond, I believe it will be just as important to consider how those technology investments enable the enterprise to participate in the emerging vision of an integrated, industrywide value chain. That vision includes a number of important elements, including increased Web-enabled connectivity, more data standardization -- particularly in the area of electronic health records -- more sophisticated decision support and increased real-time capabilities.

An integrated value chain is important because it holds the promise of improved quality and reduced medical errors, increased collaboration and more efficient workflow among health professionals, better access to data for research purposes, as well as substantially reduced costs.

Consider this: A woman is brought into the emergency room unconscious after collapsing on the street. The key to making the right diagnosis is timely access to the patient's medical history, but since she is unconscious she's in no position to answer questions. The patient has no medications in her possession to indicate a current medical condition. There is no information for family members, doctor or medical facility. With a sudden loss of consciousness, the range of possible diagnoses is vast and the treatment for each varies widely. However, there is the health plan ID card. In tomorrow's world, emergency rooms could be equipped with a state-of-the-art system able to access the Internet. While the patient is evaluated in the traditional way and with only the information available, another professional could securely access this integrated network where the electronic health record could be viewed. Within seconds, the attending physicians would have the information needed to quickly treat her condition, whether it was heart disease, any one of several metabolic diseases, diabetes or another cause. Current prescription information, financial responsibility, benefits information, etc. would be at their fingertips, enabling a prompt response at a critical point in time. In more routine circumstances, medical errors could be reduced when specialists and primary care physicians are able to share information about treatments and prescriptions for a common patient, avoiding negative interactions or other consequences.

However, our industry's transaction infrastructure has historically been batch-oriented. Connectivity among the various players is not in place. Clearly this must change. There are near-term advantages from expanding electronic interaction and moving toward real time. For a typical office visit, integrated systems could provide a complete view of the patient's financial responsibility, including the ability to debit electronically the patient's FSA or HRA account using a combined ID/payment card, which Humana was the first to introduce in 2003. When Humana named Availity LLC as its primary gateway for the submission of claims and encounters, we were able to provide more responsive service to healthcare providers through the real-time capabilities of both companies, reduced technical complexity and increased service accountability by reducing the number of our clearinghouse relationships. These are steps that I believe start to lay a foundation for the future, one that could include real-time adjudication of claims.

To me, the issues for health insurers involve making smart choices about the type and level of technology investment in these areas, and getting a better understanding of what value means to consumers. Current legislation and federal initiatives indicate that we also have an opportunity to further develop this vision and how it produces that value.

In 2005, I see our greatest challenges to be staying tightly focused on business alignment internally while extending strategic alignment of IT beyond the enterprise to ensure on-going competitive advantage as our industry embarks on a period of dramatic and promising change.