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Managed Care Plans Push PHRs


By Howard J. Anderson, Executive Editor October 2007
A growing number of health insurance companies are offering their enrollees some version of personal health records. They say these records can help them to provide consumers with timely information on how to stay healthy, among other benefits.

But some question the value of payer-sponsored personal health records that are based primarily on the basic data included in claims. And critics worry that some payers might use the information in these records for the wrong purposes-such as to deny future claims-because there are no explicit federal rules prohibiting secondary uses of the data.

Many patients receive care at multiple provider sites, each of which may have its own electronic health record or rely on paper records. But payers have a wealth of claims data from a cross-section of providers, outlining all the tests, procedures and medications for each enrollee, says Meg McCabe, who heads e-health products for Aetna Inc., Hartford, Conn. "We have a good head start in providing a complete health record," she says.

A few payers are offering personal health records that are not pre-populated with claims data and only offer the consumer the ability to enter their own information. "The fact that we can insert claims data makes it far easier; the patient doesn't have to enter all that data," she says.

The most significant impact of claims-based PHRs, she contends, is that they provide payers the capability to analyze data and then forward to the patient and their physician suggestions on ways to improve their health, such as getting a timely test or following a certain diet, McCabe says.

Questions Raised

Some observers, however, question the value of a record based primarily on the codes used in claims. "Those codes are not really diagnostic codes; they are reimbursement codes," says Margret Amatayakul, president of Margret/A Consulting LLC, a Schaumburg, Ill.-based firm specializing in electronic records. "They don't provide enough detail on treatment."

The American Health Information Management Association, a Chicago-based group representing medical records managers, has voiced similar concerns. "We really think that it's preferable that PHRs be integrated with providers' electronic health records," says Linda Kloss, CEO at AHIMA.

Following that same philosophy, Group Health Cooperative, Seattle, is integrating providers' electronic records with its MyGroupHealth personal health record. Because the organization owns a hospital, is affiliated with a major medical group practice and runs a managed care plan, it's in a position to build a more complete PHR, says Ted Eytan, M.D., associate medical director.

"Claims data is not enough," he says. "I have never had a patient tell me that claims data is empowering. That's not what people want."

Instead, Eytan says, consumers want a PHR that enables secure messaging with their physicians and provides access to current, complete information on their care.

A Starting Point

Many larger payers, however, argue that a personal health record initially based on claims data from multiple providers offers a more comprehensive view of treatment than the existing disjointed mix of paper and electronic records from multiple provider organizations. Until various provider records systems are integrated, either through regional health information organizations or other methods, payer-initiated PHRs provide a starting point, many payers say.

Today's payer-initiated PHRs enable consumers to begin to benefit from preventive medicine, says Kelly Murphy, e-health manager at Humana Inc., Louisville, Ky. "We're allowing members to take a consumerism approach to managing their own health," she says.

Some industry observers question the wisdom of accessing PHRs on the Internet, citing privacy concerns.

"If my insurance company puts my PHR on the Internet, they better have some good lawyers," says Vincent Ciotti, principal at H.I.S. Professionals, LLC, a Santa Fe, N.M.-based consulting firm. "Internet security is going to be breached. You're asking for trouble if you share PHRs on the Internet."

Instead, Ciotti advocates that patients retain control of all their records by storing them on a smart card or on their home computers. "Medical records are extremely confidential and private, and need to be kept that way," he stresses.

In contrast, Amatayakul believes that payers are motivated to keep patient records secure "because a breach would be very public and no insurer wants that to happen." For their part, payers counter that PHRs are on secure Web sites that have the highest level of protection, similar to the protection used by banks to protect sensitive financial data.

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