E-Health Development Stages

Managed health care is an excellent industry for capitalizing on the benefits of e-commerce, the collective aspects of which are referred to as e-health. The development of e-health capabilities for managed health care companies falls broadly into the following stages:

1. Quality web page awareness is the simplest stage in development, with web page development now readily available through business and consumer software applications. Virtually all health plans have at least a basic web page, with company information and product portfolio information. While the basic web page may allow hyper links to other Web sites, most information is static and no transactional capabilities or data inquiry are allowed.
2. Building basic interaction capabilities with constituents, which includes members, providers, and plan sponsors. Virtually all national and many regional/local health plans and carriers have varying abilities to provide e-mail communication and to access detailed databases for information retrieval. However, these interactions tend to be limited to specific functions, such as accessing on-line provider directories or pulling down health plan information.
3. Building self-service capabilities for constituents marks a critical leap in the use of Internet technology since it requires real-time transactional competence combined with the ability to coordinate data from various information systems. This stage is the biggest growth area for health care plans in the 2000–2002 time period, as they increase their ability to offer on-line enrollment, referrals, and claim submission. While this stage will greatly improve the administrative quality of plan operations, most transactions are still "stove-pipe," with the constituent interacting in a specific function.
4. Transformation into seamless integrated operations is the ultimate stage in e-health development for health plans, wherein all transactions are real-time and span end-to-end across different operations, without interruption. Cross-functional electronic capabilities will enable specific business areas and systems (e.g., claims, plan eligibility) to interact simultaneously to serve the customer. In addition to further improving administrative capabilities, this stage holds significant potential for accelerating a patient's access to proper treatment, such as in the integration of information needed for effective disease management programs.

The Benefits of E-Health Development

At the center of the e-health evolution is the health plan member, who is the ultimate consumer of medical services as a patient. Eligibility data, enrollment data, claims data, treatment data, payment data all converge on the member/patient. Members are becoming more self-sufficient as they become more empowered with usable information, which in turn helps them maximize the value of their health plans. For members, the benefits of e-health include:

1. Maintaining personal health and family eligibility information;
2. Selection of a primary care physician as well as being able to inquire about other types of providers;
3. Checking on claim status, family eligibility, and flexible-spending account reimbursements;
4. Accessing health plan information such as the summary plan description; and
5. Searching general health care information about specific illnesses or general health topics.

Empowered and satisfied members reduce the administrative burden on plan sponsors. With e-health tools to speed up and improve operational duties, the plan sponsor can concentrate more on tailoring its benefit programs to best fit the needs of its employees. For plan sponsors, the benefits of e-health transactions include:

1. Plan set-up and maintenance, which can review for state benefit requirements and proper underwriting of benefit plans;
2. On-line member enrollment, which can provide immediate notification of enrollment errors and provide for direct production of member ID cards; and
3. On-line summary plan description, booklet, and certificate of coverage editing and production.

Similarly, with reduced manual intervention and paperwork, medical providers can return to practicing medicine and focusing on the best medical solutions for their patients. For providers, e-health benefits include:

1. Ability to submit claims electronically;
2. Checking patient plan benefits and eligibility;
3. Maintaining patient rosters for each type of health plan; and,
4. Receiving reimbursements electronically.