PCHIT Personas: Health Plan

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The Library of Congress, General view of one of the classification yards of the Chicago and Northwestern Railroad, Chicago, Ill. (LOC), January 1, 1940.

Sites visited

  • Individuals from various health plan organizations

The persona of a typical health plan has been challenging to discern in the first 90 days.

The integrated health plan / delivery system organizations Kaiser Permanente and Group Health are discussed within the integrated delivery system persona.

A Key Stakeholder

Conversations with health plan representatives and with others about their experiences with health plans around PHRs raised many questions about the health plan role in advancing PHRs. As the image above shows, health plans sit at a cross-road of data.

Health plans theoretically stand to benefit substantially from more efficient use of delivery system resources and greater consumer engagement in care management. Questions emerged around PHR ownership, and on whether widespread adoption via the health plan is possible (see Health Plan Perspective). We were not able to get information across a breadth of business units which limits the generalizability of this assessment at this time. Given equal effort, we were less successful in arranging contact with health plan organizations relative to delivery of care organizations.

The unclear role of this stakeholder is reflected in the literature. First, in the writing of national PHR leaders:

Because health care payers and purchasers are the primary beneficiaries, they should probably be the primary ones who bear the cost of PHRs. However, the evidence supporting the rationale for payers to provide PHRs is not mature, and they may be reluctant to do so.

(see: Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption. J Am Med Inform Assoc 2006;13:121-6.)

Second, in the opinions of consumers using a PHR for diabetes care, when asked what they are willing to pay for a PHR:

There are several reasons that may account for these attitudes toward user fees. First, the group discussions may have influenced the participants’ attitudes. For example, in one of the focus group sessions, a participant pointed out that if the portal succeeds in helping patients manage their diabetes, it may decrease the number of diabetes-related hospitalizations and thereby prove to be a cost-saving measure for the health system. At the end of the same session, only one participant in the group thought that a user fee might be acceptable.

(see: Hess R, Bryce CL, McTigue K, et al. The Diabetes Patient Portal: Patient Perspectives on Structure and Delivery. Diabetes Spectr 2006;19:106-10.)

The PHR opportunity that health plans have is that they have access to a wide range of data that could populate their members’ PHRs. If they create an effective infrastructure to manage and integrate those data, they can offer their members a useful tool. According to one large health plan executive, “Our role in the HIT space is leveraging that infrastructure to be the conduit between clinical and administrative data; we can facilitate important data connections.”
Health plan executives also recognize that the biggest opportunity to make effective use of PHRs for better care management and increased cost-effectiveness is for their members with chronic conditions. For this large health plan, although its overall PHR adoption rate is only 10% to 15%, its adoption rate among those actively managing chronic conditions that it targets is between 30% and 40%.

Once the health plan creates the data infrastructure, the keys are figuring out how to present the data in a context-relevant manner, how to align incentives for both clinicians and members, and how to proactively deliver timely, relevant, tailored messages to members that make the data meaningful to the individual. The other big challenge that health plans face in that respect is that—due to lag time in administrative data processing—they often don’t have access to “timely” data, making it difficult to target their messaging to particular moments in care.

It is understood that several pilot programs to support personal health records or components thereof are under way in the regions we visited (see A Virtual Reality). Plans also appear to be active in other areas to promote quality of care, such as in supporting disease management and lifestyle programs. Transparency initiatives underway include improved availability of cost, quality, and outcomes data. (see U.S. healthcare payers to limit IT investments in 2008).

In the practice settings we visited, we detected an ambiguous message from health plans about the value of personal health records in care. The experience at the practice level may not represent that at the strategic and marketing levels of plans. This is similar to the issue of having “Vision from the board room to the bedside,” (see: Patient-Centered Care, What Does it Take?) that many delivery systems face internally already, and therefore not specific to health plans.

It is noted by others that in health plan environments, “consumers have not raced to adopt them (PHRs).” Again, this is in comparison to environments where PHRs are unambiguously promoted and are showing strong demand from patients.

Unresolved Issues

  • Overall health plan intent with regard to PHR adoption is not understood based on our experience to date
  • For health plans actively engaged in PHR promotion, where is the best locus of control (patient, provider, plan) for successful PHR implementation and what should the role of the health plan be?
  • Health plans are trying to figure out how to effectively integrate clinical and administrative data, and how to overcome administrative data processing lag time in order to ensure that PHR data are populated in a timely manner.


Data about customer experience with health plans (see: Forrester Research: Customer Experience Index Snapshot: Health Plans, as well as the impact of PHRs on affordability (see: Zhou Y, Garrido T, Chin H, Wiesenthal A, Liang L. Patient Access to an Electronic Health Record With Secure Messaging: Impact on Primary Care Utilization. Am J Manag Care 2007;13:418. are supportive of a strong role for health plans in this ecosystem. We would therefore like to continue to engage in this area next.

We are also working to communicate with national innovators in health plan environments, as opposed to health plans in the markets we have visited.

We are also scheduled to engage in a co-shadowing experience with health plan executives this month (February, 2008).

Ways to Engage

  • Identify innovators as a starting point
  • Bringing the patient experience forward – co-shadowing, interaction with consumer groups

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