From opaque to crystal clear: national health plan arms its members with sophisticated decision support tools to help them compare and contrast hospital performance for surgeries and treatment of serious medical conditions - Decision Support

Health Management Technology, Jan, 2004 by Robin Blair

Say what you will about copays and coinsurance. Those $25 and $50 items that employees kibitz about in the cafeteria don't count for much once you've had a penetrating look inside a four-day, $63,597 inpatient procedure. More and more, consumers ate getting real looks at real healthcare--costs, lengths of stay, mortality rates, risk of infection and how well their favorite hospital stacks up on the IT meter.

"Decision support, clinical" is a phrase no longer reserved for doctors and nurses. Today, millions of employees can access customized benefit portals, data repositories and decision support programs for data and individualized reports to help them make the right healthcare choices. Health plans kick open the doors.

For several years, CIGNA HealthCare, headquartered in Bloomfield, Conn., has carried the banner to more than 11 million members covered by its health plans. "Via portals, we wanted to bring better information to our three main constituencies: employees, employers and providers," says Joseph Mondy, assistant vice president, communications, for CIGNA Systems/ eCommerce. "When we surveyed those constituencies about their priorities, each one of them identified employees--consumers--as the most critical constituency to receive information, so that was where we started."

That was more than two years ago. Today, consumers covered by CIGNA HealthCare plans have a gargantuan amount of generic and plan-specific information available to them via myCIGNA.com. Provider directories, plan specifics for health, dental and pharmacy, in-network versus out-of-network costs, mail order drug prescriptions and a huge drug database from which covered members can generate customized comparisons are the tip of the iceberg.

Plan members also can view the status of their own or family members' medical, dental and pharmacy claims. They can take the short course on preventing healthcare fraud, access a glossary of financial terms that rivals an investment banker's and drill down into the essentials of well-baby care. It's plan-specific and, where applicable, formulary-specific.

Armed with Information

Still, infant immunizations and prescription refills for the wife generally don't break anyone's bank. But what happens when Charlie Consumer needs a hip replacement, colon surgery or angioplasty? What happens when Charlie or a family member faces inpatient hospitalization to treat a serious medical condition, one with high-dollar costs and significant risks to the patient?

The days of trusting one's PCP alone to provide all the instructions and all the answers are gone, as any PCP with Internet-armed patients knows. Today's consumers want details--even details they don't fully understand--about surgery, specialists' credentials, aftercare options, risks, recovery and maintenance--and along with that, they are also acquiring information about costs, complications, patient volume and mortality.

At myCIGNA.com, one gem of a link is the "hospital quality tool," which CIGNA cautions "takes you off myCIGNA.com. CIGNA does not control of sponsor the linked site's content or links." It's worth the side trip.

For those health plan members contemplating angioplasty, hysterectomy or other major surgical procedures or medical treatments, this diversion connects the member to clinical decision support for the consumer--sometimes marketed as Select Quality Care (but customizable in name and content for each purchasing customer)--and powered by HealthShare Technology of Acton, Mass.

CIGNA is one of a growing number of health plans to make HealthShare's technology available to its members. HealthShare offers the compilation of publicly collected data on up to 177 diagnoses and procedures in up to 14 medical and surgical categories that would include, as examples, hip replacement, heart valve replacement, mastectomy, carotid endarterectomy, adult asthma, diabetes, pneumonia, septicemia and stroke.

Selecting Variables

HealthShare Vice President Jenny McGee says the hospital comparison tool is supported by Medicare data collected from all 50 states and by all-payer data collected in 22 states, from hospitals that have treated at least 10 patients per year for a given condition or procedure. "Consumers can compare and contrast hospitals in their service area for multiple factors based on dozens of diagnoses and procedures," she says. "The reports they can generate ate adjusted for severity of illness. That way, hospitals that treat the sickest patients don't have results that appear unfairly skewed."

For example, a CIGNA HealthCare member who is contemplating a knee replacement can type in his home ZIP code and then specify the number of miles he is willing to travel for the surgery. He might select up to 30 miles, and he might determine that he wants to compare five, six or seven hospitals that perform the procedure.

Next, the consumer encounters several opportunities to build his own values into his data pursuit. How important is patient volume, the number of patients receiving knee replacements at those hospitals within a year? The consumer can choose from unimportant all the way up to extremely important. The same is true for mortality rates, the occurrence of problems of unfavorable outcomes (a variety of common outcomes specific to the surgery or condition under discussion are tracked), average length of stay and cost of the procedure or treatment. He can generate a 10- or 15-page report that compares all hospitals on all factors and ranks his best bets for a healthcare choice.