The internet and managed care: A new wave of innovation

Health Affairs

Volumn 19, Issue 6, 2000, Pages 42-56

  Goldsmith, Jeff ^a  

^a Health Futures in Charlottesville   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CASE MANAGEMENT; HEALTH INSURANCE; HUMAN; INSURANCE; INTERNET; MASS COMMUNICATION; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PERSONNEL MANAGEMENT; UNITED STATES;

CASE MANAGEMENT; DIFFUSION OF INNOVATION; HUMANS; INSURANCE CLAIM REVIEW; INSURANCE POOLS; INTERNET; MANAGED CARE PROGRAMS; ORGANIZATIONAL INNOVATION; PERSONNEL MANAGEMENT; UNITED STATES;

EID: 0034328365     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.19.6.42     Document Type: Article

References (25)

1. Blue Cross plans have a significant lead over their health insurance competitors in electronic claims submission, with about 80 percent of all Blue Cross claims submitted electronically in 1999. Medicare has an even higher rate, with more than 97 percent of Part A claims and 81 percent of all Part B claims submitted electronically in 1999. See Faulkner and Gray, Health Data Directory, 2000 Edition (New York: Faulkner and Gray, 2000), 21. Unfortunately, these estimates do not break out tape submissions from interactive electronic formats such as dedicated lines and Internet modalities.
2. Christine Malcolm, Computer Sciences Corporation, personal communication, June 2000.
3. Janice Young, Gartner Group, personal communication, May 2000.
4. L. Downes and C. Mui, Unleashing the Killer App: Digital Strategies for Market Dominance (Boston: Harvard Business School Press, 1998).
5. G. Hamel, "Will the 'Frictionless' Economy Slip You Up?" Wall Street Journal, 6 June 2000.
6. J.P. Lathrop, G. Ahlquist, and D. Knott, "Healthcare's New Electronic Market-place," Strategy+Business (Second Quarter 2000): 36.
7. P. Kongstvedt, 1999 Managed Care Benchmarking Study (Washington: Ernst and Young, February 2000).
8. I. Morrison, "The 1% Solution," Health Forum journal (July/August 1999): 45.
9. Employee Benefit Research Institute, Employment-Based Health Care Benefits and Self-Funded Employment-Based Plans: An Overview, Facts from EBRI (Washington: EBRI, April 2000).
10. B. Richards, "Employer Benefits: Automating Human-Resource Operations Used to Be a Luxury Only Big Companies Could Afford; Not Any Longer," Wall Street Journal, 15 November 1999. An illustrative new entrant into this market would be eBenX.com.
11. Faulkner and Gray, Health Data Directory, 20.
12. L. Lessig, Code and Other Laws of Cyberspace (New York: Basic Books, 2000).
13. This format is Version 4010 of the American National Standards Institute ASC X12N. It contains standards not only for electronically submitted institutional and professional dental and pharmacy claims, but also for claims status, enrollment and disenrollment notices, eligibility verification, health plan premium payments, payment and remittance advice, referral certification, and authorization transactions. For diagnoses, HIPAA specifies ICD-9-CM; for inpatient procedures, ICD-9-CM v.3; and for outpatient and physician procedures, CPT-4.
14. In March 2000 a coalition of six major managed care firms announced their plans to collaborate in creating a cooperative national electronic interchange called MedUnite to facilitate electronic claims transmission and settlement. A regional consortium of integrated health systems and insurers in New England has created a cooperative model EDI system called NEHEN, which is expected to save the participating institutions more than $60 million a year.
15. See M. Hagland, "Big Risk, Small Reward," Healthcare Business (Nov/Dec 1999): 35.
16. Lee Newcomer, Vivius, personal communication, July 2000.
17. See L. Page, "Fee for Episode," American Medical News, 15 May 2000, 13-14, for a discussion of this methodology, and a specialty services payment firm, Adesso, which has developed it.
18. See J.F. Kasper, A.G. Mulley, and J.E. Wennberg, "Developing Shared Decisionmaking Programs to Improve the Quality of Health Care," Quality Review Bulletin (June 1992): 183-190; and E. Wagner et al., "The Effect of a Shared Decisionmaking Program on Rates of Surgery for Benign Prostatic Hyperplasia," Medical Care 33, no. 8 (1995): 765-770.
19. See J.F. Kasper, A.G. Mulley, and J.E. Wennberg, "Developing Shared Decisionmaking Programs to Improve the Quality of Health Care," Quality Review Bulletin (June 1992): 183-190; and E. Wagner et al., "The Effect of a Shared Decisionmaking Program on Rates of Surgery for Benign Prostatic Hyperplasia," Medical Care 33, no. 8 (1995): 765-770.
20. J.P. Lathrop and D. Carlebach, "HMOs'R'us: A Prescription for the Future," Strategy+Business (Fourth Quarter 1998): 16-20.
21. See the Vivius Web site, . A competing approach is offered by another Minneapolis start-up, HealtheCare, . See L. Page, "An Insurance Alternative: Firms Selling E-Healthcare," American Medical News, 15 May 2000, for a review of several competing alternative approaches.
22. See the Vivius Web site, . A competing approach is offered by another Minneapolis start-up, HealtheCare, . See L. Page, "An Insurance Alternative: Firms Selling E-Healthcare," American Medical News, 15 May 2000, for a review of several competing alternative approaches.
23. John Lee and Jack Friedman, Sisters of Providence Health System, Portland, Oregon, personal communication, May 2000; and David Jones, Humana, Louisville, Kentucky, personal communication, July 2000.
24. John Lee and Jack Friedman, Sisters of Providence Health System, Portland, Oregon, personal communication, May 2000; and David Jones, Humana, Louisville, Kentucky, personal communication, July 2000.
25. Gartner Group, 2000 Healthcare Payer Application Study (Stamford, Conn.: Gartner Group, May 2000).