A Call for Care That’s Personal, Accessible and SocialWhen considering why MA beneficiaries “don’t like communicating about health by computer,” health plans should dig deeper

A Call for Care That’s Personal, Accessible and Social

Consider today’s older Americans as digital immigrants. This is in contrast to their adult children or grandchildren who were born digital natives. As digital immigrants, older people are adapting to a new(er) digital world, still retaining their “accent” learned in the analog world. “Today’s older folk were socialized differently from their kids, and are now in the process of learning a new language,” Marc Prensky wrote in his seminal essay, Digital Natives, Digital Immigrants, in 2001.

Today’s Medicare Advantage (MA) beneficiaries are digital immigrants increasingly learning about, understanding and valuing the convenience of online access, quick turnaround time, and personalized service and support they find in other aspects of their digital lives outside of health care. As immigrants, people learn to adapt to new environments, often retaining a foot in the past.

While more Medicare Advantage beneficiaries are adopting and adapting to digital lifestyles, too many of those wise souls, many keen to learn and take advantage of new and effective health care services, still have gaps connecting with Medicare plans for administrative, clinical and social support.

To better understand the diverse perspectives of Medicare Advantage beneficiaries, HealthMine surveyed 800 people enrolled in MA plans age 65 and over with at least one diagnosed chronic condition. The study, conducted in April and May 2019, gauged

older consumers’ views on personal health status, health plan services, digital technology, health care costs, and confidence in the future of Medicare coverage. This survey follows up HealthMine’s 2018-19 Medicare Advantage survey to explore how beneficiaries might have changed over one year.

Not a lot has changed over the year in terms of digital behaviors among Medicare Advantage beneficiaries. What has changed is the growth in popularity of Medicare Advantage plans, which covered over 60 million Americans as of January 2019. Traditional, fee-for-service Medicare insured about 39 million older people. Medicare Advantage covered 22.4 million insured, growing nearly 33% since January 2015.

By Jane Sarasohn-Kahn

Continuous Health Action

HealthMine’s 2019 Survey of Medicare Advantage Beneficiaries

More Medicare Advantage

beneficiaries are adopting and adapting to digital lifestyles ““

A Call for Care That’s Personal, Accessible and SocialHealthMine Reports August 2019 1

A Call for Care That’s Personal, Accessible and Social 2HealthMine Reports August 2019


Analysts expect enrollment in Medicare Advantage to continue to expand as Baby Boomers quickly age into the program and look for more personalized benefits beyond traditional Medicare such as dental care, vision coverage, gym memberships, and other novel benefits. To support this new era for Medicare, the Centers for Medicare and Medicaid Services (CMS) granted Medicare Advantage plans flexibility in April 2019 to provide more supplemental benefits such as nutrition support, home care services, and transportation.

For MA beneficiaries in the HealthMine study, health care starts with the doctor.

The most-trusted touchpoint for helping manage “my” health is the doctor. Virtually all MA beneficiaries trust their doctors in helping manage their health.

Family and friends rank a distant second place to physicians, falling to 27% of MA beneficiaries, followed by pharmacists at 19%.

Physicians have been ranked among the most-trusted professions by Americans for the many years that Gallup has polled this question, consistently in good company with two other highly-valued health care workers: nurses and pharmacists. Most Americans view the three health care professionals with the highest levels of honesty and ethical standards above all other professions in the U.S.

MA beneficiaries so value their physicians that four in ten would switch plans to spend more time with a doctor, HealthMine found.

“Who do you trust to help you manage your health?”Nearly all Medicare Advantage beneficiaries say doctors, nurses and other providers

Trusted health management touchpoint % of MA beneficiariesDoctor or care provider (PA, NP, etc.) 94%Family/close friend 27%Pharmacist 19%Health plan 17%A grocery store 1%A technology company (eg. Amazon, Apple, Google, Microsoft) 1%

Source: HealthMine Medicare Advantage Survey, 2019

My doctor is my trusted and primary touchpoint for health ““

Medicare Advantage enrollment continues to climb Enrollment has increased 32% since 2015

Source: CMS.gov



Personalization is also important when it comes to planning healthcare needs and finances for men versus women. The HealthMine survey revealed that male MA beneficiaries tend to be more digitally- engaged, accessing portals and using online tools (including telehealth) more frequently than women.More men also found it easier to access their medical data.

Women were more likely to turn to friends and family for health support, to seek rewards and to be more concerned about health-financial security and the future of Medicare coverage. Female MA beneficiaries were less sure about accessing their data online and were also less knowledgeable about the availability of online tools including telehealth. More women were comfortable with using the phone to communicate with their health plan than using digital tools, which were preferred by more men.

Mars vs. Venus: differences between men and women

Average health spending by age and gender, 2016

Note: *Indicates that, for the age range, the difference in estimates for the males and females is statistically significant (p<05)Source: Kaiser Family Foundation analysis of Medical Expenditure Panel Survey

The differential issue of women’s financial wellness in the context of health care spending is not trivial.Fidelity Investments identified two main drivers underpinning women’s health care cost challenges in retirement: first, Americans are living longer – especially women. A healthy 65-year-old woman alive in 2019 has a 25 percent chance of living to age 96, compared with 93 years for a man. Second, while women tend to live longer than men do, women’s savings tend to be lower. Fidelity found that men ages 65 to 69 have average retirement account balances of $191,000; and women, only about $117,000.



Virtually all of the MA beneficiaries in the HealthMine survey had internet access. Half of these folks said their internet cost was expensive, and half believed it was affordable based on their personal gauge of affordability.

In 2018, 2 in 3 people 65 and over (66%) were using the internet; based on this statistic from the Pew

Research Center, the HealthMine Survey MA beneficiaries over-index on internet adoption. The most common activities older people do online are surfing websites, shopping online, reading the news, getting directions, banking, and social media, a 2019 AARP survey found.

Younger MA beneficiaries are growing digital muscles Three in four people over 50 have smart phones; six in ten have a laptop or desktop computer.

Adults 50+ have embraced technology to make life easier

Base: Those who own a desktop or laptop, tablet, or smartphone (NET).Q.NEWTech2 Have you used your device to do any of the following activities?Source: AARP.org/Research

Mainstream technology usage remains strong and large with smart phone adoption in the lead

*represents a statistically significant difference between years at the 95% confidence level.Base: Total Respondents. Q. Tech1 Which of the following items do you have?Source: AARP.org/Research

AARP learned that one-half of people 60-69 used social media daily to stay connected. However, only a tiny proportion of the digitally-connected MA consumers surveyed used social networks for health applications.

This is a lost opportunity based on a study by William Chopik, a professor at Michigan State University. Chopik’s research learned that greater technology use among older people was associated with better self-rated health, fewer chronic conditions, higher subjective well-being and lower depression. His study also concluded that technology use reduced feelings of loneliness.



Aspirational, indeed: only one-third of MA beneficiaries accessed a health portal regularly. One in four people don’t use a portal at all, the HealthMine poll found.

This represents a significant design gap, and an opportunity to fill that chasm: only 30 percent of MA beneficiaries said they had easy access to a portal. Nearly one-half of people were unsure if their health plan even granted them digital access, so there’s a gap in knowledge of whether Medicare Advantage plans provide personal health data portals to beneficiaries – and if so, they don’t seem to be very discoverable.

“Patient portals—secure online connections to personal health information—have been hailed as a simple and efficient way for patients and providers to exchange information in between face-to-face visits,” allowing patients to view test results, schedule appointments, request prescription refills,

and exchange secure messages with providers, research published in Health Affairs explained.

Patient portals can increase patient engagement with the potential to generate positive health outcomes, researchers noted.

However, even though most older Americans have adopted the base technologies for accessing portals – namely, computers, tablets and smart phones – barriers remain for older people regarding their attitudes about using these technologies for personal health applications.

Phone contact is more common among the HealthMine surveyed MA beneficiaries than digital access: currently, 45% of MA beneficiaries interact with their health plan via telephone, and just under that proportion (42%) interact with their health plan via digital means. Only 13 percent of MA beneficiaries use mail to contact their MA plan.

There is pent-up demand among MA beneficiaries for more digital access: one-half of people want to interact with their plan via digital tools, versus 38 percent by phone. So digital interaction with health plans is aspirational for an additional tenth of MA beneficiaries.

A desire for digital, but dissatisfaction with health care portals

How do you currently interact with your health plan?Digitally 42%

By phone 45%

By mail 13%


How would you prefer to interact with your health plan? Percent of Medicare Advantage beneficiaries who use the technology

Technology Total Male Female 65-70 71-75 76-80 81+

Digitally 51% 56% 46% 58% 53% 45% 45%

By phone 38% 34% 42% 32% 35% 43% 41%

By mail 11% 10% 13% 10% 12% 12% 13%


Only 1/3 of Medicare Advantage

beneficiaries accessed a health portal regularly ““



Fewer people over 65 years of age liked using a computer to communicate about their health. One-half of people over 65 also didn’t see a need for this sort of access to personal health information. The bottom line of this study was that older peoples’ concerns about personally using computers for health care were about the utility/use/benefits of doing so, and the security of the technology for protecting personal health information.

When considering why MA beneficiaries “don’t like communicating about health by computer,” health plans should dig deeper to understand the tech-adoption barriers for specific people. For one beneficiary, the dislike of using a computer for their health may involve the cold nature of the technology, lacking a human form or empathy. For another person, the avoidance of using a computer for health could be more about personal information privacy/security concerns. A third group of beneficiaries may be shy to ask for assistance

in learning how to go online to access a portal or a telehealth provider.

Most participants in a recent study into older adults’ perceptions of technology (Vaportzis et al.) and barriers to interacting with tablet computers were eager to adopt the technology, but were apprehensive about certain aspects. These perceptions included too much and too complex technology, feelings of inadequacy and being compared with younger generations, lack of social interaction and communication, and certain negative features of tablet technology.

A study from The National Poll on Healthy Aging conducted by the University of Michigan assessed older adults’ reasons for not setting up their patient portal. Prevalent concerns were that older people did not communicate about their health by computer, didn’t have a need to do so, or weren’t comfortablewith technology.

Common reasons for not setting up a patient portal

Reason 50-64 years old 65-80 years old

Do not like communicating about health by computer 46% 62%

Not comfortable with technology 30% 47%Source: HealthMine Medicare Advantage Survey, 2019

Focus group themes and subthemes

Theme Subtheme

Barriers to using technologies and tablets

• Lack of instructions & guidance• Lack of knowledge & confidence• Health-related barriers• Cost

Disadvantages and concerns about using technologies and tablets

• Too much & too complex technology• Feelings of inadequacy & comparison w/younger generation• Lack of social interaction & communication• Negative features of tablets

Advantages and potential of technologies and tablets

• Positive features on tablets• Accesing information• Willingness to adopt technology

Skepticism & mixed feelings about technology & tablets

Source: Vaportzis et al.



According to the HealthMine study, most MAbeneficiaries that track health metrics use the data only for themselves and only share with their doctors in-person when they share at all. However, there is interest among the surveyed MA beneficiaries to share their personal health information for research. We can consider this “data altruism,” a concept fleshed out by an Institute of Medicine collaborative project that reinforced research from Consumer Reports finding the vast majority of U.S. adults thought their health data should be used to help improve the care of future patients.

This form of using health data to pay-it-forwardfor fellow patients was also confirmed in a recentDeloitte survey on health consumer engagement.

In this research, 47 percent of seniors were foundto be willing to share their blinded EHR data withhealth plans compared with 54 percent of Millennials. Furthermore, more people with chronic conditions are more likely to be willing to share information tracked in apps or digital health tools with doctors to help them provide better health care.

Looking to the future, a plurality of MA beneficiaries in the HealthMine survey were keen to engage with health data: 53 percent were interested in accessing their claims data, one-half would welcome a comprehensive personal health record, and 39 percent would like a dashboard to “see” their health.

A desire to share health information

Consumers with a chronic condition are more willing to share their tracked dataSurvey question: How willing would you be to share the information tracked in your apps for devices for the following reasons?*

Chronic disease No chronic disease Total

Blinded/anonymous contribution to anorganization that does health care research 43% 34% 39%

Blinded/anonymous contribution to adevice developer to improve device/program 44% 34% 40%

Share with emergency services if experiencing a sudden emergency situation 58% 46% 53%

Alert myself and share with family if in danger due to a fall or other health emergency situation 57% 48% 53%

Share with my doctors to help them providebetter care to me 66% 52% 60%

*Chart shows the percentage of respondents who answered 4 or 5 on a 5-point scale, where 1 is “not at all willing” and 5 is “extremely willing.”Note: For the purposes of this research, a “chronic condition” is defined as any disease or health problem that has lasted for three or more months. Examples include arthritis, diabetes, cancer, heart disease, high blood pressure, high cholesterol, asthma, allergies, back pain, depression, alcohol or drug dependence and others. Source: Deloitte 2018 Survey of US Health Care Consumers.Source: deloite.com/insights

*Source: HealthMine Medicare Advantage Survey, 2019



Most seniors surveyed by Deloitte in August 2018 were “on board with virtual health options.” Among older U.S. adults using technology for reasons other than health, of most interest would be monitoring

health issues; accessing, storing, or transmitting personal health information to a clinician; and, monitoring health issues, shown in the bar chart.

Seniors who use technology for other reasons are more interested in using tech for future health care needs Survey question: How interested would you be in using technologies in the future?

Note: Figure shows respondents who are interested in using the technology, where “interested” is defined as answering 2 or 3 on a three-point scale in which 1 is “not at all interested” and 3 is “very interested.” Source: Deloitte 2018 Survey of US Health Care Consumers.



Domains of financial health literacy & related conceptual skills Domains of FHL Skills

Manage Healthcare Expenses • Budget effectively for healthcare expenses • Manage healthcare and household bills simultaneously

Pay Medical Bills • Understand and pay medical and household bills

Determine Health Needs and Treatment Options

• Determine savings needed for healthcare and other expenses• Understand medical care options• Understand premiums, deductibles, co-payments and coinsurance• Determine prescription drug coverage

Make Healthcare Decisions with Availble Resources

• Choose appropriate Medicare and drug plans• Change insurance plans as needed• Choose appropriate treatment options

Source: The growing need for resources to help older adults manage their financial and healthcare choices, MacLeod 5 et al. BMC Geriatrics, November 2017


Does your health plan offer you any incentives to take actions, (e.g. annual doctor’s visit) in order to better manage or improve your health?

Clearly, one of the biggest barriers to older patients not engaging with digital technology for health care is peoples’ perceived lack of utility – which is rooted in a lack of personalization yielded by the available tech and tools.

There’s not a lot of “push” from MA plans, the HealthMine survey respondents said, except for billing and screening recommendations. But few MA beneficiaries said they received personalized risk management or predictive medical cost information individualized to them. There’s a growing need for resources to help older adults manage their financial and health care choices, researchers from Optum noted in a study on financial health literacy. “Many older adults havelow financial, health and health insurance literacy, each of which become increasingly important due to the decisions they face, especially with declining

health and fixed incomes,” researchers on the growing need for resources to help older adults manage health care finances observed. Older adults in the U.S. face challenging decisions about their health care and finances, complicated by Social Security benefits, end-of-life plans, life insurance, Medicare, Supplement and Prescription Drug (Part D) choices. Resources that support and assist with decision-making have become increasingly necessary.

About half of MA beneficiaries in the HealthMine survey said their plans offered them incentives to take actions to improve health. Only 18 percent were offered incentives to use digital tools. But this is an opportunity for health plans and providers to consider because over half of MA beneficiaries said they were, at least sometimes, motivated to change health behaviors based on incentives.

Does your health plan offer you any incentives to manage your health DIGITALLY (e.g. using tools, interacting with an online portal, accessing your EMR, etc.)? Source: HealthMine Medicare Advantage Survey, 2019

Lack of personalized health care for both clinical/physical health and financial wellness



The demand for personalized health care cost tools and supportWhen it comes to personalizing information for personal health care finance, the HealthMine survey revealed few MA beneficiaries (31 percent) have received tools that offer customized information on the costs of prescription drugs, and nearly two-thirds of MA beneficiaries lack predictive tools for costs overall.

Planning for health care costs among older Americans is a huge challenge: in 2019, the estimated cost for health care in retirement for people retiring at 65 was gauged at $285,000 per couple in assets needed today, Fidelity Investments calculated.

But most of the HealthMine survey respondents lacked personalized advice from their Medicare Advantage plans for predicting and planning for medical costs. Most people felt plans’ messaging about costs were

too mass in nature, not meant for “me.” One-third of beneficiaries wanted to hear about their expenses, fees, and costs, and receive supportive advice on how to lower those expenses.

Cost was the most frequent driver of Medicare Advantage beneficiaries switching plans, the J.D. Power 2019 Medicare Advantage Study identified. Clearer, streamlined and well-designed and executed communication about and assistance with managing costs could help improve health plans’ customer satisfaction scores and Star Ratings.

Retiree health care cost estimates ever time

Source: Fidelity Investments



“The HealthMine survey found that MA beneficiaries were interested in engaging in their health, with growing adoption of digital platforms to access the internet – albeit not so much for health care interactions. But there’s pent-up demand among seniors to receive more personalized support for care and cost management.

First, many older people remain unsure about the availability of digital “on-ramps” for their care. The health care industry must adopt more user-centered design approaches that provide real benefits and utility – as defined by consumers themselves – along with delivering customized messages and advice tailored to the individual.

One technology platform emerging as an on-ramp for health care at home is the voice assistant. In April 2019, Amazon announced that the Alexa Skills Kit would enable Covered Entities and Business Associates to build health care applications operating under HIPAA rules. The first skills launched were from Atrium Health, Boston Children’s Hospital, Cigna, Express Scripts, Livongo, and Providence St. Joseph Health System. This demonstrates that health care providers, pharma, health plans, and digital health companies have begun to design programs that can bolster peoples’ self-care, health activation and health literacy in the home.

Where a phone is preferred, health care stakeholders can use digital technology as a complement to voice via phone, nudging people to adopt digital as appropriate and desired based on personal preference.

In addition to a lag in digital health adoption, there’s also a gap in older peoples’ use of social networking for health. Although most seniors are engaged in social networking, few have used it for personal health engagement. But Chopik’s and others’ research demonstrates that digital social networks can be useful adjuncts to offline social connections to address the risk of social isolation that can come with aging.

Furthermore, Baby Boomers -- “younger older” people – are more social and are graduating into the world of Medicare. These mature digital immigrants will be more likely to adapt their use of social platforms for health management over time.

One noticeable symptom of loneliness and isolation in the HealthMine study was peoples’ low response rate to a question about caregiving: only a small proportion of people said they had a caregiver.

Was this low response denial, lack of knowledge about benefits of caregiving, or a feeling of stigma in the context of perceiving a loss of independence? AARP developed useful advice to help older adults accept caregiving support at home. AARP’s research found that eight in 10 people age 50 and over want to live at home as long as possible – but many folks are reluctant to accept help they need. To address these concerns, AARP recommended reminding people that we are all dependent on each other in some way; to acknowledge that people want to help, an action that gives people joy; and, to remind older people at-risk that they’re in control by asking for help and, in so doing, staying independent at home longer.

Opportunities to engage, inspire, personalize and socialize

There’s pent-up demand among

seniors to receive more personalized

support for care and cost management “



Social isolation can kill, the American Psychological Association noted in May 2019. The influence of social relationships on risk for mortality is comparable to that of smoking and alcohol consumption and twice the risk factor to physical and mental health as obesity. A diverse social network is associated with better health outcomes like greater immunity to infectious disease and improved heart health. Social support also buffers the negative effects of stress.

At the same time, there are risks associated with a shrinking social network in later adulthood. As people age, their social network can erode through the aging, disability and death of friends, along with the trend toward more distant family networks.

Incentives can also be artfully designed to nudge and inspire older people to try out digital technology for supporting new-and-improved health behaviors. Women, in particular, may be persuadable through financial incentives given their marginally greater concern about financial wellness in retirement. An eHealth Inc. survey on Medicare consumers found that many Medicare beneficiaries were willing to use digital health tracking devices if they improved care or saved money – like blood pressure monitor, heart rate monitor, blood sugar monitor, an EHR, or a fitness tracker.

A call-to-action: support personal risk-managementThe biggest gap, and an opportunity, articulated by the HealthMine survey consumers, was the lack of personalized health support and medical cost predictive tools. The study asked, “Does your health plan understand when you’re doing better or worse?” The group’s response was nearly universally, “no.” Four in five older people did not receive health risk advice based on their current behaviors.

Yet 73 percent of folks said their plan understands their health at least “somewhat” well (51 percent somewhat and 22 percent “very” well). Furthermore, two-thirds of people said their plan “helps me support my health.”

But only 19 percent of the MA beneficiaries said their plan knows when their health changes, for better or worse. This is the opportunity for risk education and more self-care personalized to the member.

How well do you think your health plan understands your health?

Does your health plan know when your health is getting better or worse?




A call-to-action: support personal risk-managementThere is sparse interaction with the MA beneficiaries following a physician visit, with one-half (48 percent) saying “none.” One-fourth said their post-visit interaction was about their insurance coverage. Only 19 percent of people said the post-visit contact concerned the quality of the care, and 17 percent on the experience. Note that beyond cost, the lack of engaging, useful information and communication depressed customer satisfaction scores across most of the MA plans, J.D. Power studied.

The contacts between people and patients has been focused largely on administrative and financial issues, and for finance, not for planning ahead to risk-manage saving and spending for medical costs.

“Value-based payments require valuing what matters to patients,” a recent JAMA essay asserted in its title. What matters to the Medicare Advantage consumers is personalized support, advice, and tools customized for their own goals and health objectives. As Boomers continue to age into Medicare, they’ll be seeking services and life-flows that fit into their vision of what healthy aging looks and feels like. Medicare Advantage plans have the opportunity to meet this demand for greater care at home, financial wellness, trustworthy advice, and independent living for as long as possible.

This HealthMine white paper represents the views of the author and HealthMine, not America’s Health Insurance Plans (AHIP). The publication, distribution or posting of this white paper by AHIP does not constitute a guaranty of any product or service by AHIP.



References

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Anthony DL, Campos-Castillo C, Lim PS. Who isn’t using patient portals and why? Evidence and implications from a national sample of U.S. adults. Health Affairs (37):12, December 2018

Brenan M. Nurses Again Outpace Other Professions for Honesty, Ethics. Gallup, December 20, 2018

Centers for Medicare and Medicaid Services. CMS finalizes Medicare Advantage and Part D payment and policy updates to maximize competition and coverage. CMS Press release, April 1, 2019

Chen J, Malani P, Kullgren J. Patient Portals: Improving The Health Of Older Adults By Increasing Use and Access. Health Affairs, September 6, 2018

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Deloitte. Consumers are on board with virtual health options, August 29, 2018

eHealth, Inc. Survey on Medicare Consumers, February 2019

Eng PM, Rimm E, Fitzmaurice G, Kawachi I. Social ties and change in social ties in relation to subsequent total and cause-specific mortality and coronary heart disease incidence in men. American Journal of Epidemiology 155(8):700-9, April 2002

Fidelity Investments. How to plan for rising health care costs - Estimated cost for health care post-age 65? Try $285,000 per couple in assets needed today, April 1, 2019

Fidelity Investments. Paying for health care during retirement.

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Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Medicine 7(7): July 27, 2010

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J.D. Power. Medicare Advantage Plan Customer Satisfaction Steady as Cost Drives Plan Selection, J.D. Power Finds. Press release, 20 June 2019

Kaiser Family Foundation analysis of Medical Expenditure Panel Survey (MEPS). Peterson-Kaiser Health System Tracker, based on 2016 MEPS data

Lynn J, McKethan A, Jha AK. Value-Based Payments Require Valuing What matters to patients. JAMA, October 13, 2015

MacLeod S, Musich S, Hawkins K, Armstrong DG. The growing need for resources to help older adults manage their financial and health care choices. BMC Geriatrics 17(1):1, November2017

Novotney A. Social isolation: it could kill you. American Psychological Association, May 2019, Vol. 50., No 5

Orbita. Amazon Alexa Is Now HIPAA-Eligible. What’s Next? Press release, April 5, 2019

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About the authorJane Sarasohn-Kahn, MA, MHSAHealth Economist, Communicator, Trend Weaver

Through the lens of a health economist, Jane defines health broadly, working with organizations at the intersection of consumers, technology, health and healthcare. For over two decades, Jane has advised every industry that touches health including providers, payers, technology, pharmaceutical and life science, consumer goods, food, Foundations and public sector.

Her passion for consumer health and transparency is shared in her award-winning blog, Health Populi. Additionally, she contributes to various mainstream publications and serves on numerous advisory boards. Her book, HealthConsuming: From Health Consumers to Health Citizens, was published in May 2019.

Documents

A Call for Care That’s Personal, Accessible and SocialWhen considering why MA beneficiaries “don’t like communicating about health by computer,” health plans should dig deeper