How Can Consumers Tell if a Health Policy or Plan is Good?
How to Find Health Ratings
Get in touch with the National Committee on Quality Assurance (NCQA). The NCQA accredits and issues "report cards" on plans that have applied for accreditation.
To find out whether a specific plan is accredited, see its "report card", or to find out what criteria are used for evaluation, contact the NCQA at (202) 955-3500 or visit their web site at
www.ncqa.org.
The Joint Committee on Accreditation accredits and puts out reports about preferred provider organizations and managed behavioral health care. For more information, visit their web site at www.jcaho.org.
K
eep in mind that the NCQA and the Joint Committee on Accreditation are funded and governed in part by the health care industry.
Read about the organizations and their standards.
Another resource is a Consumer Reports article from August 1996, entitled "How Good is Your Health Plan?" This article ranks many of the large plans based on a satisfaction survey.
You can order a copy from Consumers Union of U.S. Inc., Yonkers, NY 10703-1057. Specify report number RO155 and send a check or money order for $5.
Get in touch with your state's department of insurance for reports on plans, or information on complaint ratios.
You can obtain a toll-free phone number for your state's department of insurance by clicking on your state via the map located at Families USA's Medicaid Clearing House web page - www.familiesusa.org/medicaid/state.htm
Some community groups, state agencies, and employers have developed their own report cards.
The National Association of Insurance Commissioners is headquartered at 120 W. 12th Street, Suite 1100, Kansas City, MO 64105-1925.
Their phone number is (816) 842-3600 and their web site is located at www.naic.org.
If You Are On Medicare
Contact your state's Insurance Counseling and Assistance (ICA) program.
These are programs in each state which are funded specifically to counsel senior citizens about health insurance issues.
Call the Medicare toll-free Hot Line at (800) 638-6833 to get the number of your local ICA, or click on your state via the map located at the Families USA's Medicaid Clearing House web page - www.familiesusa.org/medicaid/state.htm
Also read our report, "Comparing Medicare HMOs: Do They Keep Their Members?", which tells the percentage of Medicare beneficiaries that elected to disenroll from various managed care plans - www.familiesusa.org/mhmo1.htm
If You Are On Medicaid
Some state Medicaid agencies give consumers information on how Medicaid managed care plans perform.
New federal legislation requires all states to give consumers managed care performance information in the future.
You can ask your state Medicaid agency if they will provide:
statistics on grievances, showing how many Medicaid beneficiaries complained about their plans, what types of problems beneficiaries encountered and whether plans resolved their problems;
statistics on disenrollments, showing how many Medicaid beneficiaries decided to leave their managed care plan;
results from external quality reviews, showing what problems auditors identified with the quality of care furnished by managed care plans and whether the plans corrected the problems.
Research the Plan
One of the best ways to judge a plan's quality is to talk to members and providers who have a history with the company.
Friends and family are an invaluable resource in telling you how a plan functions and whether their needs are served.
Ask them how easy they find access to specialists, how quickly they can get appointments with their primary care provider, and whether they feel they always receive the health care that they need. Keep in mind that these are subjective answers, and make sure you find out what they mean by a "long wait", etc.
Find out how providers are paid -- whether they are salaried, capitated, or paid-by-service.
These make the difference in whether your physician will financially benefit from his/her decisions to give you care.
If they are salaried, then they get the same amount of money regardless of your care (make sure to ask about bonuses for staying under estimated costs!). If they are capitated, then they are given a specific amount of money per month for your care and get to keep what isn't used.
If they are paid-by-service, then the plan pays them for each service that they provide. Note which plans reward providers for not authorizing or giving care, but note that there are quality plans in each of these categories.
Ask a primary care provider the process for referring patients to specialists. Do they have to let authorization for each referral?
Find out how complicated the process is and how much time is usually takes to make an appointment with a specialist.
One of the most important aspects of quality is the caliber of the providers. Having providers who are available, knowledgeable, and willing to take the time to go to bat for you with the administrators is priceless.
Families USA is working on a guide that focuses on obtaining publicly available information on managed care from a number of sources, including state and federal agencies and private organizations like NCQA and large employers, and analyzing this information.
If you don't have the resources to undertake a monitoring project like this one, contact a health consumer group in your area and encourage them to work on this.
Always check to see if information is publicly available, even if you don't immediately assume so.
The Families USA report will focus on Medicare information. The guide will be available in 1998.
Families USA has developed a list of questions that attempt to discover whether managed care policies and procedures adequately protect consumers.
Use these as a guide when evaluating a policy.
Emergency Care
Does the HMO allow you to get emergency care without first calling an HMO number? Does the HMO define an emergency as a problem that the average person would consider an emergency?
(If not, you could wind up paying the entire emergency room bill if your problem turns out not to be a true emergency.)
Care From Specialists
Does the HMO allow women to have an ob-gyn doctor as their primary care provider and/or see an ob-gyn doctor for an annual check-up without first obtaining a referral? Does the HMO provide you with an adequate choice of specialists?
If you have an ongoing chronic disease, does the HMO allow you to see an appropriate specialist without making you first see your primary care provider each time you need care?
(If it doesn't, you could waste a lot of time with doctor visits to your primary care provider when you really need to see a specialist).
Does the HMO have a clear arrangement for referring you to a specialist if you were to have life-threatening conditions, or other problem that requires specialty care over a long period of time?
If the HMO doesn't have a doctor available who can meet your needs, does it have a clear arrangement for referring you to specialists who are not part of the HMO plan?
Travel and Waiting Times
Does the HMO assure you that you can get an appointment in a reasonable length of time, especially if you have an urgent problem?
(If you only need a checkup, you can expect to wait for several weeks to get an appointment.)
Can you get to the HMO doctor's location without traveling for more than 30 minutes?
Contracting Hospitals/Other Facilities
Continuing Care
If you are pregnant or have a life-threatening or long-term condition, does the HMO allow you to keep seeing your former doctor for awhile before you have to switch to a doctor in the new HMO?
If the health care provider you are seeing for pregnancy or for a life-threatening condition no longer contracts with the HMO, will the HMO allow you to keep seeing your provider for a period of time?
Grievances and Appeal of HMO Decisions
Does the HMO provide you with a description of how it makes decisions of what is and is not appropriate care?
Does the HMO give you written notice that you can ask for an appeal if your HMO refuses to pay for a service, or refuses to allow you to see a specialist, or have a particular test or treatment?
Does the HMO provide you with a detailed description of how you ca appeal if you are denied care, or care is reduced or stopped?
Does the HMO allow you to make grievances and ask for appeals verbally, rather than only in writing?
Does the HMO offer any assistance to patients who want to ask for an appeal?
Does the HMO guarantee that you will receive a decision on your appeal?
Does the HMO guarantee that you will receive a decision on your appeal within a reasonable time, say two weeks?
Does the HMO have a way for you to get an appeal decision more quickly, say in three days in the case of a life-threatening situation.
Confidentiality of Patient Records
Does the HMO promise in writing not to share information about you with anyone other than those providing your care, processing payments on your behalf, or anyone else you specifically say should get the information?
Does the HMO promise in writing not to release information from your medical record to your employer without your permission?
Communications
Does the HMO respond to your questions clearly and promptly?
Materials and Resources
There are many publications and organizations to assist you in finding out which plans serve their members the best.
Health Pages Magazine is a consumer's guide to managed care.
It supplies comparative information for different geographical areas each time it is published. Their offices are located at 135 Fifth Avenue, New York, NY 1010 and can be reached at (212) 505-0103.
The Good Health Web has a database of over one thousand health organizations. They are located on the web at www.social.com/health. Just click "organizations" and the key word "quality," "managed care," etc.
If you want to know what an association of health plans thinks you should expect from a plan and what standards you should hold them to, you can contact the American Association of Health Plans. Their address is 1129 20th Street, NW, Suite 600, Washington, DC 20036-3421.
You can also call them at (202) 778-3200 or visit their web site at www.aahp.org.
Families USA has published a book, Health Care Choices for Today's Consumer. It include guidelines on if a plan is right for your needs, in addition to tips on how to best utilize a plan once you have it. The book is available in bookstores and to order it for $17.95 you can call (202) 628-3030.
There is a health and human services information web page provided by the government.
"Healthfinder" can be found at www.healthfinder.gov.
You can review many topics, including "quality of care", "managed care", or anything else for related web sites and organizations.
U.S. News & World Report has published a ranking of HMOs that covers 223 plans in 46 states.
This information is in chart form and is available on their web site at www.usnews.com.
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