A Plan to Help You Choose Among Health Plans

Many public and private employers encourage their workers to choose so-called managed-care plans that limit your health care options but save you--and your employer--money in premiums, deductibles and co-payments.

However, some workers are reluctant to enroll in managed-care plans such as health maintenance organizations because they’re concerned about the quality and availability of services. In the past, it was difficult to gauge quality, because plans volunteered little quality-related information--and consumers didn’t know what questions to ask to make such determinations.

But that’s changing too. A variety of organizations are creating formulas to measure plan quality. For example, a group of employers, consultants, insurers and health care providers came up with a measurement called HEDIS, for Health Plan Employer Data and Information Set. Meanwhile, the California Public Employees Retirement System, which offers 25 different plans to roughly 336,000 state, county, municipal and special assessment district workers, is conducting satisfaction surveys.

Although few open-enrollment packages include the results of these efforts yet, consumers can benefit by knowing the questions these experts are asking--and the kind of responses they expect to hear.

The HEDIS program, which was designed to help employers (rather than employees) screen plans, rates them in four broad categories: quality, access and patient satisfaction, membership and utilization, and finance.

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In many cases, the HEDIS questions are technical and require significant medical knowledge to weigh the responses.

For instance, HEDIS aims to measure how well individual plans perform in preventive medicine. It looks at the availability--and use of--immunizations, cholesterol screening, mammograms and Pap smears.

It also measures the number of low birth-weight babies born to members of the plan and the percentage of the plan’s participants receiving prenatal care in the first three months of pregnancy.

HEDIS also attempts to measure different plans’ quality of treatment for acute and chronic diseases--as well as mental health and substance abuse--by evaluating readmission rates and follow-up procedures.

However, in the category of “access and patient satisfaction,” the HEDIS questions are easy to fathom:

* Does the health plan survey participant satisfaction?

* What percentage of its members are “very satisfied” with the plan?

* What percentage of the plan’s physicians are actually accepting new patients? (This reflects a criticism often voiced by some members of managed-care programs, who say that even though their plan has a long list of participating doctors, many on the list say they’re too busy to take new patients.)

* How do consumers gain access to the plan’s services? Are there published procedures regarding what you must do to see a doctor or specialist? Does the plan provide employees to answer questions over the phone?

Meanwhile, after conducting a series of public meetings and focus groups, CalPERS developed a set of 80 questions to determine participant satisfaction. The pension fund divides its questions into nine categories that address everything from administrative problems to quality of care.

Asking plan sponsors variations of these questions can help you determine how likely you are to be satisfied with any given plan. The questions:

* How long must you wait to get an appointment for a routine visit? How long must you wait to get an appointment for an urgent problem? To get advice over the phone? How long are patients typically kept waiting during office visits? Are patients informed when the doctor is running more than half an hour late? How are after-hours medical needs addressed?

(If the plan sponsor can’t answer some of these questions, consider asking participating doctors directly.)

* How are the plan doctors chosen? What percentage are board-certified? Does the plan have physician profiles or biographies available so you can consider the doctors’ backgrounds and education before choosing?

* Is there a medical “gatekeeper” who determines when you can see a specialist? If so, how flexible is the gatekeeping process? Must you always see the gatekeeper first, or can you self-refer to a specialist in some circumstances? If so, what are they?

* What is the procedure in an emergency? Does it vary based on the type of emergency? For example, if your child has a bad fall and you’re worried about a concussion, can you seek out-of-system care close to home, or must you go to an in-system doctor or hospital to get reimbursed? Is the answer the same for heart ailments, strokes, premature labor, asthma attacks and broken bones? What happens if an emergency turns out to be a false alarm? Can your claim be denied after you’ve already received care?

* How are administrative problems handled? Is there an appeals process for denied claims? How does it work?

Soon--possibly within a year--many employees will receive the results of consumer satisfaction surveys with their open-enrollment materials, says Nancy Quinlan, a spokeswoman for CalPERS.

In the meantime, consumers must do their own homework.

Health Cost Work Sheet

How do you determine the most cost-effective health plan for your family? Plot your out-of-pocket costs in each plan by adding up your health-care usage in a typical year. A look at last year’s check register--or your family health insurance file--may help you complete this work sheet.