Information Drought on Health Plans Starting to Ease

It’s often said in health care circles that people spend more time choosing a car repair shop or hairstylist than they do selecting a medical plan.

That’s not surprising, given the difficulty of comparing one health plan to another. How do you know which one is right for you or your family? How can you tell which one has the best doctors and provides access to the best hospitals?

Although change is afoot, the vast majority of employers still offer little information on quality of care. Instead, they hand out thick packets with glossy health plan brochures, “provider directories” and befuddling “explanation of benefits” statements written by insurance company lawyers. It’s no wonder that many workers feel a sense of dread and confusion each year when faced with the task of making a crucial decision affecting their own and their family’s health.

“It’s surprising how little information you get from your employer,” said Jeanne Finberg, an attorney for Consumers Union who specializes in health care issues. “Until very recently, employers have focused on the bottom line, with some kind of blind faith that most plans have reasonable quality of care.”

The good news is that change is sweeping the health care industry, sparking an information revolution of sorts that is already putting more medical quality data at consumers’ fingertips. One sign of this change is the recent spate of reports in popular magazines like Newsweek, Consumer Reports and U.S. News & World Report that provided “quality ratings” of various health maintenance organizations across the country.

Recently, an organization called the National Committee for Quality Assurance, a Washington-based health care accreditation group, began making its evaluations of HMOs available to the public for the first time. Before these efforts, it was practically impossible to gather information to compare the quality of care at HMOs in California or elsewhere.

Employers are playing a lead role in spurring the efforts of the National Committee for Quality Assurance and similar groups. In California, groups such as the Pacific Business Group on Health, a consortium of major employers such as Bank of America and Pacific Telesis, have encouraged HMOs to provide data in areas such as preventive health care and member satisfaction, then made the findings available to workers. The California Public Employees Retirement System, the giant state pension fund that also purchases medical insurance for nearly 1 million people, makes medical quality “report cards” available to members.

Southern California Edison, a Rosemead-based utility company with a national reputation for innovation in health care, is an example of how companies are helping workers cope with the changes in managed care.

Last year, Edison distributed a “consumer guide” on medical care to all its employees and retirees. The guide, prepared by Health Pages, a New York-based publisher of regional guides to medicine, included comparative information on certain health plans, doctors and hospitals, along with general information on such subjects as breast cancer, diet and arthritis.

Future guides will go even further to help employees evaluate HMOs and other health plans, said Suzanne Mercure, Edison’s benefits manager. The company wants to use data on medical quality to “tell our employees how Edison values each plan,” she says. “We want to put more emphasis on quality factors because we think the plan’s cost is not enough of a differentiation. What makes a difference is the plan’s performance.”

But Mercure and others note that very few employers are taking advantage of the new data that is available on medical quality. Smaller companies may not have a benefits manager who can focus on health quality issues. And benefits departments at many larger corporations still focus primarily on one issue: price.

In the managed care era, when physician choice is limited and access to medical care is tightly governed, it is increasingly important that people be informed, assertive consumers about health care quality, said health care advocates, doctors and benefits managers.

“Managed care is negotiated care, and negotiations are becoming an important factor,” said Vincent Riccardi, a La Crescenta physician who founded American Medical Consumers, a consumer advocacy group.

Even if you work for a company that provides scant information on its medical plan offerings, Riccardi and others suggest a number of things you can do to sort out the differences among plans.

“A doctor you like and who can help you is the most important factor,” Riccardi said. “Don’t put premiums as the most important element because they become the least important factor when you are really sick.”

Consumers Union’s Finberg suggests people look closely at mental health plans, which often are administered separately from basic medical plans and have sharply different benefits. “Mental health plans often have bigger co-payments and more exclusions,” she said.

People with special health care needs--a heart condition, diabetes or a disabled child--should carefully check the health plan’s policies that may limit or exclude services for a particular medical condition. For example, many HMOs, as a cost-cutting measure, use restricted lists of prescription drugs from which physicians are strongly encouraged to prescribe for members. Contraceptive drugs are one common drug that is excluded in many health plans, Finberg said.

“You rarely get this information from the employer, and the health plan brochures usually don’t tell you about some of these exclusions,” Finberg said. People who are already taking a particular medication, she advised, should check with the HMO to find out if that drug is on the approved list.

Experts also say that many members of managed care plans don’t fully understand the consequences of their choice of a primary care physician. Primary care doctors, typically a family doctor, internist, pediatrician or obstetrician-gynecologist, are responsible for providing basic medical services and must authorize referrals to specialists.

“By picking a primary care doctor, people are also picking a medical group and often their choices are more restricted than with the HMO alone,” Finberg said. “They must be referred to specialists that that medical group contracts with.”

That means, for example, that even if the dermatologist you like is in your HMO, you may not be able to see that doctor if he or she doesn’t contract with the medical group you chose.

It may take time to evaluate the quality of care and benefits provided by the health plan you are considering, but it will be time well spent. The payoff comes when the plan you choose delivers the quality care you and your family expect.