Competition, Complaints Spur Health Plans to Evolve

Students have returned to class, football season has kicked into full gear and the first round of sitcoms has premiered on television. The telltale signs of fall are here, but they wouldn’t be complete without health-insurance enrollment forms arriving in the mail and a blizzard of advertisements for medical plans.

For some, choosing a health plan is a task about as pleasant as a root canal. While many people select a plan simply on the basis of cost or whether they can see a particular doctor, the consumer-oriented products and services many plans are offering this year make it worth your while to spend more time scoping out the options.

For instance, consumers considering an HMO may be surprised to find that some programs now allow them to make appointments with a specialist without going through their primary-care physician. A few plans are adding options that allow members to get prescription drugs not on the plan’s approved list, known as a formulary. In addition, some plans are now promoting a more efficient and consumer-friendly procedure for resolving member complaints.

Consumer advocates say some of these new offerings represent the industry’s effort to address broad public anxiety about managed care. But health industry officials say they are simply responding to demands in a competitive marketplace.

Competition is heightening as many plans work harder to get or maintain accreditation by the National Committee for Quality Assurance, an independent, nonprofit organization which reports on managed-care health plans across the country. Several organizations use the NCQA accreditation as the basis for publishing “report cards” that help consumers evaluate and compare the performances of HMOs.

In answer to consumer demands and unfavorable publicity about restrictive policies, many plans have recognized access to care as a major issue and are responding accordingly. Many health plans in the state began allowing direct access to routine ob / gyn services a few years ago, although state law signed this year now mandates it.

Now access is opening up for other specialists, a benefit that usually has been reserved for enrollees in more expensive point-of-service or preferred-provider organization plans. These programs are marketed with catchy names like Access Advantage and USAccess. Names aside, not all access plans are created equal. The programs in place at PacifiCare, Cigna and Blue Cross of California allow physicians to refer patients to specialists without getting approval from a third party, but only within their own medical group. Two other HMOs, Kaiser Permanente and Lifeguard, are structured so that doctors can refer patients to any physician within their network.

Increasingly, however, plans and medical groups are permitting patients to bypass the primary care doctor and make appointments with specialists directly. In January, Health Net will roll out its Elect Open Access program. Aetna’s USAcess plan will give members the option of using a doctor outside its network, although the member will have to pay a deductible and a percentage of the doctors’ fee. It will be up to employers to decide if they offer the new programs, which could cost more than the plans’ standard HMO products.

But some providers see self-referral plans as a step back to the days of unmanaged, fee-for-service care. Such programs could potentially jack up the cost of health care, said Dr. Richard Dixon, medical director of the National Individual Practice Assns. Coalition. He also argued that it is easier to coordinate a patient’s health care by going through one doctor. “Physician organizations are expected to make sure their patients get the best effective care,” Dixon said. “It makes it more difficult if physicians have no idea what’s Warren Foon, a vice president with Los Angeles-based Maxicare, says about 40% of the plan’s medical groups now allow patients to self-refer to specialists, under certain circumstances.

Employers and members “are demanding that the managed care industry handle referrals better than we have historically,” Foon said. “I foresee that more groups are going to be developing mechanisms to allow for expedited self-referrals.”

Another new feature of some health plans is access to alternative treatment options. Lifeguard, Health Net and PacifiCare plan to offer an acupuncture benefit by January. Blue Shield of California, meanwhile, offers members a discount on such services as massage therapy and stress management.

Alternative therapies are “not as expensive as other high-ticket items,” said Michelle Simpson, director of major accounts at PacifiCare. An employer seeking to enhance health benefits, for example, will likely find it cheaper to offer an acupuncture benefit rather than an expanded prescription drug program.

Health plans also are using the Internet to appeal to consumers by allowing, for example, the option of online enrollment.

“The consumer-oriented approach is something the industry needs to look at because of the backlash we’re all experiencing in managed care,” said Alan Puzarne, senior vice president for Blue Shield. “It’s about time, frankly.”

The issue of how health plans resolve member disputes has been a sore point for the industry. Earlier this year, Health Net rolled out a new program that allows members who are dissatisfied with the plan’s handling of their complaints to have their cases heard by an independent review board. Health Net offers consumers a choice between two independent medical organizations.

While other health plans have used external review organizations for disputes involving experimental medical procedures, Health Net’s program is much broader than most.

Peter Lee, a director with the Los Angeles-based Center for Health Care Rights, a Los Angeles patient-advocacy group, applauds Health Net’s effort. “That was true leadership,” he said, though he added that truly independent review panels should not be chosen by the health plan.

Many consumer advocates see the new plans and policies as a preemptive strike against government regulation. “The plans have to show some responsiveness to take some of the wind out of the sails” of legislative proposals that would allow consumers to sue their health plans, said Betsy Imholz, senior attorney for Consumers Union in San Francisco.

Sara Singer, executive director of the Center for Health Policy at Stanford University, notes that legislation “typically happens late in the game.” By the time bills reach the floor of the legislature, lawmakers have already been deluged with calls. She said that though health plans regulate themselves to attract more customers, they may also do so to avoid new legislation.

But PacifiCare’s Simpson said many of the benefits and changes in health care began before legislation regulating health plans was introduced and that market forces provide more pressure. “I can feel Health Net and Blue Cross breathing down my neck every day, and that is more a factor than legislation,” she said.