The Power of Choice
“Power to the patients” could be the slogan for a spate of new laws and other changes that are giving California consumers more tools to grapple with the complexities of managed care.
Having a dispute with your HMO about a denial of medical services? Beginning Jan. 1, you will have the right to have your case reviewed by medical experts outside your health plan. It won’t cost you a dime, and your health plan will have to abide by the experts’ decision.
Already this year, with little publicity, California patients gained the right to get a second opinion from a medical specialist when their primary care doctor refuses to make a referral. Or the patient might have seen a specialist but isn’t satisfied with this physician’s recommendations about how to deal with an illness. Whatever the situation, there is a right under state law to get the second opinion--and have your health plan pay for it.
Another legal protection assures Californians continuity of care with the same physician. For example, a woman in the second or third trimester of pregnancy can continue to see the doctor through delivery of the baby, even if her employer changes health plans. And someone under treatment for an acute or serious chronic condition, such as cancer, can continue seeing the same specialist--and the doctor’s charges will be covered, regardless of a shift to a different health plan.
Most Californians see doctors who belong to a medical group, whether small or large. A health plan may drop various medical groups, or the groups might choose to withdraw. The new California Department of Managed Health Care has ordered health plans that are dropping medical groups to notify their enrollees of the right to stay with their doctors. All of these consumer reforms are a welcome reminder to patients of their rights as they enter “open enrollment,” the annual period during which workers must make changes in their medical insurance that they will depend on for a full year. Companies offering more than one health plan--about 18% of U.S. employers give workers a choice--use the fall period to flood workers’ desks and mailboxes with brochures, directories and often-confusing forms.
As employers and health plans come up with new combinations of benefits and restrictions, it is getting more difficult to navigate through the choices. It is well worth your time, however, to study the brochures, leaflets and Web sites, rather than relying on a co-worker for a recommendation.
“For many consumers, the time of ‘open enrollment’ doesn’t get the attention that it warrants,” said Peter V. Lee, president and chief executive of the Pacific Business Group on Health. The organization helps major employers evaluate and negotiate for the purchase of health insurance for their workers. The 45-member PBGH includes CalPers (state workers enrolled in the California Public Employees Retirement System), the University of California, Bank of America and Chevron. “The choices workers make in October may have a profound impact on the range of doctors or hospitals they can actually get to use later,” Lee said.
What Patients Don’t Know
Unfortunately, many people don’t even understand the basics of the choices they must consider. About a quarter of all people enrolled in health plans through the job don’t know whether they belong to an HMO or not, according to research by the Center for Studying Health System Change, a Washington-based research group.
Typically, an HMO requires all members to get their care from doctors and hospitals within the HMO’s network of providers. There is a co-payment for each visit to a doctor’s office. Patients must select a primary care doctor, who serves as a gatekeeper--you can’t go to a specialist without a referral from the primary care physician. In the most restrictive types of health plans, going outside the network means paying the doctor out of your own pocket.
Patients get more freedom to choose with a point-of-service, or POS, plan. This system uses an HMO network as its core of operations, but allows access to outside physicians. The plan will cover these outside visits, but only after the patient has satisfied an annual deductible. This could range from a couple of hundred dollars to a percentage of total salary, which can be quite substantial. And the co-payments will be more costly than a visit to the HMO network physician.
The fewest restrictions are found in preferred provider organizations, essentially an extensive list of physicians. The patient may visit any doctor on the PPO list and can typically seek out a specialist for treatment without needing a referral from a primary care doctor.
Once the definitions of the various health plans are clear in your mind, you should look for a plan that has a strong track record of preventive care. “The first goal is to keep ourselves and our loved ones healthy,” said Daniel Zingale, director of the California Department of Managed Health Care, which regulates health plans covering 23 million Californians. “People need to scrutinize health plans for preventive-care access,” he said.
Some worthwhile yardsticks might include a health plan’s success rates in childhood immunizations; mammograms to detect breast cancer; use of beta blockers for patients who have had heart attacks; and follow-up consultations by doctors with patients hospitalized for mental illness; eye exams and blood sugar level testing in diabetics.
“The good news is there are an increasing number of tools consumers can use to choose between health plans,” said Lee, of the Pacific Business Group on Health.
Evaluating the Health Plans
While every health plan claims to provide high-quality care to its members, yardsticks are available to corporations and their employees to make sophisticated judgments, cutting through the often exaggerated claims of the HMO television ads showing happy consumers.
Many companies rely on the National Committee for Quality Assurance, an independent organization, which has an elaborate system of audits to measure performance at health plans. More than 60 separate measures of plan performance--such as the percentage of women over 50 who have had mammograms--are compiled and reported for health plans that have agreed to participate in NCQA reviews.
The Web site, https://www.ncqa.org, gives health plans ratings on a star-system. Consumers can check to see how health plans in their own communities compare. Under broad categories such as “living with illness,” for example, the NCQA includes information derived from health plan records on how people with asthma are helped in managing their condition. Plans with 80 or more of a possible 100 points get the 4-star rating of “excellent.”
Reports are available on health plans covering 50 million people, about a third of all Americans with private health insurance. In addition to providing audited reports, NCQA also offers accreditation of health plans, in effect a seal of approval that a plan meets quality standards in a number of areas.
For corporate managers, the accredited health plans appear as a better investment of company and worker dollars to help keep employees healthy. General Motors, for example, makes a larger contribution to covering the cost of accredited plans selected by its workers. Some firms refuse to offer workers any health plan lacking accreditation.
NCQA is “truly the gold standard when it comes to accreditation,” said Lee. The PBGH, hoping to help workers in their selections, has its own version of report cards, available at https://www.healthscope.org, which looks at California HMOs. The report is an independent survey, looking at both the experiences of consumers in dealing with the HMOs, and tallying various measures of plan performance.
However, the report cards are limited in their efficacy. They measure overall health plan performance. An HMO may have hundreds of thousands of Californians enrolled, but ultimately, care is delivered at the local level by a medical group, an aggregation of doctors. And there aren’t yet good numbers on how medical groups perform. “We still don’t have enough information to make an informed choice below the level of the health plan,” said Lee.
This makes it even more vital that consumers choose carefully from among the different types of health plans. California, where managed care originated and grew into the dominant force in health care, offers “a good deal more choices and options than in the recent past,” said Walter Zelman, president of the California Assn. of Health Plans, an HMO trade group.
“There are lots of positive opportunities for consumers who put some time and effort into the selection process,” he said. “But there may be big pitfalls disappointments for those who don’t.”
