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How to judge the quality of a health plan
Insure.com
For those with a choice of health plans, people generally make their decisions
based largely on two factors: price and whether your family's doctors are
included.
There are other ways to judge the quality of a health plan.
Accreditation groups rate the health plans
One way health plans try to prove their worth to employers, consumers, and
state regulators is by seeking accreditation.
Accreditation is earned when the health plan meets certain quality standards
set by independent organizations. Health plans also seek accreditation as
a means of self-improvement when weaknesses are spotted.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
is not only interested in evaluating health plans, but is also actively
looking for ways to reduce the number of medical errors. "Confusion
in identifying patients, miscommunication among caregivers, wrong-site surgery,
infusion pumps, medication mix-ups and clinical alarm systems will be the
focus of [our] National Patient Safety Goals for 2003," according to
Dr. Dennis O'Leary, JCAHO's president.
"The know-how to prevent these errors exists," says O'Leary. "We
now need to focus on making sure that health care organizations are actually
taking these preventive steps."
Some states require health plans to achieve accreditation. Some states require
only certain features of managed care plans to undergo accreditation.
A major challenge facing accrediting groups is determining what is meant
by "quality." When evaluating health plans, most accrediting bodies
look at the information provided to patients, the grievance and appeals
process, preventive care services, credentialing of doctors and other providers
in the network, and similar measures.
Each accrediting organization measures quality in slightly different ways.
When you're shopping for a health plan, keep in mind what features are most
important to you. Just because an accrediting agency considers something
important doesn't mean you will. For example, perhaps you have a chronic
illness and thus are more interested in programs specifically for your condition.
Perhaps you have children and are concerned about preventive care and immunizations.
Maybe you've had a bad experience and want to make sure your new health
plan has a good track record dealing with customer complaints.
The National Committee for Quality Assurance (NCQA) is the most visible
of the four organizations, because it focuses strictly on health plans.
If a health plan does poorly on NCQA accreditation, you might never know
it. Health plans can choose to keep their results private.
Updated standards
As health care changes, so are the groups rating health plans. NCQA is preparing
to add new criteria to its evaluation process. "The new measures address
many of our nation's top health care priorities," said NCQA President
Margaret O'Kane. "By focusing attention on these areas we can expect
to see improvements that will save lives, prevent suffering and help doctors
deliver the best possible care for their patients."
Another accrediting group, the Accreditation Association for Ambulatory
Health Care (AAAHC) has updated the criteria it uses to evaluate health
plans. "The standard changes in our 2003 Handbook reflect the comments
and concerns of both organizations and individuals with an expertise and
interest in ambulatory health care," according to Dr. C. William Hanke,
president of the AAAHC Board of Directors. "Such input is invaluable
as we strive to ensure AAAHC standards remain abreast of the various issues
and trends in ambulatory health care."
Financial strength ratings can show long-term potential
One area consumers often neglect to investigate when they're shopping for
a health plan is financial strength.
It's easy to assume a health plan, especially a large one, will be there
day after day. There's ample evidence this is not always the case. Even
the largest health plans, such as Harvard Pilgrim Health Care in Massachusetts
(which failed in 1999), can encounter financial trouble and fail, forcing
consumers to seek new health coverage.
Most state insurance departments require health plans to maintain a specified
amount of money in reserves - money set aside to pay patient medical claims
and other debts if the health plan gets in financial trouble.
There are several major companies that look at the financial health of insurers.
These ratings will tell you how solvent your health plan is, but they give
no indication as to customer service or satisfaction. Among them:
- A.M. Best provides ratings of an insurer's financial strength
and ability to meet ongoing obligations to policyholders. It rates insurers
of all types, including health plans.
- Fitch Ratings provides claims-paying ability and debt ratings
on life, health, property/casualty, title, bond and mortgage insurers.
- Moody's Investors Service provides credit ratings for roughly
700 insurance companies worldwide, including HMOs.
- Standard and Poor's (S&P) rates the financial strength of
more than 4,000 insurance companies worldwide in the life, health, property/casualty,
reinsurance, mortgage, and title insurance sectors.
- Weiss Ratings track the financial safety of insurance companies,
including HMOs and all Blue Cross and Blue Shield plans.
Employer groups create their own standards
Accreditation by independent organizations is not the only indicator of
quality. The Pacific Business Group on Health (PBGH), for example, is one
of many business coalitions evaluating the quality of health plans on behalf
of their member employers. PBGH's reports include such measures as customer
satisfaction, chronic care, preventive care, prescription drugs and care
for the elderly. It also offers customizable health plan quality worksheets
consumers can complete to compare health plans.
Its sister organizations include the Colorado Business Group on Health,
the Louisiana Business Group on Health, and the New York Business Group
on Health. Many of these coalitions are members of the National Business
Coalition on Health (NBCH). The NBCH and its partner, the Quality Measurement
Advisory Service, help local business coalitions and other groups that purchase
health care.
Report cards show which health plans make the grade
You'll find report cards issued by consumer groups, state insurance officials,
and independent web sites. A few states require health plans to submit data
to a state agency that issues report cards. "Report cards" grade
health plans on a variety of quality and performance issues. Of all the
ways to evaluate health plans, report cards are probably the most consumer-friendly.
Most report cards include information on things such as the ease of getting
referrals to specialists, the doctor turnover rate, and overall customer
satisfaction.
Just as with accreditation, the information you'll find most useful in a
report card is going to depend on your own health concerns. Report cards
can help you compare quality measures for different health plans.
A potential downside of report cards is they generally do not include information
on subcontracted groups. For example, many HMOs contract out the management
of their mental health or pharmaceutical services to unrelated companies
or subsidiaries.
Complaint rankings reveal customer satisfaction
Many state insurance departments track the number of customer complaints
filed against insurers, including health plans (mainly HMOs). Most states
issue these complaints as a ratio or index. The index weighs the number
of complaints against a company by its size, so larger providers are not
unfairly rated.
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