November 13, 1998
The Working Group Report, submitted to the ERISA Advisory Council on Nov. 13, 1998,
was approved by the full body and subsequently forwarded to the Secretary of Labor. The
ERISA Advisory Council was established by Section 512(a)(1) of the Employee Retirement
Income Security Act to advise the Secretary with respect to carrying out his/her functions
under ERISA.
Working Group Members
Judith F. Mazo, Chair (11/97-98)
The Segal Company, Inc.
Neil S. Grossman, Vice-Chair (11/96-99)
William M. Mercer Co. Inc.
Dr. Thomas J. Mackell, Jr., Chairman (11/96-99)
Simms Capital Management, Inc.
Marilee P. Lau, (11/95-98)
KPMG Peat Marwick, LLP
J. Kenneth Blackwell, (11/96-99)
Treasurer, State of Ohio
Kenneth S. Cohen (11/95-98)
Massachusetts Mutual Life Insurance
Barbara Ann Uberti (11/96-99)
Wilmington Trust Company
Judith Ann Calder (11/97-00)
Abacus Financial Group, Inc.
Rose Mary Abelson (11/97-00)
The Northrup-Grumman Corp.
Michael R. Fanning (11/96-99)
Central Pension Fund, International Union
of Operating Engineers and Participating Employers
Michael Gulotta (11/97-00)
Actuarial Sciences Associates
James O. Wood (11/95-98)
Louisiana State Employees Retirement System (LASERS)
Executive Summary
When the Working Group on the Disclosure of Health Care Quality (the Working Group)
began its study in May 1998, this issue already had received significant attention within and
outside Washington, D.C. For example:
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In connection with changes in the Medicare program, the 1997 Balanced Budget Act
contains a list of information disclosure requirements for plans participating in Medicare.
These include explanations of benefits, premiums, plan service areas, quality and
performance indicators, and supplemental benefits. The Health Care Financing
Administration has undertaken a massive campaign to educate Medicare beneficiaries
about their options.
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In late 1997, the Presidents Advisory Commission on Consumer Protection and
Quality in the Health Care Industry (the Commission) published its Consumer Bill of
Rights and Responsibilities.1 2 The document recommends that participants be given a
right to accurate, easily understood information about the policies,
performance, and characteristics of their health plans and the plans providers and
facilities. The President directed relevant federal agencies to conform their programs
and plans to the Bill of Rights and to consider ways its recommendations could be
implemented through agency actions, such as regulations.
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To facilitate purchasing decisions, health plans and large employers developed the
so-called HEDIS standardized measures of plan performance, which allow
for comparative analysis of managed care plans. Some employers provide this
information to their employees. In addition, many plans are accredited by private
organizations, such as the National Committee for Quality Assurance (the NCQA)
and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).
Their assessments are available to employers and the public.
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A number of patient protection bills were introduced in the 105th
Congress by members of both political parties. Disclosure of health plan information to
participants was a critical element of each of the bills, although they differed on specifics.
In general, the bills identified (i) information to be furnished to participants
automatically, ranging from basic descriptions of benefits to summaries of a plans
financial payment incentives, and (ii) information to be made available to participants on
request, including network characteristics, claims denial criteria and statistics, enrollee
satisfaction data, and providers experience and compensation arrangements.
Against this backdrop, the Working Group heard testimony from individuals associated with
business, organized labor, and private consultancies, as well as representatives of federal
regulatory agencies and the Commission. These witnesses presented diverse opinions and
perspectives. The Working Group quickly recognized that there are numerous indices of
health care quality, many constituencies for information about the quality of care, and that this
information is in various stages of development. In other words, useful information is not
always available and available information differs in its validity and reliability. No witness
disputed the basic proposition that information on health care quality (as well as the quality of
health care information) was a key to an efficient marketplace. Not surprisingly, however,
stakeholders did not always agree on the means for assuring that health plan participants make
informed choices.
A brief overview of the Working Groups recommendations follows. They are
discussed in more detail in the full report.
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The Working Group recommends that consumers be furnished certain basic information,
currently available in the marketplace, about (i) all service providers and (ii) commercial
health plans. These disclosures should be timely, accurate, and up to date. Information
about providers should include addresses, office hours, languages spoken, academic
credentials and licences, areas of specialty, and the hospitals where the doctors have
admission privileges. Information about plans should include participant costs, such as
premiums, deductibles, co- payments, and annual, lifetime, and out-of-pocket maximums,
and (to the extent not proprietary) the plans criteria for selecting network
providers and internal quality control procedures.
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Today, information on patient satisfaction is not widely available. The Working Group
believes this information is an important measure of quality, which should be developed,
accessible to consumers, and used to rate network plans and providers. Thus, the Working
Group recommends that service providers collect patient satisfaction data for each
encounter.
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The Working Group believes there is no better gauge of plans and
providers performance than the impact of care and treatment on patients
health. Common sense indicates that this information would be given significant weight
by consumers in choosing plans and providers, especially where an individual has a
known condition. However, benchmarking results against established norms is, at best, a
nascent science. Thus, the Working Group recommends increased support for
outcomes research.
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These categories of quality information are at a different stages of development. Thus, the
Working Group recommends that Congress phase in the obligation to furnish this
information to consumers requiring basic provider and plan information first,
patient satisfaction information next, and outcomes information last.
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The Working Group recommends that employers sponsoring health plans and commercial
health plans shoulder the burden of disseminating quality information.
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To realize these goals, the Working Group recommends that Congress establish an
independent federal agency (the Quality Board). The Quality Board will (i) finance
research on health quality measurement, (ii) set standards for developing uniform, valid,
and reliable patient satisfaction and outcomes information, (iii) facilitate the
communication of quality information to consumers, (iv) underwrite public education
about the quality information, and (v) help train individuals to counsel and advocate for
consumers on health care matters.
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Pending establishment of the Quality Board, the Department of Labor should launch a
public education program to promote awareness of quality issues among health care
consumers. At the same time, it should take steps to educate fiduciaries of ERISA health
plans about their responsibility to take quality into account when selecting managed care
organizations and other entities to provide services under the plans. The Department
should also consider modifying its pending proposed amendments to the Summary Plan
Description regulation, to call for disclosure of certain quality information, or to explain
its absence if it is not available.
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In our judgment, the Quality Board is necessary at this time to establish uniform quality
measures, provide impetus for further research on measures of quality and roll out an
implementation plan on a national basis. The Quality Board would build on the efforts of
commercial health plans, employer and union groups and public bodies to provide quality
information to consumers. The requirements for information to provided at the
individual provider level are, necessarily, bold and will involve a significant
implementation effort. At least initially, we do not recommend that the mandate include
penalties.
Working Group Report
Introduction and Background
1.Purpose of Study
Our charge, as we have understood it: identify and evaluate the issues regarding disclosure of
health care quality information to the ultimate consumers of health care. Our prime concern
has been to consider what an individual or family would want and need to know to make
intelligent decisions concerning their health coverage. We have generally addressed the
questions from the perspective of those who are or may be eligible for coverage by
employment-based health plans (not just those covered by ERISA), but much of our analysis
and our main recommendations relate to all end users of the health care system.
The current focus on the need for disclosure to health care consumers of a wide variety of
information concerning quality is, we believe, a logical development from this decades
national debate over managed care, managed competition and the role of the
health care industry in the United States. This Working Group agrees with the proposition that
not only would well- informed consumers be better equipped to handle their own health
care needs, but also that, through the operation of the market, more knowledgeable purchasers
would raise the health care quality bar generally. In short, as more people have usable
information about quality, health care and health coverage providers will be prompted to
compete for their business on the basis of quality.
This Report is an impressionistic response to what we have been privileged to learn over our
six months of deliberation from an exceptional array of experts who have graciously
summarized for us a broad area of study. We have, we hope, scratched the surface at some
points where deeper excavation would be most productive.
2.ERISA Context
a.Labor Department Authority
i. Summary Plan Descriptions. A major premise of ERISA is the
determination that a powerful way to protect peoples interests is
to give them the information they need to act for themselves. The
principal vehicle under ERISA for providing needed information to
benefit-plan participants is the Summary Plan Description (SPD),
supplemented during the intervals between republication by the
Summary of Material Modifications (SMM).3
In response to the Presidents directive that the Executive Branch
agencies implement the Bill of Rights to the extent feasible under
existing law, the Labor Department has proposed amendments to the
regulation prescribing the content of SPDs, to require more specificity
in the description of plan benefits, procedures for requesting benefits,
and limitations or other factors that could prevent a participant from
receiving benefits. The Department has concluded that it does not have
the authority to require plan sponsors to gather information on health
care quality and disseminate it to employees and participants through
the SPD.4
ii. Fiduciary Implications. In February, 1998 the Department issued an
Advisory Opinion stating that an ERISA fiduciary must take into
account the quality of the care provided by an insurance company or
HMO, when selecting a vendor to provide health coverage or benefits,
and should not base the decision solely on cost.5 This does not, by itself,
imply an obligation on the fiduciaries part to communicate to
the participants about the quality issues that the fiduciaries consider in
connection with choosing health coverage, or about quality issues that
the individual participants could or should take into account when
choosing among available coverage formats or among individual
providers.
On the other hand, plan sponsors are concerned that if they do give
participants qualitative information concerning health coverage options
and available individual providers, the plan sponsors will be held
accountable as fiduciaries or otherwise for the outcome
of choices that families make based on that information.
3.Disclosure to Whom?
a.Employers/Plan Sponsors. Measurable progress has already been made in
developing quality measures to be used by employee benefit plan sponsors to evaluate
competing insurance companies and HMOs. Substantial work is underway to hone
those tools, and to come up with mechanisms to set performance standards to which
commercial plans can be held accountable. These include generalized resources such
as the HEDIS data on HMOs, assembled by the National Commission on Quality
Assurance (NCQA) and proprietary measurement and evaluation services offered by
consulting firms, as well as information developed by and for certain major
employers and employer coalitions, such as the Big Three US automakers and the
UAW, the Pacific Business Group on Health and CALPERS.
This information varies in format, content and reliability. It is expensive to develop and only
appropriate for sophisticated users, who themselves typically seek expert help to interpret the
information. A major limitation is that it is only available from and with regard to
managed care institutions. An open-panel fee-for-service or Preferred Provider Organization
(PPO) coverage program by definition cannot be measured for the quality of care it produces,
because the party providing the coverage is not taking responsibility for selection or
monitoring of the performance of the providers whose services are paid for.
Plan sponsors have a crucial need for useful, understandable information that enables them
to make some judgments about the quality of the health coverage and services that they are
providing for their plan participants. Quite simply, employers do not want to spend the
large sums that it takes to provide health coverage for below-par care. In fact, this has been
one of the motivations for moving to managed care, where there is some opportunity for
quality control. The fact that, in the ERISA universe, there is a fiduciary duty to consider
quality is a secondary consideration in most cases.
Not only do benefit plan sponsors need quality information, as bulk purchasers of health
coverage and health care they are in the best position to call for its creation and to give it
meaning by using it for marketplace decisions. They are also perfectly placed to demand,
collect, repackage and disseminate relevant health care quality data to employees and their
families.
Note, all of the above is equally or even more true of the sponsors of public health benefit
plans that are not linked directly to employment, such as Medicaid and Medicare.
b.Plan Participants. There is very little information available on a systematic basis to
plan participants and their families, the end-users of the health care system, to enable
them to make judgments and choices based on quality. What is available is of unproven
reliability: mass-market magazine surveys, Web sites, anecdotal reports from friends
and co-workers, their own doctors personal view. Some unions, consumer
organizations and retiree groups prepare guidelines to help their members focus on the
relevant factors in making health plan coverage choices, but nothing that ventures much
beyond descriptive elements to focus on qualitative considerations has come to our
attention.
Some major employers and groups within organized labor are moving to fill some of the
gaps for their constituencies, as evidenced by the presentations to the Working Group
by the Employer Quality Partnership (EQP) and the Service Employees International
Union (SEIU). However, the lack of quality-measurement data at the individual
provider level limits what they can do to help people make the decisions that they tend
to consider the most important: where should I take my family for care?
c.Prospective Participants. In the ERISA community we focus on plan participants
because they are the people who are entitled to disclosure under ERISA, and the group
whose interests must be legally paramount in the course of fiduciary decision making.
Health quality information at some level is also relevant for potential plan
participants, both new employees and people evaluating potential employment
opportunities.
d.The Government. As the countrys largest purchasers of health care and
health coverage, both for their own employees and for people covered by public
programs such as Medicare and Medicaid, government agencies have a
correspondingly large need for health care quality information. By exercising their own
health care purchasing power, governmental entities can promote the development of
usable quality measures, test out formats and approaches for effective delivery of
the information at the consumer level, collect data on their own program
participants experiences and the impact on their health care choices, and make
this quality information available to private sector plan sponsors and to the public. For
example, JCAHO accreditation has been a requirement for hospitals eligibility
for Medicare and Medicaid participation, which has promoted its criteria to something
close to a general standard.
Government agencies, primarily at the state level, can also contribute in their
regulatory roles, as licensing authorities for managed care plans and health care
providers. This would include not only collecting and making appropriate use of
information concerning enforcement actions against specific players in the health care
market, but also setting standards for and policing the accuracy of what commercial
plans and providers say about themselves. If and when any of the federal
managed-care reform proposals is enacted, this last function will become a federal
government responsibility as well.
4.Quality of What?
a.Commercial Health Plans
In the area of health quality measurement and disclosure, the most progress has been
made in measuring and reporting on the quality of the health coverage programs
offered to employees and plan participants. In particular, the development of quality
measurement tools has accompanied the spread of managed care. Among other things,
this may be due to the facts that:
i. Enhanced overall quality, through the integrated management of
individuals care and an emphasis on preventive services, is a key
element of what managed care organizations offer,
ii. Employers are uncomfortable with limiting participants
choice of providers without some assurance that the limits are based on
informed, quality-based judgments made at the level of the managed
care plan,
iii. Because they are organized systems, managed care companies have
the kind of relationship with the providers, who are either employees or
contractors, which enables them to collect the information, and the
systems to assemble and process it, and
iv. In a competitive market increasingly dominated by overtly for-profit
players, measurable claims to quality can provide a sales
advantage.
Quality information about commercial health plans is evidently relevant for employers
and plan sponsors, as purchasers of health coverage programs for employees and their
families. Employees who may have a choice among commercial plans have a similar
need for usable comparative quality information. Employees have choices among plans
if their employer offers a choice, either among managed care plans or between a
managed care and a PPO or other type of plan. And many dual-career families can
choose between the plans offered by both spouses employers.
b.Providers
There is very little reliable information available to the public in general or to health
plan participants in particular concerning the relative quality of individual providers
physicians, hospitals, laboratories, etc. although this is what plan
participants need the most.
There have been isolated efforts to gather and publish specific data on health care
results, by provider. For example, Pennsylvania and New York provide comparative
information about heart-bypass surgeons online, through their web sites, and HCFA
has published data on hospitals mortality rates. However, the information often
does not reach the consumers who would most benefit from it, at the point when they
most need it.
c.Care and Treatments
What works, what doesnt? When is surgery preferable to more conservative
treatment? Are all FDA-approved cholesterol-lowering drugs functionally equivalent?
What individual sensitivities and other factors indicate that a patient would not benefit
from the standard treatment for his or her condition? What serious conditions can be
handled effectively on an outpatient basis? Is a physician always better equipped
than a nurse or nurse-practitioner to deal with individuals health problems?
What is the best way to administer chemotherapy for a specific cancer? What
questions should the doctor ask and what tests should she order in response to a
particular set of reported symptoms?
In the past people looked to and relied on their personal doctors for guidance on these
kinds of issues. With the explosion of medical knowledge and options, individuals
today have even more need of expert assistance. Yet it has become correspondingly
more difficult for primary care physicians to keep up on the literature well enough to
give sophisticated advice in more than a few areas.
A great deal of information on these matters is available to the public, through health
newsletters, Internet websites, the popular press and wellness and health-education
programs from some employers and plan sponsors. The challenge is to wade through
all of it, to find the segments that are reliable, relevant and comprehensible.
5.What Is Quality In Health Care and Coverage?
a.Clinical Quality
i. Outcomes. The ideal would be to find and measure out what people,
treatments and institutions consistently produce better outcomes for
their patients: less illness, more and quicker cures, healthier
populations. Right now we either do not know what that would be or we
cannot measure it accurately, in part because of limits to our science and
in part because of the huge variety of circumstances in which the
medical arts need to be applied.
Efforts have been made to track and compare certain institutional
outcomes, for instance, by measuring mortality rates at different
hospitals for patients with an identified category of illness. However,
these statistics can mask a multitude of causes, such as the severity of
the patients illnesses, their general state of health otherwise, etc.,
which can account for the differences among institutions without regard
to the excellence of the professional services provided. Analyzing
caseloads to correct for those elements is, at present, too expensive to
implement broadly enough to make the information useful and available
to the population at large. Without that type of correction and
reinterpretation, however, resistance from within the provider
community is likely to breed enough skepticism about those reports to
inhibit their general use as common consumer tools.
On the other hand, some factors, such as the frequency with which
specific procedures are performed, have been identified as likely
predictors of successful outcomes. This has led to the Centers of
Excellence concept, which, despite some backlash, appears to offer a
promising precedent for the markets use of information about
quality results to produce purchasing and delivery mechanisms designed
to capitalize on it.
ii. Inputs. More readily measurable is the extent to which a health plan
or a provider takes the effort to assure that patients receive the screening
and care that they need. Current standards for evaluating managed care
organizations, for example, look at such items as the percentage of
age-eligible women receiving mammograms, blood pressure testing,
etc. These could be adapted for application to institutional and
individual providers as well. The results, though, provide only indirect
information about the quality of the organizations or
individuals performance as a care giver, and therefore
translating them into data usable at the individual consumer level is a
delicate challenge.
b.Service
i. Objective Standards. Another dimension to quality in
health care and coverage is the level of service customers receive from a
plan or provider. A trusting, respectful relationship between the
individual and the provider/organization can contribute in a major way
to the effectiveness of the care that is provided, just as the absence of
trust on the patients part can undermine even the best science.
Factors like waiting time to make appointments, promptness in keeping
appointments, convenience of facilities and office hours, responsiveness
to questions, ethnic sensitivity, etc. are vital to establishing that trust. To
some extent they are part of the current standard evaluations of
managed care organizations but, again, have not penetrated much below
that level (just as quality evaluations in general have not penetrated
much below the plan level).
ii. Customer Satisfaction Surveys. The best way to find out how well
an organization or institution is getting through to its customers is to ask
those customers. A number of large employee benefit plans, including
the behemoth Federal Employees Health Benefit Plan, as well as
commercial health plans, do survey their memberships. With the spread
of Total Quality Management (TQM) concepts, some hospitals probably
do so as well. Whether these surveys get to the level of detail about
individual providers that could produce useful guidance for plan
participants is a question.
The survey results are used by the employee benefit plans and the health
plan organizations to fine-tune performance, identify areas of weakness
and address substandard performers. The FEHBP discloses the survey
data to participants and, through its Web site, to the public, and other
plans sponsors probably do so also. The managed care organizations
only disclose that type of information selectively, to support their
marketing campaigns. Indeed, their agreements with individual
providers may preclude their disclosing evaluative information about
those providers.
6.Why Disclose?
a.Informed Choices by Individuals
This seems self-evident: individuals should know something about the quality of care
they are likely to receive from the institutions and professionals to whom they turn.
This is not a new need, but it is a newly urgent one.
i. For one thing, managed care combines health coverage with the
provision of care in new ways, even when the program is loosely
managed, as in a PPO. In making decisions about health coverage,
individuals are also deciding where and from whom they will receive
care, as the coverage decision will narrow the field of available
providers. The quality of the providers that are in a coverage
programs network, then, becomes key information in deciding
on the coverage program.
ii. Once enrolled in a managed-care plan, many individuals have to
choose a Primary Care Physician (PCP).6 This could be the most
important decision they will make, as the PCP controls access to all
other aspects of the health care system. Whether participants or plan
sponsors appreciate it or not, individuals need all of the information
they can get when choosing and dealing with a PCP. Information on the
quality of the physicians available as PCPs should help inform that
choice, and information on the quality of the groups other
providers should enable them to hold their PCP accountable for the
quality of the referrals made on their behalf.
iii. The coupling of coverage and care through a managed care
organization means that when the employer changes carriers at least
some people will need to change physicians. And, since relationships
between managed care organizations and the providers whose services
they cover are also fluid, a family may need to choose a new PCP even
if its health coverage does not change. In sum, managed care is likely to
present people with more occasions on which they must select doctors
than has been customary in the past, and thus a greater need for
relevant, reliable and accessible information on which to base those
selections.
iv. Although issues of quality are typically raised in the context of
managed care, by definition indemnity-type plans give participants
virtually unfettered choice among providers, restricted only by the
providers availability and the patients ability to pay
whatever the provider may seek above the plans allowable
charges. This is true for the indemnity branch of a Point of Service
(POS) plan, as well as for the increasingly rare full-indemnity coverage.
The need for organized, reliable information about the quality of
competing vendors services is even greater when the choice is
among so many competitors. But this type of information has not been
forthcoming in the past, and experience suggests that individuals acting
on their own, without the organization and support of an employee
benefit plan, are not likely to be much more successful in obtaining it
now.
b.Informed Choices by Group Purchasers
i. As noted above, ERISA plan fiduciaries generally have a legal duty to
take quality into account when choosing organizations to help run their
health benefit plans, including administrators, insurance companies,
managed care organizations, utilization review services, etc. This
includes not only the quality of their direct service to the plan sponsor
and participants (prompt and accurate claims processing, helpful and
polite responses to inquiries, etc.) but also the quality of their judgments
about care and the provider networks they assemble to provide it.
ii. Apart from any question of legal responsibility, employers and other
plan sponsors provide health coverage for a myriad of business reasons,
all of which relate one way or another to pleasing the employees and
having confidence that they and their families are being well taken care
of. From a business point of view, quality and employee satisfaction
should be at least as important a consideration in choosing a health plan
service provider as cost. And, since the people making the decisions on
behalf of the plan sponsor are typically covered by the same program
themselves, they have a direct personal interest in making sure the
coverage works well.
c.Public Benefit
i. Sentinel effect. Disclosure is a consistent theme of business
regulation in the United States, spurred by the hope that most affected
entities will prefer to correct problems rather than publicize them. To
the extent this judgment is accurate for the health care industry, our
society should benefit generally from increased disclosure on quality, to
the individuals and families who use health services as well as to the
group purchasers who can exercise their economic muscle in response
to the information.
ii. Market invigoration. Few would deny that the resounding defeat of
the Clinton Administrations 1993-94 health care proposals,
followed by electing of a Republican Congressional majority, was a
strong political endorsement of a market-based approach to health
coverage, rather than a universal mandate or government-provided
coverage (single payer). For the market for health care to work
effectively, purchasers must be adequately informed. This means they
must understand and be prepared to take into account quality issues,
along with or even above price. A health care market defined by price
competition alone would be a national disaster.
iii. Self reliance. Health care decision-making has become too
sophisticated to leave to the experts. With limitations on the time that
physicians can spend with patients and cost-driven pressures on
provider institutions to strip staff down to the lowest supportable level,
individuals and families must be equipped to inform and make
decisions for themselves. To consult effectively with professionals, they
need to know what to ask, where to focus and how to evaluate the
answers they receive. Usable quality information that is readily
available to people who are getting or considering getting care has
become an essential component of the health care delivery system in the
United States.
7.Costs of Disclosure
a.Identifying quality factors and measurements. Determining what
quality is, in health care, and settling on effective ways to measure it
are not simple challenges. On the clinical side, certainly, we will only reach final
answers when we are satisfied that medical science has resolved all of the mysteries
that human and electronic brains can handle. Given the value assigned to medical
research in our society, it is fair to assume that its pace will continue or accelerate, so
that our notions of quality health care will be under constant revision.
Given the immensity of our likely investment in medical research, the incremental cost
of identifying useful ways to measure what we consider to be quality,
while substantial, is likely to be a very small percentage of the total.
b.Collecting and analyzing the data. Under current conditions this might be the most
expensive aspect of a universal quality-measurement campaign. Providers are widely
dispersed, with the majority still functioning as small businesses; the issues that need
exploring are vaguely defined; health care information systems are still in a relatively
rudimentary state; and, outside of certain major health plans and the federal Medicare
and Medicaid programs, there is little focused public pressure for more and better
information. In the face these and other cost-generating factors, such as the need to
work with experts to interpret the information that is available, it is no wonder that
so far the impetus to measure and report on quality has not spread much past the level
of hospitals and commercial health plans.
c.Making quality information available to consumers. The cost of disseminating
benefit-related information to employees and their families is dropping, as more and
more of it is handled electronically. For example, it is much less expensive to post data
on a companys or health plans website than to print and mail booklets
to all who would want to see it7. However, the ability to publish and to receive
information electronically is still far from universal, and the cost of acquiring those
capabilities is still substantial.
Another expense associated with informing people about health care quality is the need
to tailor the presentation to the needs, interests and context of each target audience.
This starts with but goes far beyond making the information available in languages
other than English. To make sure the information is usable, it must be prepared with
awareness of such considerations as communicating in ways that are compatible with
the groups cultural norms, using media that the target group is likely to consult
and trust, recognizing and accommodating literacy limitations, etc. For example, in
some communities the local church might offer the most constructive means of
getting out the message. Or it may be more effective to get the information to those to
whom the target audience is likely to look for advice, such as the adult children of
Medicare beneficiaries, than directly to the group itself. This is a challenge common to
all employee communications efforts, made more daunting by the complexity and
sensitivity of the subject matter.
II. Recommendations
The Working Group on Health Care Quality Disclosure unanimously recommends the
following:
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Quality information on providers. Employees and their families start their quest for
health care with one question: ?What doctor should I go to?8 This question becomes
especially urgent when the individual is faced with a serious health problem.
Specialist choices in a managed care plan may be limited and an employee needs
assurance that he or she is going to receive experienced, competent, compassionate care.
Coming up with effective ways for them to get the information they need to answer these
questions intelligently should be a top national priority. The witnesses and the
Working Group members kept returning to the Consumer Reports analogy: we have access to
substantial, reliable information, arrayed in easily usable formats, to help us buy a car or a
refrigerator. Yet most of us get virtually no serious guidance on choosing the people and
institutions to which we entrust our familys health. That gap needs to be filled.
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Quality information on all providers. Appropriate quality information should be
elicited, and made available to the public, on all providers, not just those associated with
managed care organizations or institutions. This includes individual practitioners
(including licensed health professionals other than physicians), group practices, clinics,
hospitals, urgent care centers, laboratories, etc.
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Quality information on commercial health plans. Without endorsing any particular
legislative proposal, we support expanded quality measurement and reporting with respect
to commercial health coverage programs and plans. Since, as indicated above, significant
progress has already been made in this area and substantial further efforts are under
way, these recommendations are addressed primarily to the area of greater need, which is
quality information about providers. Without addressing it much further in this Report,
we nevertheless believe that a public campaign similar to what we are suggesting with
regard to providers should be launched to assure that adequate, reliable and usable
information concerning commercial health plans is made available to employees,
benefit-plan participants and other consumers.
Among other things, this would include quality information on network providers,
including an explanation of the health plans selection and de-selection criteria, and
the plans internal quality control mechanisms. The extent of the health plans
obligation would, of course, vary based on the nature of the plans relationship
with the providers and its reasonable access to information about them. In calling for
disclosure of network eligibility criteria, the Working Group wants to make clear that no
company should be compelled to disclose proprietary information about its internal
business operations. However, the hope is that the market will reward more complete
disclosure.
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Phase-in to full measurement and disclosure. The universal quality measurement and
disclosure effort should proceed in steps along a legislated time line. The time line should
include explicit deadlines, with a mechanism for periodic Congressional review if a
deadline turns out to be impractical or unrealistic. The stages should include:
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Phase 1: Disclosure and dissemination of relevant information that is readily
available to the provider, such as (in the case of physicians, e.g.): board
certification, AMAP certification, 9 languages other than English, educational and
training credentials, year of admission to practice, office hours and any formal
discipline approved against the provider by licensing authorities in any State.
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Phase 2: Collection, disclosure and dissemination of consumer satisfaction
data, including the consumer satisfaction survey results. We recommend that
every patient should be given a basic consumer satisfaction survey form to
complete in connection with every provider visit, with more in-depth surveys
and other consumer testing administered selectively. Electronic completion and
submission of the surveys should be encouraged.
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Phase 3: Collection, disclosure and dissemination of clinical quality data,
based on evolving standards as indicated by medical research. This would
include confirmation and measurement of level of performance of recommended
procedures and, where possible, outcomes measures.
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Federal agency leadership. A new federal entity should be created to spearhead and
help finance the development of health quality measures, communications vehicles,
formats, etc. As this must bring together expertise in the medical area and in public
and employee communications with an understanding of the operations, dynamics and
economics of employee benefit plans and of the health care industry, it might be a joint
effort of the Departments of Labor and HHS, like the Commission, with appropriately
representative private-sector participation on its board. (For ease of reference, this
agency is called the Quality Board in this paper.)
A principal purpose for making this a federal government activity is to socialize the
development costs described in item 7, above, including the development of efficient
means of collecting, analyzing and disseminating the needed information. The Quality
Board should operate both through its own experts original research and by
funding and evaluating research and development efforts of private sector organizations. It
should be required to coordinate its agenda and priorities, to the extent reasonably possible,
with those of private sector foundations that are active in this field in order to
leverage the available resources to the best advantage.
The Quality Board that we are recommending is similar to the Advisory Council on Health
Care Quality called for by the Commission, although the Quality Board would have a more
substantive standard-setting role. The Labor Department should work with the private
sector Forum for Health Care Quality Measurement and Reporting, another Commission
recommendation that is in the organizational stages, to develop the concept of the Quality
Board more fully and to propose legislation to create it.
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Uniform standards and data collection formats. One assignment for the Quality
Board will be to develop uniform quality measurement and reporting criteria. First and
foremost, this would make it possible to comparison-shop. But having uniform
measurement standards should yield significant other benefits:
a.The cost of compliance for providers could be dramatically reduced if a single,
streamlined format were used, and it would be easier to make specific allowances for the
incremental costs in reimbursement formulas.
b.It would be much easier to promote public education on understanding and using
the
information.
c.The validity of the information could be readily confirmed, perhaps through periodic
Quality Board audits.
d.Upgrades, based on research and experience, would be easier to design and install if
everyone were working from a common base.10
The Quality Board would work with HCFA to integrate its data collection requirements
into the new uniform electronic data interchange (EDI) standards that HCFA is developing
for health plan transactions, as mandated by the Administrative Simplification
provisions of the 1996 Health Insurance Portability and Accountability Act
(HIPAA). Once
all providers, health plan sponsors, insurance companies, managed care organizations and
other third-party administrators are communicating through common electronic formats as
HIPAA requires which means once all of them have purchased and installed
the means for that kind of electronic communication adding the data elements
needed for quality measurement should be a much simpler task.
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Mandate universal quality measurement and reporting requirements.
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Federal minimum standards. With uniform sets of standards, developed by a
disinterested public body with substantial private sector input (and based, in all
likelihood, on insights and experience gleaned from private sector initiatives), it
would be feasible to require all providers to comply.11These mandatory
quality measurements would set the floor. Ideally, groups in the private sector
would design additional measures or approaches, either for competitive purposes
or in collaboration with one another or in response to particular group
purchasers. This type of private sector experimentation and innovation might be
encouraged and supported by grants from the Quality Board. The Quality Board
would also be authorized to review and comment on the methodology of,
and conclusions drawn by, quality measurement and reporting tools used by
private sector groups, at the request of consumers, benefit plan sponsors, or state
or federal agencies.
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Enforcement. We are not prepared to recommend the imposition of fines or
other penalties for failure to comply with the quality reporting standards, at the
outset. Rather, we hope compliance would be spurred by market considerations:
if most providers have quality ratings, consumers should be wary of those
who do not. Compliance, along with high scores, could be honored publicly, and
the Quality Board could attempt to stimulate press coverage of high and low
performers, or non-performers. However, once the minimum disclosure
standards have been established and following a suitable transition period that
gives all parties a reasonable opportunity to comply, we believe that failure to
respond to a consumers specific requests for required quality
information should be subject to the same type of moderate civil penalties that
reinforce ERISAs participant- disclosure rules, see ERISA section
502(c)(1)(B).
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Managed care organizations might set a minimum quality rating as a criterion
for participation in their networks and, ultimately, a providers or a health
care organizations participation in public programs might be contingent
both on compliance and on scoring at or above a set level.12 States might decide
to include compliance with the quality standards at a minimum level in
their professional licensing requirements, but that would not be part of the
federal mandate.
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Support for consumer satisfaction surveys. The Quality Board should work with
specialists in the measurement of consumer satisfaction to design survey forms that are
appropriate for different types of providers and, if possible without sacrificing
consistency, for different target populations. These would be established as the baseline
measuring tools. The Quality Board should also design and install efficient, economical
means of collating and analyzing the data, perhaps by contracting with private firms to
perform that function for all providers in a region, or all providers of a given type, etc.13
Individual providers should not be compelled to undertake that part of the task, and
centralized processing could serve as a quality-control check on the consumer satisfaction
measurement procedure.
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Guidance and support on communicating quality information.
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Communications help and encouragement. The Quality Boards
mission would also include funding research into effective ways of
communicating quality information to employees, their families and the public.
Those insights would then be promoted heavily to employers and other
benefit-plan sponsors, as well as insurance companies and managed care
organizations. In addition, the Board would develop models, templates and
standardized publications in a range of languages, which plan sponsors and
commercial health plans could adapt and distribute, both to explain the process
and to communicate results.
-
Creating communications media. The Quality Board would also install
and/or help finance the installation and maintenance of websites, dedicated
computer kiosks in libraries, post offices and other public buildings, and
generally promote the development of electronic channels through which the
quality information can be made widely available. It could also create and
distribute quality-communication software. These same efforts could also make
electronic submission of consumer satisfaction surveys easier, and therefore
more likely.
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Assistance rather than mandate. On the information-dissemination side, the
role of the Quality Board would be to help and encourage, as well as to finance
the developmental work. Although plan sponsors and commercial health plans
would be required to provide the basic quality information to employees,
their families and the public, the Quality Board would not prescribe uniform
formats and media for doing so.
-
Health plan and employer disclosure obligation. The quality information extracted
from providers must be conveyed to the ultimate consumers of health care services
efficiently and in ways that make it most likely to receive appropriate attention. We
recommend that benefit-plan sponsors and commercial health plans be required to report
basic health quality information as identified by the Quality Board to employees, plan
participants and their families and to the public. It is important that, within reasonable
limits (e.g., mailing to the employees address), plan sponsors take the effort to
bring information about health coverage and benefits to the attention of employees
families, as spouses or other family members are often the ones who make the actual
decisions.
As all employees with employment-based health coverage, and their families, should
receive this information, the obligation should not be limited to any given class of
employer. Following the design of HIPAA, this might be achieved through the adoption of
parallel amendments to ERISA, the Public Health Service Act (administered by HHS)
and the Internal Revenue Code, with due provision made for State-level jurisdiction over
and regulation of commercial health programs.14
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Public education. The Quality Board, working with the Labor Department and other
agencies with relevant expertise or constituencies as well as interested private sector
groups, should underwrite an ongoing campaign to educate the public about the quality
information that they will be receiving. This would cover the role of quality
considerations in selecting health plans and health care providers, the need for
individuals to take responsibility for safeguarding their health and obtaining care when
needed, the value and limits of the quality indicators available. It might also create
and distribute guides for choosing plans and providers, which would give illustrations
for people in differing circumstances (e.g., two- earner couple with young children,
empty-nesters nearing retirement, single person with a health problem, etc.).
-
The Labor Department need not await the creation of the Quality Board or other
enabling legislation before launching this public education campaign.
-
The public will also need an explanation of the consumer satisfaction survey
process in which they will be asked to participate. The Quality Board should
publicize the fact of the customer-satisfaction information gathering campaign
and explain how to fill out the survey forms, where the data will go and how it
will be used. This might be accompanied by some health-education basics
to remind people doctors may deliver high-quality health care without
necessarily ordering a lot of tests or prescribing medication, and directing them
to other resources (e.g., reliable Internet sites) that will help them judge whether
their treatment was appropriate.
-
A separate public education program, for employers and benefit-plan sponsors,
should also be promoted by the Quality Board. This would include advice to
make it easier for them to meet their quality-reporting obligations, dealing with
such items as how to deal with employees questions, customizing the
quality material for specific groups, etc. It should also market the process
to employers, by underscoring the value to them of having quality as part of the
health care purchasing equation and of making sure their employees in fact
appreciate the coverage they are providing. Coming from the other direction, the
Labor Department should provide more concrete guidance, perhaps in the form
of an Interpretive Bulletin, on the obligations of ERISA health plan fiduciaries
with respect to quality considerations.
-
Health care guides. Written information will only go so far, in bringing the
publics knowledge concerning these matters to a comfortable level. Most of us
will also have questions we want to address with people who know more about it. We
suggest that people interested in becoming skilled at providing this kind of assistance
should be recognized as health care guides. The Quality Board should develop training
materials and templates to help people gain this expertise. The kinds of people who might
become health care guides would include volunteers in community centers and service
organizations, hospital employees assisting patients and their families with health
care planning, someone on an employers benefits staff or anyone who is likely to
be in a position of advising others about making their health care and health coverage
choices.
Ideally, consulting, administrative-services and other private might market these services to
benefit-plan sponsors and others, having given their staff more intensive training to deepen
both their analytical and communications skills. In addition, the Quality Board should
make grants to community organizations and others working with low-income and other
special-needs populations, to support the engagement of health care guides, who might also
serve as advocates for their constituencies within the health care system.
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Protection for giving information in good faith. Employers, plan fiduciaries and
commercial health plans acting in good faith should not be exposed to liability for
compliance with these new disclosure requirements. The statutory amendments creating
the duty should also include a privilege for those providing the quality information, which
would protect them from liability for the consequences of the actions that people take
in reliance on that information.
This would provide protection from any vicarious malpractice liability to someone claiming
to have been injured because the provider did not live up to its quality score and from
defamation liability to a provider who received a low quality rating. They would also
have ERISA fiduciary protection, comparable to that provided under ERISA section 404(c)
to plan sponsors and fiduciaries that offer participants a choice among investments for their
defined contribution plan accounts, if they act prudently and in the participants
best interest in developing and distributing the information or in engaging others to do so.
The Quality Board and the Department of Labor would issue binding guidance explaining
the extent to which these protections apply not only for information given to satisfy the
minimum legal requirements, but also for the additional educational and informational
efforts that the Board would be trying to stimulate plan sponsors to undertake.
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Interim Steps
The Working Group believes that action on quality-disclosure should not be put on hold
waiting for the passage of legislation establishing the Quality Board. We believe the Labor
Department could and should take the initiative under ERISA to encourage
employers and employees understanding of health care quality indicators,
and to demand information from providers. Since ERISA focuses on the management
of employee benefit plans and they deal with managed care plans, utilization review
agencies and other vendors, at this stage it is probably necessary to address quality at the
commercial plan level rather than directly with individual providers. However, a
government-prompted interest in quality on the part of group purchasers could have value,
if it stimulates further efforts by the commercial plans to explain and capitalize on their
quality assurance standards.
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The Labor Department should undertake a promotional campaign, based on the
theme set out in the SEIU letter, emphasizing fiduciaries duty to take
quality into account when selecting health plan vendors. This would include
identifying the primary factors that they should consider, and explaining the
existing quality measures. It would also identify the information and
materials related to the decision-making that, in the Departments
judgment, would have to be disclosed to plan participants upon request. This
might take the form of an Interpretive Bulletin, comparable to the guidance
issued on the selection of annuities that established the safest
available standard.15
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As part of this plan sponsor educational effort and the consumer education
campaign recommended above, the Department should encourage plan
participants to request quality information from their employers and to urge their
employers to press the commercial plans for information about individual
providers. Although it would be attenuated, this pressure from the ultimate
consumers could have some market impact.
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We recommend that the Department reconsider its apparent conclusion that it
cannot require the inclusion in the SPD of whatever quality information is
available to the plan sponsor. We believe plan sponsors should be called upon,
for example, to include in the SPD an explanation of how any managed care
plans used by the ERISA plan select the providers offered through their
networks. If the vendors will not give that information to the ERISA plan
sponsors, that lack of quality data should be disclosed in the SPD. For
commercial plans that do not have limited provider networks, the SPD should
note the fact that any screening of providers for quality is the sole responsibility
of the participant.
Witness Summaries
May 4, 1998
Janet Corrigan, Executive Director of the Presidents Advisory Commission on
Quality and Consumer Protection in the Health Care Industry. She led the Commission as it
developed, by consensus, the Consumer Bill of Rights and Responsibilities and the Final
Report, published in 1998.
Corrigan revealed the Commissions opinions behind parts of the Consumer Bill of
Rights and Responsibilities and the Final Report.
Corrigan began by discussing the right to information (1) as a consumer protection issue and
(2) as a critical quality of care issue. She noted that quality of care is very uneven so
information and comparative information on quality of care is viewed as essential for
consumer protection and also for the industry to understand its current state of quality and
whether it is improving over time. Yet, there is little evidence of comparative data being
available to individual consumers at the marketplace level with regard to the plan.
Corrigan explained that we are beginning to see some data coming from consumers with
regard to comparative quality and comparative satisfaction at the health plan level. Some
information is also being compiled through the work of NCQA and HEDIS, but this is limited
to technical quality measures. (Ex.: PAP smear rates, mammography rates) This information
is not sufficient to aid the consumer in his or her decision. Furthermore, there is no type of
comparative information on quality or satisfaction levels that applies to physicians or
hospitals or nursing homes or home health agencies, yet that is the area where consumers have
most of their choices. Corrigan said the Joint Commission on Accreditation of Health Care
Organizations and AMAP are trying to define some quality measures and encourage providers
to produce this type of data.
Despite these efforts, Corrigan stated we need more standardized descriptive information on
health insurance plans and how they operate and the network of providers available to
consumers in the public domain. She does not believe that consumers, if put together, or
workers are somehow going to come up with the magic list of things they want to know.
Although, in many cases, Corrigan believes the information you want to provide to a
purchaser is very similar to the information a consumer would be interested in. Ultimately,
Corrigan concluded that the first step is to reach agreement on the set of measures that you are
going to use and then the health plans and the providers and the institutions have to use those
measurements to produce the data. The data then needs to go into a central data base.
She testified that the private sector will not be able to grow into providing standardized
information without some regulatory intervention because (1) the purchaser organizations lack
purchasing power to encourage the industry to make the kind of investments in clinical
information systems that are needed and (2) the measurement organizations are competing
with each other instead of coordinating and complementing each other.
To meet this goal, Corrigan suggested that we need to be explicit about recognizing the value
that we get from health care quality data so that there is a willingness for health plans,
provider groups, group purchasers, public and private foundations, and others to make the
investment in the underlying automated data systems, share the costs, demand these types of
data, and take initiative to evaluate them and make the results available on the community
level. She concluded that public policy is guiding the industry into a leap from the purchaser
level to the individual consumer level and we are struggling with how to move from health
plan data down to individual provider and provider group data, which is the important data
because that is where we see differences in quality. To succeed, Corrigan advocated biting the
bullet and making the jump to collecting other types of data. She noted that the jump will
have to be achieved incrementally because of the cost.
Accordingly, she recommended front-end loading the system so health care providers,
hospitals, and plans pay a fee to put their data into a central data base whether it is in a private
accrediting entity or in a public organization. Alternatively, the industry could create a
coalition of group purchasers, public and private, that put up the money to support the
process and then put it in the public domain.
Even if comparative data becomes available to the consumer at the plan level, Corrigan listed
the next step as making the data available to the consumer in a meaningful way. She noted
that the complexity of health care data makes measuring quality complex. So, it is hard to get
the desired data. Choosing the proper format to provide the information to the consumer in
a manner in which they have the proper support and access to interpret and use it thereby
presents another hurdle.
Ultimately, Corrigan described a more organized coordinated approach to information
gathering and dissemination. This would include a form of quality measurement which would
be a coordinating entity in the private sector (the forum for quality management) that attempts
to get these groups to work together under the guidance of a comprehensive framework
(which it would design).
Meredith Miller, Deputy Assistant Secretary for Policy, Pension and Welfare Benefits
Administration, Department of Labor:
Miller discussed the Departments expectations and concerns in response to the
Advisory Commissions recommendations.
Miller reported that only 19% of private establishments offering health insurance offer two or
more plans, with the choices being greater among larger employers.
She noted that both the number of plan choices offered to an employee and the size of the
employer affect the determination of what information is relevant for distribution and
gathered for distribution. For example, there is a question as to what data workers need who
have a choice of one plan and how they navigate and understand their own plan versus the
comparative data necessary for workers who have more than one choice. She also expressed
the opinion that a major challenge to collecting and distributing information will be the cost,
because it creates different capabilities and the need for different strategies with small versus
large employers.
Miller queried as to what information employers should get from institutions and also, what
information employers should report to plan participants. She asked whether the provided
information would be the same when the consumer is in a self-insured plan, an HMO, or a
PPO.
Miller described how many data experts are looking to experts from the plan sponsor
community to provide input on the data question.
Robert Doyle, Director of the Office of Regulatory Interpretation, Office for Pension and
Welfare Benefits, Department of Labor:
Doyle discussed some of the Departments concerns in response to the Advisory
Commissions recommendations.
Doyle began by listing items a fiduciary might consider when looking at quality: the scope of
choices and qualifications of medical providers and specialists available to participants, the
ease of access to providers, the ease of access to information concerning the operations of the
health care providers, the extent to which internal procedures provide for timely
consideration and resolution to patient questions and compliance, the extent to which internal
procedures provide for confidentiality of patient information, and the satisfaction statistics.
However, Doyle noted that, where a participant has the opportunity to choose between health
care providers, there is no affirmative obligation on the part of the sponsor to pass through
quality information. There is nothing precluding a plan sponsor from providing information
they may have taken into consideration in making their selection of a provider, but there is
no obligation to share that information either.
Doyle suggested an employer may hesitate to make certain disclosures, particularly when such
disclosures reveal the process behind the exercise of their fiduciary responsibility in selecting
health care providers. He suggested sponsors may be reluctant to share information depending
on the source on which they relied.
Doyle expressed his opinion that the summary plan descriptions currently contain much of the
information on benefits and coverage limits for the individual plans.
June 8, 1998
Deborah Gage, President and Chief Executive Officer, Solution Point, Inc.:
Gage described how her company, Solution Point, solely focuses on measuring and providing
information systems to health care organizations, providers, managed care plans, and others to
help them measure and predict consumer demand behavior and satisfaction for improving the
process and outcomes of care.
Gage testified that we are where we are today in the health field because: (1) a historical lack
of competition and a very diverse risk and economic structure in health care has resulted in
health care essentially not being managed or treated as a business either by consumers or
those who offer health care services; (2) health care is highly under-managed; (3) our
culture and attitude toward medicine; and (4) a lack of consumerism in that we dont
expect the same level of information, service, and quality that we expect from far less
important decisions that we makesuch as buying products for our home.)
She noted that most information gathering has been looking at the quality of health care from
a clinical process perspective and clinical outcome perspective, including most of the federal
dollars and industry money which are focused on highly technical clinical process. Little has
been done to measure the health care system from the viewpoint of the consumer. Gage
reported that this trend must change because health care is now a substantial portion of the
GNP, a huge portion of corporate profits. Corporate America is now looking at the purchase
of health care as an investment in their human capital. Accordingly, health care is a consumer
business in the midst of changing to become more responsive to the consumers
needs. So the focus for information gathering must shift to human capital asset
managementi.e. consumer concerns.
Gage testified that consumer needs begin with the need for basic, easily accessible
information addressing: what is available, how do I access it, what is the coverage, what will
be my experience with this product or service, price information, performance information,
risks, successes, understanding outcomes, comparative reports from other consumers, benefit
levels, and features of the network such as spent waiting for treatment. She remarked that
most of the time consumers purchase these products blind.
Gage stated that the increasing number of report cards of consumer comparisons are very
rudimentary measuring at a very basic level, and not very accessible to consumers. There is
virtually no pricing information and very limited information about the features and functions
of the plan. The available information does not include any monitoring of participating
physicians. (Gage noted that the AMAP is taking steps toward that end and she knows of a
company in DC that is gathering information through an annual, self-reported audit regarding
legal malpractice and other physician-related issues.)
Gage explained that employers ought to be providing (or asking their suppliers to provide as a
service) to their own employees performance reports on how they are doing, and ask their
employees if they are satisfied with the benefits they are receiving. They need to develop,
measure, and continue to report on the quality matrix that they can produce from the
consumers perspectives. They should have supplier quality assurance programs using
standardized, continuous quality improvement initiatives. Managed care companies, like
providers, should also have a role in ensuring that their suppliers report their performance
to consumers, using standardized, continuous, quality-improvement initiatives.
Gage reported that there is no current standardized consumer-based measure of quality, but
she recommended that the measurement should be made at a product level. Measurements
should be those important to consumers such as baseline consumer satisfaction with the
outcome and processes of health care. Gage predicted that those who score below the mean
will object and then go improve their systems and processes.
Gage explained that there is a lot of geographic diversity, which makes it difficult to measure
quality across volume and diversity of products and services. Lack of product and consumer
segmentation and public policy issues around quality and access also inhibit the information-
gathering process. She noted that segmentation is very important so the consumer can
really understand what is driving these differences by product, employer and plan. Thus, the
more specific the question, the better the answer. With a general question you are going to get
a lot of variation with the answer but over large populations it becomes useful to have that
information.
Gage recognized that the issue is what level of information should be publicly available and
who should provide it. To have the greatest credibility, Gage thinks the initiative must come
from the Joint Commission, NCQA and AMAP because those are the doctors, hospitals, and
managed care plans. Yet, she believes they will only put a spotlight on the problem, this is an
issue the industry must address. She further believes the research should be conducted by a
part of Government that has more expertise with consumer reporting.
Gage suggested that employers could play a large role in facilitating the availability of the
information because of their purchasing power. Gage recommended the employers publish
consumer information in the same way that other public industries provide information for
those who want to consume these services. She noted that small employers have no leverage
whatsoever to make any decision other than price, which is presented to them by some
broker.
Gage concluded that these new human capital measures are the outcomes that employers are
seeking, and to the extent that employers will aggressively begin to measure these and hold
the health system accountable for quality outcomes from their perspective, Gage thinks they
will see a step forward in health quality.
Henry Miller, President, Center for Health Policy Studies:
Miller addressed the trend in his research and consulting organization to focus on the
development of data and the use of data to measure performance within the health care
industry.
Miller opened by stating that the health care system is under-managed, having just recently
turned from a cottage industry to an industry requiring industrialization and needing to deal
with issues such as measurement of its quality and the quality of its services.
Miller focused his testimony around four questions: (1) what data do participants really need;
(2) how can that data be assured to be accurate and uniform; (3) how concerned do you need
to be about patient confidentiality and provider confidentiality; and (4) who is responsible
for the release of the information.
Miller testified that employees first decide which plan best meets their needs, usually based on
cost of the plan to them, the provider network that the plan offers, and their perceptions about
the reputation of the plan. He stated that data on costs and network competition are readily
available, and generally offered to everyone. HEDIS, for example, addresses quality, cost,
satisfaction, and effectiveness issues.
Looking first at data on consumer satisfaction, Miller noted there is a wide variety of data that
can be collected but it is difficult to deal with. It is not gathered uniformly and requires a great
deal of effort to interpret because satisfaction can be an ambiguous term. He
recommended that including satisfaction data in any kind of requirement will require choosing
information that is most easily made available and does not require a massive new
information infrastructure.
Miller then discussed information on physician performance. He emphasized the importance
of the consumers ability to obtain data on physicians who actually provide their care,
including patient satisfaction rate, satisfaction compared to other physicians, difficulty in
scheduling an appointment, and specialized capabilities that could be useful to the
consumer. He suggested that selecting a primary care physician is easy because consumers
dont worry too much about the outcomes. Consumers worry about the quality of the
physician but the kinds of procedures he will be performing probably are not life-threatening.
Most managed care plans can make this basic information available, and some do. For
specialists, however, participants need much more, such as patient satisfaction rates, the
number of times he has performed the procedure, and familiarity with the problem.
Miller reported that despite the explosion in health care data over the past ten years, there is
very little data available on physician performance, and little of that is available to plan
participants. Most of the physician data currently being collected is mandatory to the managed
care plan, such as patient satisfaction surveys and claims forms information. A great deal of
that information is available to managed care plans. Whether the plan will turn this
information over to a consumer or employer is questionable. For example, the idea behind
distributing physician information is to show that some are better than others, and if you
have a large network of physicians, it is not necessarily in your best interest to indicate that
some of them are better than others.
Miller also testified that while there is some outcome data available, it will take several steps
to make sure that it is valid, quality information. He mentioned that he doesnt put a lot
of worth in the current surveys, for example, because the measures that are useda
magazine survey where just the physicians are surveyedare useful but wont
show really unlikely results.
As for patient confidentiality concerns, Miller pointed out that the data used is the aggregate
of each individuals experience with that physician.
Miller stated that responsibility for the release of information to plan participants should be
limited to either the employer or the managed care plan. The managed care plan has the data
and the employer can usually get the data, but neither are currently providing the information
to consumers.
July 7-8, 1998
Frank Titus, Assistant Director of the Office of Insurance Programs, Office of Personnel
Management:
Titus explained what the OPM expectations were for carriers with request to the Advisory
Commissions recommendations and how to meet them.
Titus began by discussing the Federal Employee Health Benefits Program (FEHBP).
He then focused on the letter his office, the Office of Insurance Programs, sent carriers
outlining the Patient Bill of Rights and their expectations with respect to the carriers for 1999
and 2000 in regard to that proposal. OPM told the President that they would place those items
in the FEHBP necessary to implement the Bill of Rights within a two-year time frame,
meaning their contractual provisions for 1999 and 2000 and the brochures would be in
compliance.
Titus described how they set out to work with the carriers in a collaborative way, allowing the
carriers to tell them how they wanted to go about implementing some of these things. The
carriers were instructed that the Bill of Rights was not law, so they did not have to be
concerned with strict compliance but should approach the bill using common sense.
Carriers did not have to create new frameworks or draw boxes around items that had Patient
Bill of Rights labels. The complying information did not have to be labeled or all in one place.
Instead, the carriers should look at their current practice because many areas probably exist
where the carriers are already in compliance, even if it is in a different place from that
listed in the bill. Ultimately, carriers were advised that FEHBP would be feeling its way on
these things and need to be ready to deal with problems on an exception basis.
Titus revealed that some carriers expressed concerns about information on protocols and
confidential information. They were told that as a general rule, general information about
formularies and about investigational experimental would be sufficient. The carriers do not
need to disclose anything that is confidential or of a trade secret kind of nature.
Titus interpreted the Patient Bill of Rights as identifying information about plans and
providers. He explained that as a government entity, they need to be sure that the information
they are relying on is accurate and consistent across plans, and HEDIS meets that need. They
are also interested in the Foundation for Accountability because those outcome measures
seem to work and in fact are being generated by some of their fee for service plans on a pilot
basis.
Although he did not know if it would happen, Titus said it would be great if carriers got
together and picked a common provider (1) so customers could not only get the information
but find out what carriers a provider participated with and (2) so that each carrier did not have
to maintain a directory. Instead, he expressed the belief that web sites have much of the
sought-after information and he assumes carriers will use those as the primary medium for
meeting their responsibilities. Titus suggested they connect through their web site to other
germane sites that they believe are reliable. The desired information can then be downloaded
and printed on demand. Titus noted that once you have done this for one purchaser, you
could make it available to all purchasers.
Titus concluded by emphasizing how important it is that flexibility be built into the law to
allow for adaptability in dealing with carriers and local circumstances. He described the need
to be able to work with the spirit of the bill if they are to move the program closer to its goals,
noting there is the potential for a program that just could not be implemented. Even so,
Titus stated he did not see beyond board certification and things like that by 2000.
Beth Kosiak, Center for Beneficiary Services, Health Care Financing Administration:
Kosiak explained HCFAs experiences in gathering and disseminating plan information
.
Kosiak suggested that the average consumers interest is not at the plan levelconsumers
think much less in institutional terms than they do in personal terms. From the consumer point
of view, the most important information is down at the single provider level. Accordingly,
CAHPS (Consumer Assessments of Health Plan Studies), which was designed to produce
a set of questionnaires that would give consumers information from the patients
perspective, expanded the number of questions on the questionnaire that addressed
doctor/patient interaction.
Kosiak explained that HCFA is currently required to provide a large amount of data to the
public. Under general information, they must list the benefits under Medicare, including cost
sharing and balanced billing liability, and information about Medicare supplemental insurance
and Medicare select. They must also provide information about election procedures, how
to get into a plan, and appeal and grievance rights. For comparative information, they must
provide information on comparing the benefits of plans, cost sharing and choice of providers,
whether a referral is required to see a specialist, service areas, continuation options,
satisfaction information, and quality performance measures. With respect to all Medicare Plus
Choice eligible beneficiaries, legislation mandates that HCFA specifically provide
understandable information, hold health fairs, report and explain disenrollment rates, provide
information on appeals and grievances, and have an 800 number available to beneficiaries
only to answer Medicare Plus Choice questions.
Kosiak discussed that upon enrollment and annually thereafter, plans have to report any
evidence of coverage in clear and accurate standardized form, including service area, benefits,
emergency coverage, what constitutes an emergency, hospice, out-of-network, grievance and
appeals, disenrollment rights, and any changes to the plan. Plans are required to provide all
and any of this information if the beneficiary asks.
Kosiak noted there are currently many plans that do not have the resources for sophisticated
data consolidation or they have the resources but they just do not do it right. Furthermore, the
way the plans describe their benefits and procedures to beneficiaries are not standardized. She
explained that small plans are going to have a real problem with standardization and
consolidation because of the sophisticated data systems, that take lots of money and personnel
and resource they may not have, but there has been no resistance from large providers.
Kosiak testified that financial resources are not the only hurdle in the way of standardization.
She described how there are many issues to address in order to provide understandable
information that beneficiaries can actually use. These issues include the problem of diverse
population with respect to ethnicity, different levels of education and literacy,
physiological and psychological changes as people age, cognitive deficits, vision impairments,
and attitudes of plan members opposing changes to their current plan. As an example, Kosiak
reported that research and experience show that retirees are the people most likely to want
one-on-one contact where they can ask questions about the plan.
Kosiak reported that every state has some form of third-party advisors that act as counselors.
They function as grantees to HCFA and are usually based in either the Department of
Insurance or the State Department of Aging, and are coordinated with either the aging and
insurance programs existing in the state.
Kosiak touched on the problem of accountability in the area of group practices, asking when
is a beneficiary truly the patient of a group of physicians or a single physician, so that a group
or single physician can be held accountable for the care of that person or that group.
August 11, 1998
Gail McDonald, Chair of the Business Roundtable Health and Retirement Coordinating
Committee:
McDonald spoke about the Employer Quality Partnership (EQP) program sponsored the
Business Roundtable.
McDonald stated that the purpose of the EQP is to accelerate the actions of the marketplace in
health care quality and to promote information to the employees and the public about health
care. She outlined that the reason for this new focus is that healthy employees are more
productive and high quality health care plans become less expensive because they are more
cost-effective.
McDonald testified that the Roundtable companies are initiating a wide variety of innovations
to enhance health care. These innovations drive the market place through a
spillover effect that benefits people who work in other companies, small
companies, and individuals who access the health care system. McDonald described
spillover as the positive benefit that accrues to subscribers when providers
improve some aspect of their plans in response to negotiations with large companies. She
also suggested that the level of quality increases for other plans if one plan adopts a change.
McDonald emphasized there is no one-size-fits-all approach. ERISA provided a foundation
that allowed innovation because it created a framework that allowed for flexibility for
companies to meet the specific needs of their employees. What may work for one group of
employees or one industry or one geography or health plan will not be right for everyone.
Quite simply, if companies had to follow 50 different sets of regulations instead of one federal
framework, all money and time would be spent complying with the 50 different frameworks
instead of innovating and improving health care.
McDonald reported that the vast majority of companies are conducting some kind of
employee satisfaction survey. McDonald remarked that the value of this and other data, in
part, depends on the level of consistency and uniformity because, fundamentally, there are
going to be comparisons on some data system. Currently, there is a lack of uniformity. She
revealed that the companies are cautiously optimistic about the quality forum recommended
by the Presidents Advisory Commission, headed by the Vice President.
McDonald distinguished the collection of data from the dissemination, which needs a lot of
flexibility because it is going to various audiences whose needs will vary. She reported that
more and more companies are using their own networks to communicate health plan
information to employees or using kiosks where employees can access computers to gain this
information. Videos and work-site meetings have also been successful because employees
respond to one-on- one interplay where they can ask questions.
Carol Regan, Health Police Director, Service Employees International Union:
Regan discussed the importance of providing plan information to consumers and the
SEIUs efforts to increase the availability of information.
Regan stated that several issues surrounding consumers rights must be considered.
One is public accountability. Regan emphasized the importance in disclosing information to
the public through many avenues. She noted that people get information in many different
ways, including from web sites, their church, their community health center, and their
doctor's office. A second significant issue is choice: the ability to select from types of
providers and access certain kinds of providers to ensure medical or other health care issues
are covered. Regan emphasized that choice is much broader than data limited to clinical
outcomes. It includes issues of affordability, comprehensive coverage, and a network of
doctors with choice.
Regan testified that a whole set of issues and principles exist regarding consumer protections.
Currently, good information is available on dated procedures, delivery of services, preventive
care, financial stability, and solvency issues. Regan suggested that this available
information may better reflect the interest of some HMOs. What is lacking is
information from the perspective of the consumer. For example, information is needed on
protection from gag clauses and the numbers of grievances and enrollment rates. Regan also
noted the need to provide consumer-friendly information in other languages.
Regan listed the efforts of the Service Employees International Union to increase the
availability of information:
(1) SEIU is asking health plans or purchasers that contract with the plans to require
collection of additional kinds of data. They are asking accrediting organizations to
broaden their database and include different information than currently available.
(2) SEIU are educating members about how to take control over their own health care
decisions and demand individual as well as group evidence of high quality care.
(3) SEIU is creating booklets which provide information on quality that tells our members
what they have a right to expect from the health care system.
(4) SEIU is joining union-based health care purchasing coalitions to be able to do things in
markets to work together with other unions so that purchase quality in a more economical
and fair way.
(5) SEIU is advocating for legally enforceable standards in this industry so we can have the
kind of quality that is measurable and information that is accessible to people across the
nation.
Regan advocated the need for an internal and external third-party representative. She proposed
having an internal representative within the plan and within the union to field questions, talk
about the plan and what it does and doesnt cover, interpret issues and advocate for
necessary changes. There would also be an individual/office to handle the same inquiries as a
public servicei.e. externally.
September 8, 1998
Marilyn Park, Office of Policy and Research, Pension Benefits Welfare Administration,
Department of Labor:
Park provided an overview of the Presidents actions following the Advisory
Commissions final report.
Park began by noting that there is some mission overlap among the dictates of the
Patients Bill of Rights and the Commissions final report with regard to
providing consumers with health plan information.
She noted that when the President received the Commissions final report,
recommending providing consumers with additional information, he put the Vice President in
charge of making the Forum move forward. This private advisory group was formed (1) to
examine how quality is currently being measured by various entities in a coordinated fashion
and (2) to think about how to do this in a more rational and comprehensive way. The
Forums long term goal was defined as developing a core set of measurements that
everyone needs in order to purchase health care based on quality, whether they are the
individual consumer or the employer. Park also described QUICK (Quality Interagency
Coordinating Task Force), the other group established by the President, by executive order, as
the public body parallel to the Forum.
Park then testified to the presence of quality web sites that need to be linked together and then
made accessible to consumers. She suggested the possibility of creating a generic web site that
everyone can access.
1998 Index
Advisory Council on Employee Benefit and Pension Plans
(Actual Transcripts/Executive Summaries for the Councils full meetings and working
group sessions are available at a cost through the Department of
Labors contracted court reporting service, which is Executive Court Reporters at
301-565-0064/301-589-4280FAX.)
For the Advisory Councils 1998 Term:
May 4, 1998: Working Group Studying Disclosure of the Quality of Health Plans
a) Agenda
b) Official Transcript
c) Executive Summary of Transcript
d) Consumer Bill of Rights and Responsibilities - Report to the President of the United
States, prepared by the Advisory Commission on Consumer Protection and Quality in
the Health Care Industry, with accompanying February 19, 1998 memo to the Vice
President from Alexis M. Herman, and its attached report, Implementing the
Consumer Bill of Rights and Responsibilities through ERISA and
Quality First: Better Health Care for All Americans, the
Commissions final report to the President of the United States.
e) An Essay: The Doctor Is Not In - on the Managed Failure of Managed
Health Care by Ronald J. Glasser, M.D. Harpers Magazine, March
1998.
f) A news article Catching the Financial Flu appearing in Bloomberg
News, April 1998.
g) Simple Retirement Solutions for Small Business, a brochure
currently being distributed by the U.S. Department of Labor.
June 8, 1998: Working Group on the Quality of Health Care Plans
a) Agenda
b) Official Transcript
c) Executive Summary of Transcript
d) Proposed Agenda of Issues by Ms. Mazo for her committee to discuss
e) Issues of Quality and Consumer Rights in the Health Care Market by
Craig Copeland, Employee Benefits Research Institute (EBRI), dated April 98. (EBRI
Issue Brief Number 196)
f) A media kit from the and two brochures from the Employer Quality Partnership 1.
Navigating the Health Care System, A Guide for Employees and Their
Families and 2. Looking for Value: An Employers Guide to Evaluating Quality
Health Plans.
g) New York Times articles, Risky Business - a Set Fee for Each Patient Gives
Doctors More Control and More of a Financial Stake by Milt Freudenheim and
In Health Care, Be Careful What You Wish For by Michael M.
Weinstein, May 30, 1998.
h) Written Testimony of the National Association of Health Underwriters, prepared by
Dr. Nancy Trenti, assistant director of federal regulatory affairs.
i) Statement of the National Coalition of Health Care, mailed to members and to be
included in handouts 6/8/98
j) Consumer Health Care Information: Many Quality Commission Disclosure
Recommendations Are Not Current Practice a study prepared by the U.S.
General Accounting Office, April 1998.
July 7, 1998:
a) Agenda
b) Official Transcript
c) Executive Summary of Transcript
d) Ms. Mazos suggested issues and points of analysis prepared for the meeting.
e) Quality Health Care Is Good Business (A Survey of Health Care
Quality Initiatives by Members of the Business Roundtable, an association of chief
executive officers committed to improving public policy), dated September 1997
f) 1998 Guide to Federal Employees Health Benefits Plans, prepared by the U.S.
Office of Personnel Managements Retirement and Insurance Service Division
revised November 1997, RI 70-1
August 11, 1998:
a) Agenda
b) Official Transcript
c) Executive Summary of Transcript
d) Ms. Mazos suggested issues and points of analysis provided at the July
meeting and re-sent to all members for their consideration.
e) Union Guide to Quality Managed Care provided by the AFL-CIO via
Carol Regan, health policy director of the Service Employee International Union
(SEIU)
f) The Business Roundtable, and more especially the Employer Quality Partnership,
also provided a total kit of its health package, including a report date June 1998 on The
Spillover Effect: How Quality Improvement Efforts by Large Employers Benefit
Health Care in the Community, and a September 1997 Health and Retirement
Task Force Report on Quality Health Care Is Good Business: A Survey of Health Care
Quality Initiatives by Members of the Business Roundtable. (Also included were
advertising slicks for its employer-sponsored campaign and three brochures previously
furnished and catalogued in this index. And a CD Help us solve one big
problem with todays health coverage. CONFUSION.
September 8, 1998:
a) Agenda
b) Official Transcript
c) Executive Summary of Transcript
d) A Summary and Suggested Plan for Report, Provided by Judith Mazo, Chair
October 5, 1998:
a) Agenda
b) Official Transcript
c) Executive Summary of Transcript
d) What to Look for When Picking a Provider, San Francisco Chronicle
special on September 21, 1998. Included are individual articles and charts on:
Californias Biggest Health Plans
Frustrated With Health Insurer? New Firms Can Help Sort Out
Problems
How the Internet Could Change Patient Care
Preventive Care Report Card (Chart)
Patient Satisfaction Report Card (Chart)
Kaiser Clinics Eliminating Language Barriers
Northern California Health Plan (Chart)
e) Your Guide to Managed Care from Health Pages (from the website -
http://www.denver-rmn.com/health/ar-manag.html) Included are:
What Is It?
How Does It Save?
Role of the PCP?
Picking a Plan
Quality Check
Traditional vs. Managed Care
Compare Plans
Rating Doctors
Healthspeak
State Control
Report Cards
f) October 1, 1998 letter from Dean Rosen, Senior Vice President for Policy and
Information and Association Counsel, the Health Insurance Association of America
(HIAA)
g) Selected Recommendations from ERISA Advisory Council Meetings, prepared by
Judith Mazos office for purposes of discussion on what kinds of
recommendations the Working Group may make in its final report.
h) A kit from the American Medical Association concerned with its accreditation
program. (Copy of full kit available in Advisory Council archival file, EBSA
Disclosure Office and with committee chair only.)
October 5, 1998:
a) Agenda
b) Official Transcript
c) Executive Summary of Transcript
d) First Draft of the Working Groups Report
e) Wall Street Journal Supplement on Health and Medicine, October 19, 1998, entitled
Patient, Teach Thyselfincluding the following articles:
1) Business Plan: big employers are starting to design their own report
cards on competing HMOs. By Joseph B. White;
2) Whos On First? To find out which HMOs are best, you just
have to look at their ratings, right? Wrong. By Nancy Ann Jeffrey;
3) Making the Grade: Improvements in quality of care suggest hospitals
are taking report cards to heart by Ron Winslow;
4) Do Your Homework: How to learn about your doctor before
you pick one by Robert Langreth;
5) Click Here: Venture onto the Web, and you immediately understand
the meaning of ?information overload. A guide to finding what
you need by Rebecca Quick;
6) Dealing with Data: Companies have lots or high-tech ideas for
improving how doctors and hospitals handle medical information by
George Anders;
7) A Little Knowledge..Doctors are suddenly swamped with patients
who think they know a lot more than they actually do by Nancy Ann
Jeffrey;
8) The Way We Were: For at least one patient and one doctor, the
practice of medicine hasnt changed all that much. But they know
its only a matter of time. By Lucette Lagnado.
November 12, 1998
1) November 9, 1998 letter from Douglas R. Guerdat, Director, Administration and
Regulatory Relations, Blue Cross/Blue Shield Association of Washington, DC.,
regarding the associations comments on the upcoming Working Group Report.
-
On September 5, 1996, the President established the Commission to advise him on how to
promote consumer protection and health care quality. Co-chaired by the Secretaries of Labor
and Health and Human Services, the Commission had 34 members, representing consumers,
business, labor, health care providers, health plans, state and local governments, and health
care quality experts.
-
Presidents Directive to Federal Agencies, dated February 20, 1998, to Implement the
Consumer Bill of Rights and Responsibilities.
-
Other notices, such as the COBRA health-care continuation election, are required in specific
instances as prescribed in the law.
-
DOL Proposed Regulations on SPD Content, 63 Fed. Reg. 48376 (9/9/98).
-
DOL Information Letter, dated February 19, 1998, to Diana Orantes
Ceresi. This principle is
derived from the fiduciaries responsibility to manage plan assets prudently, in the
interests of plan participants. This comes into play for almost all ERISA health funds even
if they do not hold employer contributions in a trust to pay benefits, because even those that
operate essentially on a pay-as-you-go basis have assets in the ERISA sense, in
the form of employees post-tax or pre-tax contributions. And an ERISA fiduciary
includes anyone with discretion over the management or administration of a plan. So,
selection of providers, arguably, is a fiduciary responsibility, even if health benefits are paid
entirely from the employers general assets.
-
For some the choice may have been made before they enrolled, if their current physician is in
the organizations network.
-
Although some of the cost is externalized to the users in the form of as computer, ISP and
phone charges, whereas using the old media all of it was borne by the producer and distributor
of the disclosure information, the aggregate savings are still very dramatic. For example, a
recent survey of transaction costs in the banking industry revealed the following unit costs per
transaction: branch bank teller - $1.80; phone representative - $1.00; ATM - $0.40; PC
banking - $0.02, and Internet - $0.01.
-
The next questions generally go to the doctor: ?Whats wrong with
me? ?What pill should I take? ?What hospital should I go to? ?Will it
work? ?Will it hurt? ?Is it covered by my insurance? ?How long until
Im better?
-
This is the AMAs new voluntary accreditation service.
-
An analogy familiar to benefits practitioners is prototype pension documents. If, for
example, the definition of compensation is always in Article II, section 5, all
plans that use the model can be updated with a simple Search-and-Replace operation when a
statutory change causes a change in the definition.
-
The mandates would be set out in regulations adopted in accordance with the Administrative
Procedure Act, which calls for publication of a proposed regulation and the opportunity for
public comment before any final rules are established. Given the potentially far reaching
impact these rules could have, the public-comment phase is likely to be a serious, substantive
undertaking, for the Quality Board and for the affected members of the public.
-
These criteria could be set, possibly at different levels, not only for Medicare and Medicaid
but for contractors providing health care services to the Defense Department, the Department
of Veterans Affairs and, of course, the FEHBP.
-
This would draw on the sophisticated tools used by market analysts to correct for possible
biases created by, for example, the fact that those completing the surveys are not necessarily a
representative sample of those receiving the services.
-
Traditionally, the Public Health Service Act is amended to impose obligations on state and
local health plans, such as COBRA and HIPAA, that parallel those imposed on the private
sector through ERISA. In HIPAA it was also the vehicle for reaching the commercial health
plans. Including the Internal Revenue Code assures that the business and economic
expertise of the Treasury Department and the IRS are taken into account in the development
of regulations, and it has been a means of applying the employment-based requirements to
church plans. Other legislation may be needed to be certain to bring the federal
employees programs into the mix.
-
Interpretive Bulletin No. 95-1, 60 Federal Register 12328, March 6, 1995.
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