Your Guide to Choosing Quality Health Care
Choosing a Health Plan
Contents
Today there are more health plans to choose from than ever before. Not
everyone has a choice. But if you do, this section can help you choose
the plan that offers the best quality for you and your family.
The quality of health plans varies widely. In 1997, a study published
by the National Committee for Quality Assurance (NCQA) showed
differences in the ways managed care organizations provide access to
care, keep people healthy, treat illness, deliver high-quality
service, and satisfy patients. For example, studies show that treating
heart attack patients with beta blocker drugs saves lives. The NCQA
found that in some health plans, most heart attack patients got beta
blockers. In other health plans, only one in three did.
Research shows that Americans say that quality is the most important
thing they think about when choosing a health plan. But research also
shows that few people understand their options well enough to make an
informed choice.
Quick Check for Quality
Look for a plan that:
- Has been rated highly by its members on the things that are
important to you.
- Does a good job of helping people stay well and get better.
- Is accredited, if that is important to you.
- Has the doctors and hospitals you want or need.
- Provides the benefits you need.
- Provides services where and when you need them.
Meets your budget.
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Your Health Plan Affects Many Things
- Who will care for you (doctors and other health care providers),
and how much choice you will have.
- What kind of care you will receive (for example, which preventive
services are covered?).
- Where you will receive your care (which hospitals, for example).
- When you will receive your care (will you receive it when you need
it?).
- How you will be cared for (the quality of care you receive).
- How much you will pay.
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What Are Your Choices?
The two major types of health plans are "fee-for-service" and "managed
care." Managed care plans can go by many names, including:
- Health Maintenance Organization (HMO).
- Preferred Provider Organization (PPO).
- Individual Practice Association (IPA).
- Point of Service (POS) plan.
But different groups do not always define these names the same
way.
Do not be confused by whether the plan is a "fee-for-service" plan, or
whether the plan is one of the many kinds of managed care plans. What
you need to understand is not the plan's label, but the
characteristics of the plan. Research shows that it is important to
understand your options and how they affect your choice of providers
and services, costs, and quality of care.
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How to Make Decisions Based on Quality
The next section lists several questions you may want to consider when
choosing a health plan. These questions are based on research about
what consumers want to know when choosing health plans. Under each
question you will find more information to help you choose the plan
that is right for you. You also will find a way to compare the health
plans you are looking at. Here's how:
Please enter the name of each plan you want to compare on a separate line (Plan A, B, and C).
Plan A: ________________________________
Plan B: ________________________________
Plan C: ________________________________
Read the questions. Which are most important to you in choosing a
health plan?
Read and think about the information under each question. Then ask
yourself the question. If the answer is "yes" for a plan, check the
box next to its name.
Of course, the answers to these questions may not be as simple as
"yes" or "no." Still, these questions should help you to think about
and compare your health plan choices.
Do this for all the questions you have chosen.
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Rate Your Health Plan Choices
Do members rate the plan highly on things that are important to me?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Before you join a plan, it is hard to know what kind of care you will
get. One way to find out is to learn what members of the plan say
about it. This kind of information is called consumer ratings or
consumer satisfaction information.
More and more States, businesses, health plans, Medicare, and even the
Federal Government's personnel office are starting to use a survey
called Consumer Assessment of Health Plans (CAHPS®). It tells them what
members think of the plans they are in. CAHPS® was designed by national
experts in health care quality, under a project funded by the Agency
for Health Care Policy and Research.
Also, NCQA has added CAHPS® survey questions to its own member
satisfaction survey. The NCQA survey is part of its performance
measurement program, called HEDIS (Health Plan Employer Data and Information Set).
The information from the CAHPS® surveys is summarized in reports to
help you compare health plans and decide which one is best for you.
Here are examples of the kind of information you will find in a report
that is based on CAHPS® survey questions:
- Do members get the health services they need? Without long waits?
- How easy is it for members to get a doctor they are happy with?
- How easy is it to see a specialist?
- Do doctors in the plan listen carefully?
- Do they explain things well?
- Are office staff polite and helpful?
- Is the health plan's customer service good at giving information
and helping with problems?
- Do members have too many forms to fill out?
- How do members rate the care from the doctors and other health
care providers in the plan? How do they rate their plan overall?
Find out where the survey information came from. Is it CAHPS®, HEDIS,
or another source? Are you satisfied that it is a reliable source? Who
collected the data?
How can you find consumer ratings? Ask your employer, Medicare or
Medicaid office, or the health plan if a CAHPS® or HEDIS survey report
is available. If not, ask if there are other consumer ratings.
You also may want to check your phone book for your State's department
of health, or the insurance commissioner's office. For more help in
finding your State health insurance contact, write or call the
National Association of Insurance Commissioners at Executive Headquarters,
2301 McGee, Suite 800, Kansas City, MO 64108-2604; telephone 816-842-3600 or,
if busy 816-374-7175. The information also is available at its Web site:
http://www.naic.org/state_web_map.htm.
Does the plan provide preventive services to help keep people well?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Does it do a good job of helping them get better when they are sick?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
The Health Plan Employer Data and Information Set (HEDIS) uses various
types of quality measures. The HEDIS clinical performance measures are
based on information such as members' medical records. These measures
help to compare how well plans prevent and treat illness. For example,
one HEDIS measure looks at how many adult smokers or recent quitters
were advised to quit by a health professional in the plan. Another
looks at whether 2-year-olds are up to date on recommended shots.
Some other HEDIS measures look at breast cancer screening, prenatal
care, and at eye exams to prevent blindness in people with diabetes.
States, employers, health plans, and groups like the California-based
Pacific Business Group on Health use HEDIS performance measures to
prepare reports for consumers. These reports are known as performance
reports, report cards, or various other names. They also may include
HEDIS member satisfaction ratings or other consumer ratings.
To find out if there is performance measure information available on
the plans you are looking at, ask your employer, Medicare or Medicaid
office, or the health plan. Or, call your State department of health
or the insurance commissioner's office.
When you read the report, check to see where the measures came from.
Are you satisfied that it is a reliable source?
Is the plan accredited?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Many health plans choose to be reviewed and accredited (given a "seal
of approval"). Contact the following organizations to find out if the
plans you are looking at are accredited, or find out from the plans.
- The National Committee for Quality Assurance (NCQA) evaluates and
rates managed care plans using more than 50 standards. The
standards focus on efforts to continuously improve quality of
care; doctors' credentials (training, licensing, and other
background information); members' rights and responsibilities;
preventive health services; and whether appropriate health care
services are provided.
Visit NCQA's Web site at http://www.ncqa.org to generate a report
card on one of hundreds of health plans. You can also call
1-888-275-7585 or 1-800-839-6487 to ask for the following information:
Accreditation Status List, which lists all the health plans
NCQA has reviewed. (No charge)
Accreditation Summary Report for any health plan reviewed
since July 1995. ($3 per report by mail)
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) evaluates and accredits all types of health care
organizations. JCAHO standards focus on patient-related areas it
views as most closely related to improving health outcomes. The
standards cover: rights, responsibilities, and ethics; continuity
of care; education and communication; health promotion and disease
prevention; leadership; management of personnel and health
information; and continuous quality improvement.
Call 630-792-5800 to ask for information on specific accredited
managed care or other organizations. Or visit the JCAHO Web site:
http://www.jcaho.org. Information on accredited organizations is
free of charge.
The American Accreditation HealthCare Commission/Utilization
Review Accreditation Commission (URAC) develops accreditation
standards and programs for managed care. Its Network Standards
address five general areas: network management, utilization
management (checking to see that health care resources are used
appropriately), quality management, credentialing, and member
participation and protection.
Call (202) 216-9010 for information on accredited organizations. Or,
for a free list of accredited organizations, visit the
Commission/URAC's Web site at http://www.urac.org.
Does the plan have the doctors and hospitals I want or need?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Here are some questions to think about:
Are you happy with your current doctors?
Call their offices to find out which plans they are in. You may be
able to choose a plan that will allow you to keep seeing those
doctors without paying extra.
Do you want to make sure the plan includes the kinds of doctors you
will want to see?
Call the plans you are looking at to get a list of their doctors
and other providers. Or, ask your employer's benefits manager.
And remember, the hospital you go to often depends on the plan you are
in and where your doctor has privileges. If going to a certain
hospital is very important to you, keep that in mind when choosing a
plan.
Does the plan provide the benefits I need?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Which health care services are most important to you and your family?
Do the plans you are comparing provide these services? Check the
health plan materials from your employer or the plans. Or, ask your
employer's benefits manager or the plan's customer service office. For
services that are provided by each plan, check the boxes next to those
services that you want or need. There are extra spaces at the end of
the list in which to add other services.
| Are These Services Covered? |
Plan A |
Plan B |
Plan C |
| Cancer screening (colorectal cancer tests, mammograms, Pap smears, etc.) |
[_] |
[_] |
[_] |
| Cholesterol screening |
[_] |
[_] |
[_] |
| Immunizations (shots) |
[_] |
[_] |
[_] |
| Prenatal care |
[_] |
[_] |
[_] |
| Well-baby care |
[_] |
[_] |
[_] |
Care for a pre-existing condition
(one you have before joining the plan) |
[_] |
[_] |
[_] |
| Diabetes supplies |
[_] |
[_] |
[_] |
| Dental exams/treatments |
[_] |
[_] |
[_] |
| Eye exams/glasses/contact lenses |
[_] |
[_] |
[_] |
| Hearing exams/hearing aids |
[_] |
[_] |
[_] |
| Outpatient prescription medicines |
[_] |
[_] |
[_] |
| Medical equipment for use at home |
[_] |
[_] |
[_] |
| Mental health services |
[_] |
[_] |
[_] |
| Physical therapy |
[_] |
[_] |
[_] |
| Hospice care |
[_] |
[_] |
[_] |
| Counseling to stop smoking |
[_] |
[_] |
[_] |
| Drug and alcohol counseling |
[_] |
[_] |
[_] |
| Alternative treatments (such as acupuncture or chiropractic services) |
[_] |
[_] |
[_] |
| Home health care |
[_] |
[_] |
[_] |
| Adult day care |
[_] |
[_] |
[_] |
| Nursing home care |
[_] |
[_] |
[_] |
| ___________________________________ |
[_] |
[_] |
[_] |
| ___________________________________ |
[_] |
[_] |
[_] |
| ___________________________________ |
[_] |
[_] |
[_] |
Do the doctors, pharmacies, and other services in the plan have
convenient times and locations?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Here are some questions you may want to call the plan to find out:
- Are the services close enough to home or work?
- Are they on convenient routes for public transportation?
- Is parking available?
- Are offices open in the evenings and on weekends?
Does the plan meet my budget?
Plan A: [_] Yes
Plan B: [_] Yes
Plan C: [_] Yes
Use the health plan materials from your employer or the plans to
answer these questions and enter the information on the line provided
under each plan.
| Cost
| Plan A
| Plan B
| Plan C
|
| How much will the premium cost me each month? |
_____ |
_____ |
_____ |
If there is a deductible, how much will I have to pay before the plan starts to pay
for medical care?
For prescription medicines? |
_____
_____ |
_____
_____ |
_____
_____ |
How much will I have to pay (co-payment) each time I use a service?
Doctor visit
Hospital visit
Prescription |
_____
_____
_____ |
_____
_____
_____ |
_____
_____
_____ |
| How much more will I need to pay if I go outside the health plan's network of doctors, hospitals, and other providers to get services? |
_____ |
_____ |
_____ |
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Sources of Additional Information
Medicare Compare
Medicare offers a variety of free guides on its Web site,
http://www.medicare.gov.
Or call the Medicare Hotline: 1-800-633-4227
How to Choose a Health Plan and Straight Talk About Health Plans
Free.
American Association of Health Plans.
(202) 778-3200
Web site: http://www.aahp.org (click "For Consumers")
Guide to Health Insurance
Covers different kinds of plans and coverage, changing jobs, and
answers frequently asked health insurance questions. 15 pages. Free.
Health Insurance Association of America
1201 F Street, N.W., Suite 500
Washington, DC 20004-1204
(202) 824-1600
Web site: http://www.hiaa.org
Putting Patients First
Contains a guide to patients' rights and responsibilities, lists
resources for 170 conditions and diseases, and has a consumer's
checklist for evaluating health plans. 24 pages. Free.
National Health Council
1730 M St., N.W., Suite 500
Washington, DC 20036-4505
(202) 785-3910
Web site: http:www.nationalhealthcouncil.org
Choosing Quality: Finding the Health Plan That's Right For You
Helps consumers evaluate health plans. Covers what to look for, plan
accreditation, report cards, and ways to evaluate quality. Glossary. 4
pages. Free.
National Committee for Quality Assurance, Publications Center
1-888-275-7585
Web site: http://www.ncqa.org
Nine Ways to Get the Most from Your Managed Health Care Program
Topics include referrals, prescription drug coverage, getting care
when you are seriously ill, legal rights and protections, and
grievances. 40 pages. Free.
American Association of Retired Persons (AARP)
601 E. St., N.W.
Washington, DC 20049
1-800-424-3410
Web site: http://www.aarp.org
Pacific Business Group on Health Web Site
Offers helpful information about choosing a health plan and evaluating
HMOs. Includes consumer and physician ratings of California HMOs.
Web site: http://www.healthscope.org
Your Guide to Managed Care
A 15-page online guide to choosing health care coverage. Part of an
online series published by Health Pages.
Web site: http://www.thehealthpages.com
Families USA
Offers an in-depth resource list and information clearinghouse on
managed care.
Web site: http://www.familiesusa.org/resources/consumer-resource-centers/
healthfinder®
Provides a gateway to reliable consumer health information from the
Federal Government and other organizations.
Web site: http://www.healthfinder.gov
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