|
Health
Plan Assessments: The Questions To Ask
Table
Of Contents
Quality
Health Care - The Variations
Health
Care: How to Measure Quality
How
To Assess Health Plans - Questions To Ask
Choosing
A Doctor
Choosing
Treatments
Choosing
A Hospital
Choosing
Long Term Care
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.
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.
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: Health Maintenance Organization (HMO); Preferred Provider
Organization (PPO); Individual Practice Association (IPA); and
Point of Service (POS) plan, to name a few.
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.
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.
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 Healthcare Research and Quality.
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 (see page 6 for more information).
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?
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 two-yearolds 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.
Is
the plan accredited?
Many
health plans choose to be reviewed and accredited (given a "seal
of approval").
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.
Does
the plan have the doctors and hospitals I want or need?
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?
Which
health care services are most important to you and your family?
Do the plans provide the services that you need from thislist:
- 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?
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?
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? |
