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Americans say quality is the most important element in choosing a health plan, yet few feel they really understand their options well enough to make an informed choice, according to recent research. Only two major types of health plans exist in the United States: fee for service and managed care.
Managed care goes by many names, such as Health Maintenance Organization (HMO), Preferred Provided Organization (PPO), Individual Practice Association (IPA) and Point of Service (POS) plan. Recent assessments of health care in America show that some 90 percent of Americans with health insurance have some form of Health Maintenance Organization (HMO) or other managed care plan. Having so many names for managed care may contribute to the lack of understanding of options.
The National Health Council, a private non-profit association of more than 100 national health organizations, has created a Patient Bill of Rights and Responsibilities as part of their national effort called "Putting Patients First."
The six patient rights are:
- Informed consent in treatment decisions, timely access to specialty care, and confidentiality protection.
- Concise and easily understood information about coverage.
- Knowledge about how coverage payment decisions are made and how they can be fairly and openly appealed.
- Complete and easily understood information about the costs of their coverage and care.
- A reasonable choice of providers and useful information about the costs of their coverage and care.
- Knowledge of which provider incentives and restrictions might influence practice patterns.
Patient responsibilities are:
- Pursue healthy lifestyles.
- Become knowledgeable about health plan.
- Actively participate in decisions about health care.
- Cooperate fully on mutually accepted courses of treatment.
With these rights and responsibilities in mind several tools are available to help consumers choose the best health plan for them and their families. A number of oversight and accreditation programs have been established to set standards for managed care and to provide reports on the how well health plans are meeting the standards.
The Consumer Assessment of Health Plans (CAHPS) or the Health Plan Employer Data and Information Set (HEDIS 3.0) are used for the accreditation process. These programs are all voluntary, and participation is viewed as a good indicator of the plan's commitment to quality care. In general, the accreditation process reviews consumer satisfaction, health outcomes, and other important factors to measure the quality of care.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) evaluates and accredits all types of healthcare organizations including hospitals. Eight of ten hospitals in the U.S. voluntarily choose to be assessed by JCAHO. The National Committee for Quality Assurance (NCQA) is a non-profit charged with improving quality of care in managed care organizations, but not PPO's. Since 1990, NCQA has reviewed over one-half of all plans nationwide. American Accreditation Healthcare Commission, formerly known as URAC, a non-profit founded to establish standards for managed care including PPO's and since 1991 has surveyed three hundred managed care plans. The National Health Council recommends comparing health plans using the CARE (coverage, access, restrictions, expenses) model. Find out what is and is not covered to determine coverage. Find out which doctors and hospitals are part of the plan to compare access.
The American Hospital Association recommends asking, "Does the hospital offer general or specialized care?" and "Is it a teaching hospital?" Consumer advocates recommend a third question "Is the hospital profit or non-profit?" Research published in the New England Journal of Medicine has shown death rates at for-profit hospitals higher than at teaching hospitals and higher than non-profit, non-teaching hospitals. In addition, research published in the Journal of General Internal Medicine found that patients at for-profit hospitals are more likely than patients at not-for- profit hospitals to suffer complications from surgery or delays in diagnosing and treating illness.
Ask which tests, treatments, and medications are covered so you can compare restrictions. Finally, to compare expenses determine the cost of the monthly premium, the deductible you must pay and the amount of co-payment of each visit or illness.
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