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Press Release October 2, 1998 |
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AUSTIN, TX -- Consumers will be better informed of the quality of HMO health care plans thanks to two new tools available to Texans this year.
The Office of Public Insurance Council and the Texas Health Care Information Council have gathered important data that will allow consumers to better compare the health plans available in Texas. "We hope these added tools will empower consumers to make better health care choices," said Lisa McGiffert, senior policy analyst with the Southwest Regional Office of Consumers Union. "No one should be left in the dark when it comes to ensuring the quality of their health."
With the traditional fall open enrollment period upon us, Consumers Union advises Texans to consider many factors when choosing a health plan. These include whether the plan is available at work, the types of benefits offered, how affordable the plan is, whether the plan includes the individual's preferred doctor, and whether a plan scored well on quality of care and patient satisfaction as measured by OPIC and THCIC. Some insurers listed in these surveys have merged with other insurers and may no longer be available.
You may have a choice of health plans because your employer offers more than one option. Or, you may be able to choose between your employer's plan and a plan available to you through your spouse. Realistically, not everyone has the option to choose among plans. While two-thirds of people under 65 are covered by employment-based health plans, less than a third of employers offer a choice in plans. If your employer only offers one plan, and you are dissatisfied with the care you have been receiving, make a formal complaint to your HMO requesting better service or easier referrals.
When choosing a plan, be sure to ask:
If your employer offers a choice, then your next step is to match each plan's benefits with the care, medication, and specialists you and your family will most likely need. Remember that specific benefit limitations will not be listed on the general brochures available-if you need details, call the plan and ask for a copy of the "evidence of coverage." If you are currently undergoing treatment, check to see if the new plan would agree to continue the care as is, including medications.
All plans require patients to pay some money when they get care. The costs vary a good bit so take out-of-pocket expenses under consideration when choosing a plan. For example, drug coverage varies significantly from plan to plan, and this can be a big expense that you will be expected to pay. Try to realistically match up each plan's out-of-pocket payment requirements to your budget. Most HMOs come with a point-of service option that allows you to go outside their network of doctors. This provides flexibility when seeking care, but the premiums and out-of-pocket costs will usually be higher.
Choice of doctor is for many consumers the most important factor when choosing a health plan. If you have found a doctor that you wish to keep seeing, it may be unwise to sign up for a plan that does not have an agreement with your provider. Otherwise, ask yourself whether the doctors on a particular HMO have offices located conveniently for you, and look to see if the doctors are accepting new patients. Many health plans have information on doctors and their availability on the web. If you see a specialist regularly, check to see if your choice of primary care doctor will prevent you from continuing your relationship with that specialist. Switching specialists can be disruptive if you have a chronic condition or complex medical history.
OPIC surveyed over 10,000 members across the state concerning their personal experiences with their health plans. "What we see is that statewide, most respondents are happy with their personal doctors. However, the customer service offered by the health plans is often less consistent," McGiffert said.
On average, only 47 percent of respondents said that they always got care without long waits. When it comes to service from the health care plans, the responses varied 25 percentage points, with only 26 percent of United members in the Houston area reporting that they always found efficient and helpful customer service, versus 51 percent of First Care members in the Panhandle. Although HMOs tout their preventive care approach, only about half of patients (55 percent) reported that their HMO doctor advised them to eat right or exercise.
Specific responses regarding the number of complaints made, the availability of specialist referrals, encountering reasonable paperwork and general care questions can be found in the brochure "Comparing Texas HMOs 1998" available from OPIC at 512-322-4143, or on the web at www.opic.state.tx.us.
Texas was divided up into six regions, and HMOs in each area were required to submit data on several performance measures. This week HCIC released comparative information on six of these measures: the percentages of board certified physicians in plan networks, breast cancer screenings, cervical cancer screenings, prenatal care during the first trimester, well child check-ups for the first 15 months of life, and eye exams for diabetes patients. These performance measures focus on preventive care-the best way to keep people healthy.
Because some health plans combined results from several different regions, some of the percentages do not necessarily reflect care given in the specific area listed.
The performance results vary significantly across plans, so THCIC brochures can alert you to how your plan compares to others in the state, as well as to the Centers for Disease Control "Healthy Family 2000," a national benchmark for preventive care. For example, the number of women who received a pap smear within the past three years in order to screen for cervical cancer varies from plan to plan by as much as 43 percentage points. Whether a woman started prenatal care in the first trimester varies by as much as 90 percentage points in some regions. The percentage of children who received six well child check-ups by 15 months of age varied by as much as 65 percentage points, and the percentage of women who had breast cancer screenings (mammograms) varied by up to 33 percentage points. With such significant distinctions between plans, these brochures can alert you to how focused an HMO is on providing preventive care.
The THCIC also has information on childhood immunization percentages and Cesarean section rates that was not released to the public but will be available to anyone interested. Contact the THCIC at 512-424-6492 or visit their web page at www.thcic.state.tx.us for a copy of the brochures "Your HMO Quality Check-up," or for more information.
Complain to your HMO. All HMOs must follow specific procedures when responding to enrollee dissatisfaction with the health plan. The law specifies when and how enrollees should be notified of the results of the HMO's review of their complaint, as well as the enrollee's options for further action if dissatisfied with the HMO's decision.
Register complaints with the Texas Department of Insurance. Records of complaints are now accessible to the public, and these are an important indicator you can review and influence. Don't think that your voice will get lost in paperwork-the Texas Department of Insurance keeps track of the specific number of complaints made to each HMO, ranging from 597 in a year to 1. (TDI can be reached toll-free at 1-800-578-4677; complaint information on the Internet is available at www.tdi.state.tx.us)
Also, don't forget to keep your employer informed about problems with your HMO. A pattern of complaints can prompt an employer to switch plans.
