Consumer Health Care Choice is the Buzz -
But How to Choose?

by Beth Remus

Most individuals today have the daunting task of choosing from a complex menu of plans for employee health care benefits --- from Health Maintenance Organizations (HMOs), to Preferred Provider Organizations (PPOs); from Point of Service (POS), to Integrated Delivery Networks (IDNs), and Physician Hospital Organizations (PHOs). And with Health care Savings Accounts (HSAs) entering the mix, the decision becomes even more complicated.

In evaluating their options, individuals typically start by comparing coverage and fees. They may then need to determine the best match given their financial and health situation, age, marital and family status. These are issues that most employers explain in simple clear ways that are easily understood by their employees.

But making a well-informed, optimal choice must go beyond looking at just these basic factors. Employees need information that is going to help them assess, and ensure, the most important piece of the health care puzzle ---- the quality of their choice. Although we would like to think that every health plan and health care provider gives high-quality care, this is not always so. And as health care costs continue to climb and consumer choice is the buzzword that is heard throughout the industry, "quality" will increasingly be the driving force behind health care decisions.

What does quality mean?

As an accreditation consultant, I am often asked how to determine the quality of a health plan. At the very minimum, I tell people that they need to look for health care plans and providers that are accredited --- which means that the plan or provider has the "quality seal of approval." For some individuals who merely want a short cut method for determining the quality of a particular plan, looking for the seal of accreditation may be enough. But, my advice to you and to your employees, as it has been to others who have asked, is that if you want to make the best possible decision you need to look beyond this seal of approval. Yes, having the seal is important --- but to make the most informed decision you need to know what this seal means and why the health care plan or provider attained this accreditation.

When you see an accreditation seal on health plan materials or a web site, it is the signal to you that the health care plan has secured national recognition for meeting or exceeding the agreed upon "best practices for their field." Best practices are standardized, published operating methods that are used by a health care organization and qualified providers to produce the best performance and outcomes in health care. Most importantly, these "best practices" are also designed to protect and minimize risk to the consumer.

Accreditation should not be confused with "licensure" or the meeting of state regulations … the "minimum requirements" in a specific field. Most often licensure only requires an initial application with a re-application fee and documents. States require licensure of health care organizations, but accreditation is voluntary and consists of cyclic (every 2 - 3 year), rigorous, comprehensive on-site reviews of the health plan related to the best practices (standards) and frequently interim reports and unannounced on-site reviews.

But what if each health plan is accredited by one of the accrediting bodies…NCQA (National Commission of Quality Assurance), URAC (Utilization Review Accreditation Commission), and JCAHO (Joint Commission of Accreditation of Health care Organizations)? If all the health plans are accredited, you are giving your employees the excellent health plan options.

Identifying the differences between the accrediting bodies is a health plan issue (e.g. the health plan must consider such factors as do the state regulations support one accrediting body over another; the cost of the accreditation and the approach of the accrediting body to accreditation) though the accrediting bodies would have the consumer believe that one accrediting body is far superior than another.

The important issue for your employees to understand is that you have chosen accredited health plans to protect them and to guarantee the implementation of best practices. These best practices will also support the employee in effectively using their health plan and in resolving problems if they would occur. There are four best practices every benefit consultant should be aware of and discuss with their employees.

The Provider Selection and Credentialing Process: Accredited health plans have a specific procedure to select providers (your doctors and health care practitioner and facilities) who practice the highest standard of health care, are in close proximity to the member and when possible, have characteristics that meet the preferences of the patient (e.g. male or female, ethnic or language preference.) These providers also have undergone a process to confirm that their credentials, backgrounds and experience meet the health plan and accrediting body specific standards. In addition, to ensure they can count on a level of quality, the health plan seeks out accredited health care facilities and programs for its network whenever possible. (Check to determine the quality and accreditation status of over 16,000 health care providers that may be on the health plan's network.)

Tip for Benefits Consultants:

  • Coach your employees on how to find a new provider, if necessary. Have them check the accrediting body's web site for comparative data regarding different health care organizations and providers. Or have them talk with the health care organization's customer service department and tell them their specific needs (e.g. male/ female, specific background, proximity to home or work). Let your employees know that accreditation requires the health care organization or practitioner to provide several options.

A Complaints and Grievance System: Problems may arise in the course of obtaining health care. It can be incredibly frustrating to not have a system that can be counted on to resolve the problem. Accredited health care plans are required to have complaints and grievance procedure for consumers. These procedures include varying requirements for communication regarding the resolution of the complaint or grievance.

Tip for Benefits Consultants:

  • Request a hard copy or download an electronic copy of the complaints and grievance process for each health plan offered to the employees. Encourage the employee to download or provide them a copy of their health plan's complaint and grievance system. Tell them to come to you if they have not been able to resolve a problem, and you will assist them in using this system for a problem with their health plan or provider. Calls from a client organization mean a lot!!. Plus you want to know if your organization is having difficulty with a specific health plan.

A Privacy and Security Plan for Patient Medical Information: The federal government and the accreditation organizations consider it critical to assure the privacy and security of the collection, storing and provision of your health care information. While certain medical information must be disclosed when applying for health insurance, it is important that only the right people have access to this information. The accreditation on-site survey of an accredited health plan includes a review of these required protections to assure they are in place and utilized by the staff in the everyday operations.

Tip for Benefit Consultants:

  • Encourage employees to request and maintain an up-to-date hard copy of their medical record and to be familiar with the information. Also if any information is inaccurate or does not fully represent the situation, support them in asking for the procedure for revising the medical record and adding an entry that corrects the information.

An Appeals Process: At times a patient or their health care practitioner believes a specific treatment, procedure or hospitalization may be necessary and the health plan sees it differently and therefore determines it will not pay for it. This is an especially difficult situation if the employee has already received the care. An accredited organization must have a way for the employee to formally question that decision. This is usually called "an appeals procedure." This procedure requires the health plan to answer an appeal within a specific time frame and assure an ethical and thorough review of the case by a peer of the doctor or health care practitioner. Also, if the employee believes that the health plan does not have all the information, accreditation guarantees the employee can submit additional information regarding their treatment and care. An accredited health plan must abide by these standards each time they determine a consumer's care was either not necessary or appropriate for the condition.

Tip for Benefits Consultants:

  • Request a hard copy or down load an electronic copy of each health plan's "appeals process." Encourage the employee to download a copy of the appeals procedure of their health plan. Tell them that if their care is a benefit and it not being covered, they should not hesitate to appeal as per procedure.

In addition to looking for the accreditation seal of approval, you should inform your employees about other ways they can assess the quality of a health plan, such as:

  • Calling the state department of insurance and asking if there are any complaints against this specific health plan. You can ask for the number and type of complaints (e.g. can't reach the health plan by phone; having trouble getting an appointment in a reasonable amount of time; or dissatisfaction with how a health plan addressed issues). A significant number of complaints to a state department of insurance is a red flag regarding a health plan.

  • Checking if the health care practitioners and hospitals of choice are on the health plan's provider list. The cost savings will be less if the health plan has not contracted with the health care practitioners and facilities. If the employee is a member of a minority group, check the availability of practitioners with their specific ethnic and racial background. There is substantial literature documenting those practitioners that speak the primary language of the patient and have knowledge and understanding of the patient's culture have better health care outcomes.

  • Checking the specific accrediting body web sites and comparing the status of the accreditation of the various health plans. Some health plans may have only received a one- year accreditation where others may have received a three-year accreditation. Also check the accrediting body web site for the specific health care outcomes of the different health plans. The State of Health Care report found that health plans that publicly reported their performance data provide improved clinical care over plans that were not willing to be public with their performance data.

While looking for the accreditation seal of approval is an important first step in selecting a quality health care plan or provider, it is important that you provide your employees with the information they need to take their decision-making process to the next level. When you help them understand what accreditation means and why it is important to them, you are really putting the "choice" in "consumer choice."

Beth Remus is the principal of Remus & Associates, Inc. in Chicago, IL. Her firm specializes in accreditation, cultural competency, quality improvement, and service design for health care organizations. She can be reached directly at 312-986-1302 or via email at . Visit for additional information.

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Copyright 2005 by Beth Remus. All rights reserved.

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