|
|
|
How Healthy Are Connecticut's HMOs?
In search of meaningful yardsticks to measure how managed care is really managing
|
Business New Haven
3/4/2002
By: Susan Cornell
|
Both the quality of an insurer and its financial stability are areas of keen importance in evaluating the health of HMOs. There are at least as many measures of performance as there are health plans in state - so it behooves both employers and subscribers to take a multi-pronged approach in assessing options.
One such tool is that of the state's Department of Insurance, which ranks auto insurers and companies that sell more traditional health, long-term care, disability, accident and Medicare supplement insurance. Among those findings, ConnectiCare and MedSpan topped the regulators' rankings with the fewest complaints against their health plans in 2000, while the lion's share of gripes were filed against FirstChoice (formerly WellCare), HealthNet (formerly PHS) and Aetna.
Based on 2000 data, the state rankings released in October indicate that MedSpan received nine complaints and ConnectiCare received 64. Comparatively, FirstChoice (or LastChoice) logged 2,847 complaints. Aetna U.S. HealthCare placed eighth with 276 complaints.
More than 4,200 complaints against HMOs were registered statewide in 2000. The insurance department issues the rankings based on the amount of business the insurer does in the state (measured by the amount of direct premiums written) to the number of complaints submitted to them by doctors, consumers and hospitals. Only complaints considered at least partly justified are considered. The bulk of complaints stem from claims handling; of those, most reflect payment delays.
The rankings can be misleading, said Tejas Patel, COO of the low company on the totem pole, because it counts only data received from commercial customers. According to Patel, FirstChoice in 2000 was exiting the small business market and had picked up more than 22,000 Medicaid customers.
“There have been very few complaints on the Medicaid business,” Patel says. “Almost 99 percent of complaints were from the commercial membership. I think this was due to the fact that we have restricted marketing and increased the premiums. Due to the drop in membership we have also had to reduce our provider network.”
As part of that process, says Patel, the company brought in new management and has restructured claim operations.
HealthNet received 890 complaints and said it was working to iron out claims problems. Aetna responded that the company has engaged in a nationwide effort to improve service.
State insurance Commissioner Susan F. Cogswell says the rankings are an important educational tool for Connecticut consumers when comparing insurance companies. She adds, “The rankings can also be used by insurance companies to evaluate how their customer-relations plans are working and how they fare against their competitors.”
“Managed Care Organizations in Connecticut,” a government rating released by Cogswell's department and updated annually, provides a comparison guide of all HMOs as well as the 15 largest indemnity insurers with the highest premium volume for managed care plans in Connecticut. This is a consumer report card mandated by the Managed Care Reform Act of 1997 (Public Act 97-99) that provides consumers with the number of physicians, hospitals and pharmacies for each managed care organization (MCO) by county, member satisfaction survey results, and a comparison of certain quality measures.
The information is based on data provided by the MCOs as of year-end 2000. The HMOs included in the guide are: Aetna-US, Anthem BC-BS, Cigna, ConnectiCare, FirstChoice, HealthNet, MedSpan and Oxford.
Quality measures include: percentage of primary-care physicians who are board-certified; percentage of board-certified physician specialists; provider turnover rate; breast and cervical cancer screening; childhood immunizations; prenatal care in the first trimester; cesarean section rate; adult access to care; eye exams for diabetes patients; beta blocker treatments following a heart attack; and outpatient drug utilization for managed-care enrollees.
Take, for example, provider turnover. The average percentage of primary-care doctors in the HMOs' provider networks as of December 31, 1999, who were not in the same networks a year later is 13.26 percent. At FirstChoice, nearly two-thirds (65 percent) of its PCPs departed the network over the 12-month period, while at MedSpan the turnover rate was a mere 2.67 percent. However as Kathleen Kiernan, legislative liaison for the insurance department, explains, “Turnover in FirstChoice was related to their withdrawal from the commercial business and increase in the Medicaid business.”
With regard to breast-cancer screening, the Connecticut HMO average percentage of enrolled women between ages 52 and 69 as of December 31, 2000 who had a mammogram during 1999 or 2000 was 77.72 percent. The highest ranked HMO in this category is ConnectiCare with a score of 83.15 percent while the lowest ranked was FirstChoice, with 69 percent receiving mammograms.
The average percentage of primary-care physicians who are board-certified at Connecticut HMOs is 87.15 percent. FirstChoice secured a first place position with 96 percent of its provider-network PCPs having attained board certification. MedSpan brought up the rear with 78.79 percent.
The report is available in PDF format on the insurance department's Web site (www.state.ct.us/cid) under the heading “A Comparison of Managed Care Organizations in Connecticut.” It is designed to help consumers compare MCOs and includes a “Managed Care Plan Comparison Worksheet” as well as a list of companies with addresses and phone numbers to obtain information on specific plans offered by MCOs. A printed copy is available by calling 860-297-3862.)
Another way to slice the pie is physician ratings. The office of state Attorney General Richard Blumenthal released a statewide survey of Connecticut licensed and practicing physicians on the impact of managed care on patient care.
The survey, one of the first of its kind in the nation, was conducted by the University of Connecticut's Center for Survey Research. (The results can be viewed at www.cslib.org/attygenl/health/physurvey.htm.) Additionally, the Fairfield County Medical Association (FCMA) rates HMOs on patient access to care, denial of care, ease of referral, restrictions on prescription medication, limitation of hospital stay, emergency room coverage and denial of claims.
The FCMA's 2001 countywide survey revealed that the six largest HMOs operating in Fairfield County “are perceived as deficient and need to significantly improve their servicing of patients. A substantial percentage of physicians are concerned about the way HMOs administer the health care of those they insure, and believe that changes must be made in order to keep patients better informed about how their health plans function.”
The report adds: “The single, most important conclusion one could draw from the survey is the relatively poor rating each and every HMO received. It is clear that in the eyes of the respondents, all six HMOs are perceived as deficient on a range of issues.”
Explains Amy Cole, the FCMA's director of governmental affairs and community relations, “It's an ongoing battle where [physicians] are treated unfairly.” Cole says, for example, that physicians or someone in the office must remain on hold for verification of coverage or referral for up to an hour.
“There's not enough staff for some carriers,” she explains. “Reimbursement issues are large. Carriers will do one of two things. One is bundling of services. Carriers will bundle and just pay for one. They're not providing patients with the customer service they are permitted so the patient has to return sometimes for a second visit. The other is downcoding: The carriers arbitrarily lower the code so the physician will have to make an appeal. They do this all of the time. Also, they are required by state law to pay interest when they don't [reimburse] on time. But they don't do it.”
Explains Karen L. Laugel, M.D., chairman of Citizens for Patients' Rights (CPR), a non-profit organization founded in 1999 by a group of Connecticut physicians to advocate health excellence: “Our statistics of problems reported to CPR represent small numbers to date, but so far in the past ten months we have found that 67 percent of patient complaints are lodged against insurers, while 20 percent are lodged against doctors, nurses and hospitals [combined].
“Out of the 16 cited insurance companies, HealthNet (formerly PHS) has been named most frequently as the offending insurer, responsible for 32 percent of the complaints against insurers,” says Laugel. “Cigna comes in second at 11 percent, and Anthem, Aetna and ConnectiCare all at approximately ten percent each.”
And then there are the business ratings, including the Weiss Rating. Weiss is a business industry rating that focuses on financial strength, capital resources, total assets, total volume of premium dollars, net worth of the insurer, profit gained on operations, and risk of insolvency. The rating scale is simple, ranging from A (excellent) to E- (very weak).
Finally, insurer ratings. The National Committee on Quality Assurance (NCQA) is a not-for-profit organization that reviews quality and performance measures of HMOs, offering an external standard of accountability.
NCQA evaluates how well the health plan provides its members with access to needed care and good customer service; health plan activities that ensure each doctor is licensed and trained to practice medicine and that members are satisfied with their doctors; health-plan activities that help people maintain good health and avoid illness; activities that help people recover; and how the plan helps people manage chronic illnesses.
Among its reports, NCQA produces “Health Plan Report Card” to equip consumers with information about the quality of health plans (including HMOs, POS plans and PPOs) based on their performance in five key areas and overall accreditation. Consumers can compare ratings of various health plans and get detailed information on individual plans. The report card shows consumers how well health plans are doing the things they should be doing - from checking doctors' qualifications to ensuring access and delivering service. The accreditation outcome summarizes how well the plan performs overall.
One accreditation program is for HMOs. To be accredited by NCQA plans must meet a set of requirements that cover a full spectrum of services and clinical care. Individual requirements are organized into five categories: access and service; qualified providers; staying healthy; getting better; and living with illness. HMO and POS plans are eligible to receive up to four stars in each report card category. Based on their overall performance, HMOs and POS plans are eligible to receive one of the following accreditation outcomes: Excellent, Commendable, Accredited, Provisional and Denied. Here's how Connecticut's plans placed:
To maintain HMO health, says Commissioner Raymond J. Gorman of the Office of Health Care Access: “The biggest challenge today is that HMOs not price themselves out of the marketplace. They are increasing premiums, and those prices are borne by the employers. The big challenge is to convince the marketplace that the coverage is adequate and that the cost is affordable.”
|
Go FirstGo PreviousGo
NextGo LastGo
to Index
|
|
