The clock ticks loudest in the fall for anyone looking to change health insurance plans. The open enrollment period at many workplaces ends sometime between late October and late November. But most of us don’t appear too concerned. Industry research shows the typical American worker spends only 16 minutes reading materials to make a choice about health insurance coverage.
Moreover, about 25 percent of health plan participants think they are part of an HMO when they’re not, said Lee Hargraves, a health researcher at the nonprofit Center for Studying Health System Change in Washington, D.C. That’s a lot of hasty decision-making, considering it’s hard to make decisions without even knowing the choices.
But the more time you take to pick your insurance plan, the more time, money and angst you’ll save later, said Paul Lerner, co-author of a new book, “Lerner’s Consumer Guide to Health Care” (Lerner Communications Ltd., $13.95). Deciding whether your company’s plan is right–or deciding among the choices, if you have some–requires due diligence and becoming your own health advocate. There are three starting points:
– First, you need to learn about the differences in coverage. There are four main types of plans: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Point of Service (POS) and indemnity or fee-for-service. Differences among them have blurred, so it is smart to give yourself an annual refresher course by taking the time to closely read the health insurance materials provided by your employer.
Interestingly, some of the newest research at the Center for Studying Health System Change shows people’s dissatisfaction with HMOs might actually be more about overall dissatisfaction with this country’s health-care system. When researchers controlled for people who thought they were enrolled in HMOs but actually were in PPO or POS plans, the dissatisfaction levels for such matters as doctor quality or lack of referral to specialists were virtually identical.
– Second, so much of deciding whether a plan is good hinges on personal factors: prevention strategies; cost of the premium, percentage of the usual and customary fee paid and miscellaneous charges such as co-payments, deductibles and prescription charges; degree of choice in picking a primary care physician, specialists and hospital; and your current health status. Sometimes, family history will dictate a course of preventive screening (such as colonoscopy for colon cancer) that is less expensive in one particular plan.
At the same time, don’t take a lot of comfort if certain extras are offered. These fringe features of a plan may be temporary, depending on consumer demand, said Gerald Hinkley, a health-care lawyer with Dickson Wright Tremaine LLP in San Francisco. One example is colonoscopy screening, which is now covered by many plans as a routine elective test.
– Third, there are intangibles that you may not find out about until you’re in a plan, unless you ask beforehand. For example, how fast will doctors in a network get back to you when you call? It helps to ask other people enrolled in the plan who see the same doctor. Ask both the doctor’s office and insurance carrier for names of other patients to contact.
Another important question: Which insurance carrier pays bills on time with the least hassle? Sometimes getting your health bills paid by the insurer seems like a matter of simply outlasting the efforts of case workers.
“Some bury patients and doctors in paperwork and request information already sent to avoid or delay payment, said Dr. Darrick E. Antell, a New York plastic surgeon and spokesman for the American Society of Plastic Surgeons in Chicago. “It’s happened to me, and certain companies are more notorious for stalling than others.”
In many cases, he added, you still won’t know what you get until you are enrolled in a specific plan. You can avoid unpleasant surprises by consulting the Illinois Department of Insurance Internet site at www.state.il.us/ins. The state tracks insurance plans for consumer complaints about payments and other issues. The plans are rated, making comparisons easy.
On top of these concerns, be aware that reading through most plans is not like sitting down to enjoy an interesting article. Information may be hard to understand and language may be dry and filled with acronyms such as UR for “utilization review” (a method for a health plan to decide whether an enrollee receives appropriate care) and murky terms such as “formulatory” (a list of prescription drugs your plan covers).
Technology might help demystify health coverage. Lerner said there are more than 20,000 Internet sites that can help explain health coverage. Plus, signing up for insurance figures to be paperless soon enough.
“All the functions will be online, including enrollment, eligibility and provider directories, which will make everything simpler, faster and maybe cheaper,” said Dr. Jacque Sokolov, a cardiologist and chairman of Sokolov, Schwab, Bennett, a national health-care management consulting firm in Los Angeles.
At present, the first thing to understand is that the less costly the plan, the less freedom it will allow you in choosing a physician and hospital.
An HMO is generally the least costly: premiums are usually low, there may be no deductibles and prescriptions are cheaper. But it’s the most restrictive, too, because you must start with your primary care physician, or gatekeeper, before you see a specialist. Often, you can’t go outside the network unless you pay and you may be limited on hospitals you can use.
“If you’re happy with your primary physician and don’t mind being in a system, it can be good,” Sokolov said.
A PPO costs a bit more, but gives you more choice. Going out of the network without a referral is possible, but the downside is that the fee won’t be fully covered.
A POS is considered a bit of a hybrid of an HMO and PPO. It’s more costly than an HMO and less than a PPO, but it allows you to opt out of a more restrictive environment if you want to pay more.
The least restrictive is the indemnity or fee-for-service plan, the type many corporations used to offer but gave up because of high costs. With it, you pay a deductible, the insurance company pays 80 percent of the fee and you pick up the remaining 20 percent. You basically go to the doctors and hospitals you want to go to.
For many people, having access to a physician or group of choice and one skilled in the medical areas they need is a key factor, said Scott Ziemba, a senior health-care consultant at the Chicago office of Watson Wyatt Worldwide consultants. The issue can change by life stage, especially, say, during pregnancy.
“The list of doctors themselves is not always as important as how easy it is to get to see them,” he said. “Some practices within a network may not be open.”
To get a network and names, ask colleagues and family, other doctors, or people who have a similar health situation for recommendations. “Once you’ve narrowed choices to three or so, call each, ask the office about their way of working, if you can meet with the doctor or have a few minutes over the phone,” said Lerner. “If the doctor is too busy, that should offer a clue about availability.”
Anyone with a chronic disease or family history of a specific illness needs to take extra time to evaluate providers, practices and preventive strategies.
“If you’re diabetic,” said Ziemba, “you want to make sure your physician is not only attuned to your illness but takes proper blood tests and checks your feet twice a year.”
Some plans work with national providers that specialize in a disease. For instance, American Healthways Inc. in Nashville offers care management services to members nationwide (check out www.americanhealthways.com for local access) who have diabetes, cardiac or respiratory disease.
The company identifies members with one of the diseases and introduces by letter its program, which includes specialized help from nurses, dietitians and others. High on the list for many consumers is being able to use a network however much they want, Ziemba said. Still others think about the convenience of a hospital or office.
“This is particularly true for people with children who need pediatricians,” said Hargraves.
Price–or the premium, co-payments, deductibles, office visits, prescriptions and so forth–is less a factor than you might think. Industry research shows Midwesterners are generally more willing than people in the East, West or South to pay a higher cost for good coverage.
If you’ve done your homework, you should feel confident that you’ve made a wise decision, but also know that sometimes no plan may emerge as the clear choice over another.
“We don’t yet have standard performance measures to compare them,” said Luc R. Pelletier, editor in chief of the Journal for Healthcare Quality, a professional trade journal.
One reason is because health plans seem to constantly evolve. A new wrinkle called “defined contributions” could become a major development. It has been introduced by Internet startup companies planning to sign up physicians, then offer their services to individual consumers in what becomes a self-directed health insurance plan.
Employees pay a fixed amount per year for coverage, while the entire worker pool still helps cover illnesses and catastrophic episodes. Some corporations like the idea because it puts more responsibility for health care on the individual, and makes workers more conscious about health-care spending.
“It is either the beginning of a new revolution in health insurance,” said Sally Trude, a senior researcher at the Center for Studying Health System Change, “or it is merely a reflection of employers’ frustration with the current system.”
