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HOW TO SELECT
A HEALTH PLAN
It's time
for you to select a health plan for your growing company. The first
thing you'll find is that this isn't easy. You can't try it on for
size or look under the hood. But you want to make the best choice,
so you do what you can. You ask your friends or other companies
how they like their health plans. If you have time, you read the
plan's brochures and talk to their staffs. And you look at how much
each plan costs. All these things may give you a gut feeling about
which plan might be right for your company. As a health-care consultant,
I regularly follow a systematic approach to determine which health
plan I will recommend to my clients. I hope this step-by-step approach
to getting information will help you make an informed choice about
which health plan is best for your company. Remember, it's a great
idea to look at the overall quality of the plans you're considering.
Step
1: Consider the basics
Make
a list, either real or in your mind, of the things that are most
important to you. Consider the following categories and be prepared
to make some trade-offs.
Coverage-Most plans cover similar benefits, but
the differences are in the details. Look at such areas as mental
health, home care, chiropractic care, or anything that is particularly
important to you.
Choice-Is there a certain doctor you'd like to choose
either for routine care or specialty care? Do you have a favorite
hospital? Some plans offer a "point-of-service" program that lets
you get care from doctors or hospitals that are not part of the
plan's network, but you'll pay more for it.
Convenience-You probably want a plan that has doctors
located near your home or office. But for you, convenience might
also mean that it's easy to get prescriptions filled, or that
evening and weekend appointments are available.
Cost-You will pay a visit fee, or co-payment, whenever
you get care.
Step
2: Consider Quality
Now, it's
time to find out a little bit more about the health plans you are
considering. Brokers, consultants and other research firms measure
how well health plans perform in many different areas, and often
will provide the information on quality to the public.
Here are some of the areas you should consider when evaluating a
plan:
Doctors-Ensure
that the health plan carefully reviews the qualifications of doctors
before it lets them into the HMO network. Also, check how often
the plan evaluates its doctors' performance and what percentage
of doctors leave the plan each year.
Prevention-Prevention can mean actually
preventing disease (through immunizations, for example,) detecting
problems or risk factors early (as in breast cancer or cholesterol
screening) or carefully managing and existing condition to avoid
complications or crises. Look at how effectively each health plan
provides members with different kinds of preventive care.
Quality
Management-Measure how well the HMO's use patient
and physician surveys and other feedback to continually improve
care and service. Health plans should be able to explain what
they do to improve quality and should have results to show that
they are succeeding.
Satisfaction-How
do the plan's members like the care and service they receive?
Make sure health plans survey their members, and where they fell
short, that they take steps to improve.
Step
3: Gather Information
Your best
source of information on a particular plan might be the health plan
itself - if you know what to ask. Here are a few suggestions:
Most
health plans have marketing brochures explaining how the plan
works and where its physicians are located. These brochures are
helpful, but they shouldn't be your only source of information.
Call
the plan's member service or customer relations department and
ask for a copy of the member newsletter, health promotion literature
or annual report. These will show you how well the health plan
communicates with members.
Ask the
plan for a sample benefits contract or subscriber agreement. It
will tell you about the plan's standard benefits package. (Of
course, your benefits may vary.)
Ask the
plan if information meetings are held for people who are thinking
about joining. This might be a good forum for asking questions.
Ask the
plan if it has a quality "report card" and, if so, ask for a copy.
Call the HMO's member service or customer relations department
for any statistics showing complaints to the employer or union
about health plans.
Another
source of information is the National Committee for Quality Assurance,
an organization that measures health plan performance. The DC based
organization judges HMOs using accreditation and report cards.
NCQA physician reviews and quality experts carefully and thoroughly
evaluate how well a health plan manages its network. NCQA checks
to see that the plan has safeguards in place to protect patients
and to evaluate the quality of care it delivers. NCQA accreditation
is viewed by many as a "seal of approval" for health plans. To date,
NCQA has reviewed about half of the country's HMOs, and only about
one third of the health plans reviewed have received full, three-year
accreditation.
In conjunction with NCQA and on their own, many health plans produce
"report cards" showing how they perform in specific areas, such
as providing their members with certain preventative health tests
or treatments. These report cards are based on a set of standardized
performance measures developed by NCQA and known as HEDIS (Health
Plan Employer Data and Information Set). NCQA is working to make
these measures even more useful so that will show how well the plan
keeps its members from getting sick and how quickly the plan returns
sick members to good health.
NCQA provides information about the health plans it has reviewed
free of charge to anyone who wants it. Here's what to ask for:
An Accreditation
Status List-This lists all the health plans NCQA
has reviewed and their accreditation status (full, one-year, and
provisional accreditation, or denial)
An Accreditation Summary Report-You
can ask NCQA for a copy of this report for any health plan it
has reviewed since July 1995. The report provides details about
how the plan measured up against an average in each specific category
of standards.
Other sources
of information on the quality of health plans include:
Your
state's insurance, public health or consumer office regulators
For Medicare, the Health Care Financing Administration (HCFA)
or the U.S. Department of Health and Human Services. Ask directory
assistance for a regional office near you.
For Medicaid, your state's Medicaid office
Business and Consumer Groups
Step
4: Ask Questions if you have Concerns
No matter
how much information you gather, you may have additional questions.
Following are a few issues that concern some HMO members. Health
plans may not be able to provide you with objective measures related
to these issues, but you should express your concerns to a health
plan consumer service representative and decide whether you are
happy with his or her response.
Access-How
easy is it to get an appointment with you need it? How long will
you wait in the doctor's waiting room? Can you talk with your
doctor on the phone if you wish to? What do you do if you have
a medical emergency? What exactly must you do if you and your
doctor decide you need to see a specialist?
Continuity-Will you see the same caregiver-whether
it's a doctor, nurse or therapist-whenever you need care? This
might be especially important to you if you need ongoing or regular
care.
Coordination-If you see a primary care
doctor and one or more specialists, how will your care be coordinated
among them so that nothing falls through the cracks and all of
their treatments work together toward your good health?
Flexibility-Can you switch doctors within
the plan if you are unhappy with your first choice? How can you
get a second opinion? What happens if you disagree with the plan's
decisioj not to cover certain services?
Step
5: Put it all Together
After
all this, you probably have a pretty good idea about the strengths
and weaknesses of all the plans you are considering. This is when
you need to decide what's most important to you, and try to match
your priorities with the health plan that will best meet your
needs. It's not always easy, but important decisions rarely are.
Robert Cohen is president of Alliance
Benefits & Compensation, LLC in Laurel, MD.
CINNAMON MAY HELP PREVENT
DIABETES TYPE-II
Cinnamon may prevent or
at least delay type-II diabetes, the type of diabetes that develops
with age when fat and muscle cells gradually lose their ability
to respond to insulin. Nutritionist Richard Anderson says patients
with type II diabetes could benefit by adding the spice to their
food or drink. "We recommend people take a quarter to a full teaspoon
a day of cinnamon, perhaps in orange juice, coffee or on oatmeal,"
he says. Clinical trials of a cinnamon extract are due to begin
within a year. The hormone insulin directs cells to remove excess
glucose from the bloodstream. If glucose builds up in the blood,
it causes symptoms such as fatigue, weight loss and blurred vision.
Anderson and his colleagues at the U.S. Agricultural Research Service's
nutrition labs in Maryland, established that cinnamon rekindles
the ability of fat cells from type II diabetics to react to insulin.
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HALF OF ALL PREMATURE BABIES WILL HAVE SOME DISABILITY
About half of the babies
born in the sixth month of pregnancy -- infants who weigh about
a pound -- will have some mental or physical disability. One-in-four
of the babies will have a severe disability, according to a study
that tracked pre- mature births in the United Kingdom and Ireland.
The study published in Thursday's issue of The New England Journal
of Medicine, offers the most comprehensive "snapshot" yet of the
very preterm infants. Dr. Neil Marlow says that because the study
represents a geographic grouping of premature births it is unlikely
that the findings reflect "any bias." Marlow evaluated all children
who were born at 25 weeks or less of gestation from March, 1995
though December, 1995. They identified 283 surviving infants and
found a wide range of disabilities including blindness, severe mental
retardation, difficulty with motor skills such as walking or crawling,
and hearing loss. Because of more aggressive treatment, the survival
rate of the premature infants is about 80 percent in the United
States but 40 percent in the United Kingdom.
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RICKETS ON THE RISE
AMONG BLACK INFANTS
As more black women begin
to breast feed, an increasing number of their children are coming
down with rickets. Rickets is a brittle-bone disease caused by the
lack of Vitamin D. Severe cases of rickets can lead to broken bones
and skeletal deform- ities. Although infant formula has 400 units
of Vitamin D -- which is equal to the minimum daily requirement
-- per liter, breast milk has only about 20 units. Another source
of Vitamin D is sunlight, but dark-skinned infants absorb less sunlight
than lighter-skinned babies, making them more susceptible to Vitamin
D deficiency. The study's authors, from Wake Forest University and
the University of North Carolina at Chapel Hill, emphasize that
they do not want to see fewer women breasted. "We agree that breast
milk and breast feeding is optimal nutrition for all infants," says
Dr. Robert P. Stewart. "But the Vitamin D content of breast milk
is inadequate." To solve this problem, the researchers recommend
that dark-skinned infants should be supplemented with Vitamin D
drops, which are available over-the-counter.
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SURGEON GENERAL SETS
OPTIMISTIC GOALS FOR 2010
Surgeon General David
Satcher says he wants the number of tobacco smokers in the United
States reduced to 10 percent of the population by the year 2010.
That would be a signi- ficant drop from the 25 percent who now use
cigarettes and other tobacco products. In 1990, the percentage was
30 per- cent. However, Satcher says his goal is realistic if fed-
eral and state governments work to discourage people from starting
to smoke. Satcher recommends increasing the tobacco excise tax and
having state governments use their tobacco industry settlement to
expand health programs to help older smokers quit. He also wants
an increase in funding for programs to protect people from second-hand
smoke. In 1990, the surgeon general's office set a goal of reducing
smokers to 15 percent by this year -- a per- centage that has not
been achieved. Currently, it is estimated that 33 percent of teenagers
and 20 percent of adults use tobacco. In 1964, 43 percent of the
U.S. pop- ulation used tobacco.
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