The San Diego Union-Tribune
It’s re-enrollment time again, the period each year when people can renew or switch their health plans.
Maybe you have moved or have a new job with a company whose medical insurance coverage offers a different array of doctors and hospitals than you had before.
Perhaps you have grown dissatisfied with your current physician or health maintenance organization.
Or possibly a change is needed to get better coverage for a certain drug or to see a particular specialist.
Health plan decisions, usually made from September through November, are both important and complicated. You need information, whether you are seeking a provider for conventional care or revolutionary, state-of-the-art treatments.
How do you find the right doctor, one who is affiliated with a fiscally sound referral network, one who is on staff with a quality hospital in an HMO that is responsive and right for you?
Few health consumers bother to do much checking, many experts say. Instead, they often rely on recommendations from friends or the sound of a name, or they randomly choose from the phone book, under the assumption all health care providers are essentially the same.
“There’s a lot more that every health consumer can and should do to take charge of their health care, to know more about the services they’ll get from their HMO, the doctors and hospitals their HMO contracts with,” said Joy Higa, deputy director with the state’s Department of Managed Health Care in Sacramento.
For example, Higa said, “we know that certain HMOs contract with better doctors and provide stronger coverage to treat certain serious chronic conditions such as diabetes, congestive heart failure and asthma than others.”
Certain HMOs “put significant resources into smoking cessation, prenatal services and prevention efforts compared to some other HMOs,” she said.
Patients also should make sure their plan covers special services, such as mental health care, pain management or weight reduction clinics they think they might need, she said.
Higa knows, because her agency has tried to resolve more than 300,000 complaints lodged by consumers in the last two years alleging denial of care, denial of insurance payment, poor quality and many other problems.
Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights in Santa Monica, agreed that people need to arm themselves with information.
“All too often, patients don’t want to prepare themselves so they don’t wind up … being a horror story, and that is a big mistake,” Court said.
More data needed
There are 45 health plans in California — about a dozen of them in San Diego County — that offer access to most of the 89,000 practicing physicians in the state. About 22 million people are enrolled in the plans.
Patient advocates lament that information about all health providers — physicians, medical groups, HMO policies, hospitals and legal disputes — is limited.
“There’s no question there’s really terrible information system disclosure at the worst possible time for the patient,” Court said.
That is gradually changing. More and more valuable data can be found on Web sites or by contacting consumer groups by fax or phone.
Many government agencies, nonprofit health consumer groups and employer coalitions are pushing to provide markers of quality that can be uniformly applied to a hospital or a physician who performs a particular procedure. They want that data posted on the Internet and updated regularly.
The Leapfrog Group illustrates how one organization is working to make all that happen.
Leapfrong, a national nonprofit coalition of employers who pay health insurance premiums, grew out of the 1999 Institute of Medicine report, “To Err is Human,” which quantified prescription, physician and hospital medical errors resulting in 98,000 patient deaths a year.
Leapfrog is trying to establish ways to measure individual hospital
improvements that reduce preventable patient deaths in the hospital and avoid longer or poorer recoveries.
Medical studies have documented that the more procedures done, the less chance of a medical error. So, Leapfrog’s Web site compares hospitals on the basis of statistics reported to the state on how often staff doctors perform seven procedures, such as esophageal cancer surgeries and high-risk neonatal deliveries.
The Leapfrog Group also has encouraged hospitals to report generally recognized markers of quality, such as whether doctors use special computers to digitally key in prescriptions for their patients. Computerized prescriptions aim to reduce drug and dosage errors resulting from misunderstood handwriting.
Not all of San Diego County’s 19 acute-care hospitals provide statistics about their performance. Leapfrog hopes that someday all hospitals in the nation will voluntarily disclose consumer information.
In another effort to help consumers select health plans, the state collects data for hospitals that perform coronary bypass operations.
A report by the Office of Statewide Health Planning and Development last year compared the frequency of bypass procedures with resulting mortality at each hospital in California. It concluded that the more times the hospital performed the operation, the fewer deaths.
Know your rights
Consumer advocates increasingly are focusing on public education campaigns to make patients aware of their rights.
“They have to be willing to be assertive, to know their rights and demand them,” said Martin Gallegos, director of the California Office of the Patient Advocate, a state agency created two years ago to protect patients’ rights.
All plan enrollees have the right to see a specialist for a chronic condition and to get a “standard referral” without having to return to a primary care provider periodically to update that referral.
Since 1999, California women have the right to choose an obstetrician-gynecologist as their primary care provider.
Patients also have the right to the same level of mental health services as HMOs allow for physical conditions.
Health plans “can’t put limits on the number of treatments covered for mental health care if they don’t have limits for other doctors or other diseases and conditions as well,” Higa said.
Increasingly important is a law, effective this year, that requires HMOs each quarter to update their lists of physicians. Some HMO were offering “phantom networks” of physicians who, in reality, were not accepting new patients, Higa and Gallegos said.
People also need to know whether the medical groups their doctors belong to are financially sound.
Consumer organizations want medical groups to reveal more information about their financial standing because there is evidence that a fiscally troubled physicians group may limit care, said Daniel Zingale, head of the California Department of Managed Health Care.
Zingale said that when medical groups falter and go bankrupt, as several have in recent years, “it’s often extremely difficult for patients to access their medical records for follow-up care.
There also may be problems getting specialist referrals or certain drugs prescribed, he said.
“Some of the medical groups and HMOs that got into deep financial trouble… stopped returning results of X-rays and mammograms to their patients,” Zingale said. “Instead, the records were going into a black hole, with the patients never getting told the results.”
He said the Department of Managed Health Care has reviewed “thousands of cases in which the department issued $2 million in penalties” to physician groups that failed to provide access to medical records.
“Some of the cases involved patients with serious conditions who needed access to information to gauge their progression,” Zingale said.
Walter Zelman, president of the California Association of Health Plans, which represents 32 of California’s health plans, said information on plans is easy to find, but not so with doctors.
Zelman said what is needed is comparative Internet ranking of doctors by how satisfied their patients are, and the success rates for surgeons and other doctors who perform certain measurable procedures. The Internet ranking also should provide statistics on how many of a surgeon’s patients died, Zelman said.
Another way for consumers to size up things is checking to make sure that plans will pay their medical bills.
Zingale said if he were picking a health plan, he would first go to a doctor or medical group and “ask to see records in terms of timely payment of doctors, and if they say no, it may be reason to worry.”
he Web site for the state’s Department of Managed Care had posted four measurements of medical group financial health, including whether the group paid 90 percent of the amount it owed within the 45-day legal limit. Last spring, the site was removed after a court action filed by the California Medical Association successfully challenged the department’s efforts to collect more
Even so, there is still financial information accessible to consumers.
Last week the Office of the Patient Advocate posted its report card on California HMOs and the 81 largest medical groups. Rankings were based on patient satisfaction, quality of care and availability of non-English speaking services. The information comes from patients’ reports and voluntary reporting on physician performance by health plans.
Patient Advocate’s Gallegos said consumers have access to more information than ever before, “but there’s a lot more work to do.”
“We hope to continue to see expansion of reporting to get more detail that’s useful,” he said.
Dr. James Knight, president-elect of the San Diego County Medical Society, which represents area physicians, applauded the effort to provide more information on patient care quality.
“As consumers begin to pay more of their health care costs today, they will rightly demand information systems that enable them to discover the cost and quality of services” before they need it, Knight said.
Knight said those systems “don’t now exist in the form they should, but people are waking up that this is the kind of stuff they need to know.”
contact Cheryl Clark at 619-642-4573 or [email protected]