Access and Service

Purchasers continue to be concerned that their members have access to adequate and appropriate health care when they need it and that the HMO is sensitive to the needs of their members. Because HMOs contract selectively with physicians, hospitals and other providers, it is important to ask careful questions to assure that service providers are accessible. Listed below are some questions that many consider important to ask your health plan representative before offering that plan to your employees. They should be able to give you answers about their plan as well as an industry norm as a point of comparison. This is not intended as a complete list, but a starting point for dialogue with the health plans.

Access to the Delivery System

How do members access primary and specialty care?
HMOs require that members choose a primary care physician from among a panel of providers. The primary care physician is responsible for coordinating preventive services and referring patients to specialty care when necessary. Many HMOs permit direct access to OB/GYNs, behavioral care specialists, and other specialties.
Can members choose a physician who is not part of the health plan's network of providers?
A physician can refer a member for medically necessary care to another physician who is not part of the network. Plans differ in their coverage of services for self-referrals to non-network providers.
How do members access care when they travel outside the health plan's primary location?
All HMOs in Pennsylvania provide coverage for valid emergencies when traveling outside the primary service area of the plan. However, coverage and method of treating urgent care outside the area vary widely.
How large is the HMO and the HMO network of providers?
The scope and availability of providers is as important as the total number of providers. Make sure that the right type of providers are available to serve the needs of your group.
What is the ratio of members to primary care physicians in your service area?
It important to know how many members on average are served by each primary care physician. That number should reflect your service area - not the entire service area of the plan. Plans should provide a current list that also indicates how many, by specialty, of the primary care physicians (PCPs) are accepting new patients.
What are the health plan's standards for geographic proximity to providers and hours of operation?
A group may require, for example, that 90 percent of its members live within 10 miles of a primary care provider. However, there are no hard and fast standards for physician-to-population ratios, nor are there rules for distance to travel. Factors such as terrain and public transportation will influence the standards for your group.
What percentage of claims for visits to a hospital Emergency Room (ER) were denied by the plan during the reporting year? And how does that compare with industry averages?
Health plans want to discourage inappropriate use of services such as the use of the emergency room for non-urgent care. Not only is it more expensive, but treating non-urgent care in the ER may delay treatment for a genuine emergency. Plans may extend primary care office hours or provide educational outreach to encourage more appropriate utilization of the ER. A high denial rate for ER visit claims may be an indicator that a plan needs to do a more effective job to encourage appropriate alternatives.
Where do you refer patients for specialty care? How are they selected?
A plan should be able to provide outcome statistics to support a decision to include a specialty provider in its network.
How are physicians selected, recredentialed and compensated?
Health plans use various criteria to recruit physician and hospital providers. For example, board certification is often used as one requirement for physician credentialing. You should ask about the plan's criteria for selecting physicians and hospitals and also how often the plan checks to see that the provider credentials are maintained.
Plans differ in the way physicians are compensated. Some plans may provide incentives to reduce the use of services. Some plans have developed programs to improve physician performance. Member satisfaction surveys are sometimes used in the formula to determine compensation for a primary care physician. You should ask if your plan uses these or other programs.

Member Services

How are complaints or grievances handled?
The Department of Health approves complaints or grievance procedures for HMOs as a condition for receiving a Certificate of Authority to operate in Pennsylvania. Ask to see those procedures and ask how quickly grievances are handled by the health plan.
How many grievances per 1,000 members were filed and how many were appealed to the Department of Health? How many were resolved in favor of the member?
Grievances are one way to assess member satisfaction with service and service providers. Not only is the number of grievances useful information, but the average length of time in answering a grievance may be an indicator of the sensitivity of the plan to consumer complaints.
What are the results of patient and consumer satisfaction surveys?
Some health plans survey their members about how satisfied they have been with services. Many of the questions are targeted at specific service areas. There is usually at least one question about overall satisfaction. The plan should be able to report the results of the surveys and indicate how the plan uses the patient satisfaction survey results as part of its quality improvement efforts.
What is the voluntary disenrollment rate? How does that compare with state or national benchmarks?
Surveys indicate that most people who change health plans do so because they change jobs or their employer changes health plans. However, plans closely monitor their voluntary disenrollment rate. When the disenrollment rate is not related to price competition, it may be an indicator of member dissatisfaction with the managed care organization (MCO). Price competition can occur as a result of the MCO's premium or the efforts of employers to steer employees by subsidizing the contribution rates.