Quality among health plans, doctors and hospitals varies a lot in this country. In order to make informed decisions, you need to know which ones do a better job than others at helping you stay healthy and treating you when you are ill. The tips below will help you find out how to choose a quality health plan, doctor and hospital.
Choosing a Health Plan
Your health plan affects many things:
• How much choice you have in your health care providers
• What kind of care you receive
• Where you will receive your care
• How much you will pay for your care
For this reason, if you have a choice of health plans, it is vital that you evaluate them carefully and choose the one that best fits your needs. If you are having a difficult time evaluating your health care options, contact the Professionals at E.B. Cohen Insurance & Risk Management to better understand your options.
If you’re trying to dig deeper into the quality of your health plan choices, ask the following questions.
What do current members think of the health plan?
One of the best ways to learn about a plan is to find out what existing members think about it. This information is called “consumer ratings” or “consumer satisfaction information.” Consumer satisfaction data is readily available to consumers in the form of a series of surveys called the Consumer Assessment of Health Plans (CAHPS). The results of CAHPS surveys are typically summarized into reports to help you compare health plans and make the best decision.
Ask your employer or the health plan in question if CAHPS surveys are available. If not, see if there is other consumer information available from your State Department of Health or insurance commissioner’s office.
Does the plan do a good job of preventing as well as treating illness?
Certain performance and quality measures (how well a health plan actually performs at helping people) are reported in the Health Plan Employer Data and Information Set (HEDIS). States, employers, health plans and other groups use the HEDIS data to prepare and publish reports for consumers. These reports, typically known as report cards or performance reports, provide a comparison of how well health plans prevent and treat illness, and may even provide member satisfaction and consumer ratings. Contact your employer or health plan, or your State Department of Health or insurance commissioner’s office for HEDIS information on a particular health plan.
Is the plan accredited?
Many plans choose to be reviewed and accredited (given a “seal of approval”) from various organizations that review and rate health plan quality. Contact the organizations listed below to see if a plan you are interested in has been accredited.
• The National Committee for Quality Assurance (NCQA) evaluates and rates managed care plans using more than 50 standards.
• The Joint Commission evaluates and accredits all types of health care organizations.
• The American Accreditation HealthCare Commission/URAC develops accreditation standards and programs for managed care.
Other questions you should ask include:
• Does the plan have the doctors and hospitals I want or need?
• Does the plan provide the benefits I need?
• Do the doctors, pharmacies and other services in the plan have convenient times and locations?
• Does the plan meet my budget?
Choosing a Doctor
Choosing a quality physician requires a great deal of care and consideration. If you are already enrolled in a health plan, your choices may be limited to doctors in your plan. However, if you have a choice of plans, you may want to select your doctor first and then choose a plan that includes your doctor.
Decide what you want and need in a doctor.
• Has he or she been rated highly by a consumer group?
• Does the doctor have experience with my condition(s)?
• Does he or she have privileges at a certain hospital?
• Is this physician part of my health plan?
Make a list of potential choices.
• Find out if a consumer or other group has rated the doctors in your area.
• The American Board of Medical Specialties can tell you if a doctor is board-certified. This means that the doctor has completed a training program in a specialty and has passed an exam to assess his or her training, knowledge, skills and experience to provide quality care in that specialty.
• The American Medical Association (AMA) can provide information on training, specialties and board certification about many licensed doctors in the United States. Use the DoctorFinder feature on the AMA’s website at www.ama-assn.org/.
Contact the doctors’ offices. Be sure the doctor is covered by your plan and is taking new patients. Ask other relevant questions to determine if the doctor will fit your needs, such as average wait times for appointments, if the doctor has experience or specialty in a particular disease, etc. If necessary, ask to speak directly to the doctor over the phone or in person.
Choosing a Hospital
Research shows that some hospitals simply do a better job than others. Keep the following questions in mind, even if you don’t have a choice because of health plan or physician constraints.
Does the hospital meet national quality standards?
Hospitals can choose to be surveyed by the Joint Commission to be sure they make certain quality standards. These standards address the quality of staff, equipment, and their success in treating and curing patients. Order free performance reports by visiting their website at www.jointcommission.org.
How does the hospital compare with others in my area?
Look at hospital reports compiled by your state or by local consumer groups. To find out what information is available, call your State Department of Health, a local health care council or local hospital association. Also, don’t hesitate to ask your doctor his or her opinion about a particular hospital.
Has the hospital had success with my condition?
Ask your doctor how often the procedure is done there, how often the doctor does the procedure and the success rate. Some health departments may publish “outcomes studies” about certain procedures.
How well does the hospital check and improve on its own quality of care?
Ask the hospital quality management department how it monitors and improves the hospital’s quality of care. Also, ask for any patient satisfaction surveys the hospital has done.
Consider these additional questions regarding the hospital:
• Does my doctor have privileges (permitted to admit and treat patients) at the hospital?
• Does my health plan cover care at the hospital?
• Does the hospital have experience with my condition?
Thoroughly doing your homework when it comes to the medical care you choose can pay off in the long run, in terms of cost, and especially in terms of quality of care.
To learn more, contact the Professional Insurance and Risk Management team at E.B. Cohen.