Evaluating health plans Featured

10:52am EDT July 31, 2002
Many employers make health plan decisions based on a combination of factors -- the cost of premiums, benefits and the size of the network. They also make decisions based on quality, although quality is intangible and sometimes difficult to evaluate.

For help, employers can turn to standards for evaluation such as those provided by the National Committee for Quality Assurance (NCQA), a private, not-for-profit organization dedicated to improving the quality of health care throughout the country.

NCQA evaluates health care quality through such things as accreditation, which involves a rigorous on-site review of a health plan's clinical and administrative processes, and through the Health Plan Employer Data and Information Set (HEDIS), a tool to measure a plan's performance in areas such as immunization and mammography screening rates.

Premium amounts alone may not always reflect the true costs -- or benefits -- of quality. Indirect costs, such as productivity, sick days and related wages, also need to be considered. Many illnesses cost a tremendous amount of money in lost work time.

For example, the NCQA reports:

* Estimated indirect costs in the United States for asthma total roughly $3.8 billion.

* Major depression costs about $23 billion in lost workdays.

* People with heart disease lose an average of 12 extra days of work and 17.3 bed-disability days each year.

* Smokers are out between two and five-and-a-half more days each year than nonsmokers.

Such numbers illustrate why a health plan's commitment to preventive care services can serve as an important indicator of quality. Effective health plans offer preventive health care initiatives such as:

* Outreach programs to encourage women to have mammogram screenings

* Disease management programs for people with chronic conditions

* Beta-blocker initiatives for people who've had an acute myocardial infarction, when deemed medically appropriate for preventing a second heart attack

* Prenatal education programs

* Preventive care reminders sent out yearly to plan participants about preventive care services recommended for people in their age and gender group

* Newsletters with practical information on preventive care.

Employers should pay attention to quality because high-quality plans tend to result in a healthier work force, which has a positive effect on the bottom line. But a recent Watson Wyatt report shows that employees place a high priority on quality, too.

Almost 90 percent of consumers surveyed feel that access to quality care is one of the most important factors to consider when choosing a health plan, an increase from a similar report five years earlier.

Consumers are now more likely to recognize that differences in the quality of health plans, hospitals and specialists do exist. Fortunately, there are solid tools available for judging that quality. Jeanne McCarthy is president and general manager of CIGNA HealthCare - Ohio region, headquartered in Cleveland. CIGNA HealthCare is one of the nation's leading providers of health-benefit programs, with managed care networks serving 45 states, the District of Columbia and Puerto Rico. CIGNA HealthCare currently provides medical coverage through managed care and indemnity programs to more than 13.3 million people, including more than 250,000 in major Ohio markets. Reach her at (800) 541-7526.