How to find quality in health insurance Featured

8:01pm EDT April 30, 2011
How to find quality in health insurance

Quality is something that consumers look for in almost every purchase they make. That includes both health care and health insurance.

But trying to define what quality means in terms of health insurance and what quality should mean to an employer trying to make choices for his or her company’s health coverage is not an easy thing to do.

“There are many aspects of health care quality and health insurance, but the simplest way to define quality in health insurance terms would be access to quality care,” says Sandra McAnallen, the vice president of network and provider relations for UPMC Health Plan. “Providing that access is what helps people to get the right care in the right place and at the right time as well as providing them with an excellent experience in terms of member service.”

Smart Business spoke with McAnallen about understanding what quality means in health insurance terms and its importance to employers.

How can an employer determine quality in health insurance plans?

Quality is a difficult thing to measure accurately, but there are certain measures that employers should look for and specific questions an employer can ask to determine if a health plan can deliver it.

For instance, for any health insurance plan you are considering, you need to research that plan’s network of hospitals and physicians for broader geographic coverage and specialty services. In many instances, a health plan’s directory of providers is available online.

A second thing to look for is accreditation. An accredited provider organization such as a hospital or a health plan is one that has met the standards of an independent organization. There are many national organizations that review and accredit health insurance plans and institutions. For hospitals, the Joint Commission accredits and certifies more than 18,000 health care organizations and programs in the U.S. Accreditation and certification from the Joint Commission is given to organizations that meet certain performance standards. The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that regularly measures the quality of care delivered by the nation’s health plans.

Is there any way to compare plans?

The NCQA provides information on health insurance plans that can be viewed at its website. You can see if a plan is accredited and compare its quality of care and member satisfaction scores with other plans. The NCQA’s website is:

You could also look for state-specific reports to find out the rate of complaints for a health plan and the hospitals it uses. Also, you can look for stories about the health plan in various publications, such as magazines and newspapers.

How does a health plan demonstrate quality?

A high-quality health plan promotes effective and efficient care in a timely fashion with no disparity among social economic groups and a satisfactory experience with member services. A health plan should enhance its members’ experiences with its care and services and by promoting effective and efficient care. Members should be assured that they would receive the recommended care for all of their health needs including preventive services and care management for heart disease, diabetes, respiratory conditions, pediatric care, women’s health and behavioral health. The recommended care will lead to improved health and eventually lower costs.

For health plans, quality is a concept that is not limited to the delivery of health care services. Quality goals are focusing on improving population health, enhancing customer experience and managing appropriate medical utilizations and cost containment by applying evidence-based medicine and avoiding unwarranted variations.

What are other quality measures that an employer should look for in a health plan?

You need to investigate how the health plan ensures good medical care. Are doctors’ qualifications reviewed before they are added to the plan’s network? Is the care provided by a health plan’s doctors and hospitals reviewed on a regular basis? Does the health plan review its own services and make the changes needed to correct the problems? How are member complaints handled? Those are all questions that should be asked and answered.

Talking with current members of the plan to learn of their experiences also can be helpful. They may know if the health plan offers specific programs designed to deal with certain conditions. Specifically, a wellness program to promote a healthy workplace would be an important quality from an employer’s perspective.

Sandra McAnallen is the vice president of network and provider relations for UPMC Health Plan. Reach her at (412) 454-8770 or