HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

Executive Summary

The Health Rights Hotline is a pilot program funded by three private foundations to help individual consumers resolve problems with the health care system in a four-county area around Sacramento, California. Beyond helping individual consumers, the Hotline’s mission is to share with health plans, medical groups, legislators, and others information on consumers’ experience in order to improve the health care system.

In its first year providing services, the Health Rights Hotline assisted over 2,400 individual health care consumers. This report analyzes the issues and types of problems raised by consumers for the period July 1, 1997 through June 30, 1998. It includes problem rates for specific health plans and medical groups as reported by Hotline callers, and compares problem rates based on how individuals get coverage, the type of health plan, and various demographic characteristics. The report also provides recommendations to health plans and medical groups on ways that they can improve services to their members/patients and advice to consumers on how to avoid or fix problems.

The data reflects consumers’ perspective of problems and issues – the Hotline does not judge who is at fault (a physician, medical group, health plan or the consumer him or herself), and does not determine whether a complaint is justified. Analysis of the problems and issues reported by callers is based on the rate of issues, rather than raw numbers. In addition, each rate is assessed for its statistical significance.

Using this Information

The Health Rights Hotline hopes that this information will be used, along with other sources of information, by consumers and employers to evaluate health plan choices and to gain a better understanding of how the health care system works and how to avoid or fix problems. By being an independent source of information, the Health Rights Hotline can also help to confirm problem identification or point out areas that require further research or investigation by health plans and/or regulators, thereby fostering improvements in the health care system.

Major Findings from the Health Rights Hotline

• Consumers are confused by a complex health care system and need assistance. Many consumers don’t understand how managed care works or how to use existing resources.
• Consumers ARE having problems in managed care and the experiences reported by the Hotline’s callers are likely representative of those facing all consumers. Consumers are having an array of problems in managed care, many of which relate specifically to the changes in how health care is delivered: problems with authorizations, access to specialists, use of non-approved medications, and poor communication and coordination among individual physicians, medical groups and health plans.
• Outreach is a challenge with relatively limited resources and no prior history to generate referrals. The fact that the Hotline was not swamped by calls in its initial year underscores the challenge of informing consumers about new resources.
• An individual’s personal characteristics or circumstances can have a large impact on the likelihood of their reporting a difficulty. The results of the Hotline’s first year indicate not only that all health plans are not alike, but also that a consumer’s likelihood of reporting a problem varies dramatically.
• Consumers in Medicare HMOs are far more likely to call for assistance than are consumers in commercial/private health plans.
• Consumers in Medi-Cal are more likely to report difficulties whether they are in an HMO or in fee-for-service than are commercially insured individuals.
• Women are two times as likely to seek assistance from the Health Rights Hotline as are men.
• Hispanics are far less likely to seek assistance with problems than are other ethnic groups.
• Consumers in Network HMOs – those that contract with a number of medical groups – are more likely to report problems than are consumers in a Group HMO (Kaiser Foundation Health Plan, the area’s only Group HMO) or in Preferred Provider Organizations (PPOs). This finding is consistent with the observation that many consumer problems relate to misunderstandings about the roles of and relationships among doctors, medical groups and health plans.
• Consumers’ problems are as likely to be with their medical group or doctor as with their health plan. Many of the problems reported by callers appear to be with the medical group or individual doctor, and not originating with the health plan.
• There are dramatically different rates at which consumers in different health plans call the Health Rights Hotline for assistance. The differences between these health plans warrant attention by the health plans themselves and by consumers.
• Consumers in different medical groups call the Health Rights Hotline with problems at very different rates. Just as with health plans, the differences in problem rates for medical groups warrant attention by the groups, the health plans that contract with them to provide services, and by consumers.

Ways to Reduce Problems

The Health Rights Hotline has identified many concrete steps that health plans and medical groups can take to prevent problems from occurring and that consumers can take to avoid or fix problems that arise. The report details specific advice relevant to each of the major problem areas. Some examples are:

Ways Health Plans and Medical Groups Can Reduce Consumers’ Problems

• Provide clear information to consumers as well as to providers on health care consumer rights and responsibilities, and health plan and medical groups’ policies and procedures.

• Educate consumers, through customer service contacts, newsletter articles, and informational flyers or posters in provider offices, about how to resolve difficulties; information should include options (in-plan or out-of-plan) for voicing complaints.

• Take ownership of consumer problems by ensuring customer service representatives can answer questions or help consumers find answers when the problem arises at another level (health plan, medical group or provider). Avoid "passing the buck."

• Provide easily understood and accessible appeals processes. Implement an independent review process for denials of care.

• If care is denied, issue written denial statements that clearly explain the reasons for the denial, the information considered and relied upon in making the treatment decision, the alternatives available to the consumer, and the process for appealing the denial.

• Establish and publicize ways for consumers with special health care needs to have their needs met without unnecessary administrative hurdles. (Examples include: allow for ongoing visits to specialists without constant reauthorizations, and make procedures for non-formulary drug authorizations known and easy to use.)

How Consumers Can Take Charge of Their Health Care

• Understand what sort of health plan you are in, how it works, your rights and responsibilities and where to go if you have problems.

• Communicate with your doctor – he or she can and should be your most effective advocate.

• Be an informed patient – understand your medical condition and treatment options.

• If you have a problem, identify the source – it could be with your doctor, at the medical group, with your health plan, or because of benefit limitations set by your employer.

• Learn how to be your own advocate – be persistent and keep good records.

• Don’t go it alone – problems often arise when you are least able to address them. Ask for help from your health plan’s customer service office, a family member, friend, your employer, insurance broker, or an independent program like the Health Rights Hotline.