| HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers |
The Health Rights Hotline helps consumers access needed health care by providing free, independent information and assistance with their health care rights in a four-county area around Sacramento, California. Through collecting, analyzing and reporting on the experiences of the Hotline's callers, the Hotline seeks to improve the health care system so fewer problems will arise in the future.
This report covers the Hotline's second year of providing services, from July 1, 1998 to June 30, 1999. During this period, the Hotline directly assisted over 3,500 individual consumers, an increase of nearly 50% from the first year. The report focuses primarily on the experiences of both insured and uninsured individuals who were served by Hotline counselors. While every day the Hotline makes recommendations to consumers on how to navigate the health care system - through outreach efforts and in response to calls - this report makes recommendations to health plans, medical groups, policymakers and regulators on actions they can take to improve the health care system for consumers.
It is not uncommon to think that people who have health insurance do not have problems getting health care. The experiences reported to the Health Rights Hotline tell a different story. This report gives voice to the many consumers who have problems getting care for which they have coverage. Problems involving delays in getting care, denials of care, disagreements over benefits and problems getting specialty care or prescription drugs all may limit consumers' ability to access needed care. This report highlights the difficulties consumers can have getting needed care if they do not know how to navigate an increasingly complex health care system.
Although most of the Hotline's callers have health coverage, a large and growing number of Hotline callers did not have insurance. The report identifies some of the problems experienced by the uninsured and recommends actions to increase access to health care for those who lack insurance.
Many consumers are still having problems with their health plan or insurance. Callers to the Hotline continue to report problems with care being delayed or denied, payment problems and inappropriate care received. The reported problems are largely consistent with the prior year's calls to the Hotline and track closely to the findings of a 1997 independent, random survey of Sacramento area consumers.
Recommendations: Health plans and medical groups need to better educate people how to use the system. California's new Department of Managed Care needs to work with a range of groups to insure effective implementation of the wide-ranging package of managed care reforms that were enacted in 1999. Effective implementation of improved consumer rights holds out the promise of addressing some of the most pressing problems heard repeatedly by the Hotline.
The largest single category of reported problems relate to concerns about the quality of care received. While most problems reported to the Hotline relate to "managed care" (the systems put in place to control or coordinate access to care), many consumers called the Hotline because they felt they had received poor care. Quality problems - characterized as patients receiving too much, too little, or the wrong care - often may not readily be apparent to consumers. However, reports by callers of quality concerns represent a growing awareness by consumers that being a "passive patient" may not be a healthy choice.
Recommendations: Health plans should educate consumers about how they can promote the quality of care they receive. Consumers need to understand their treatment options including drugs prescribed and fully participate in decisions regarding their care. In addition, there needs to be system-wide efforts to reduce poor quality care and prevent avoidable errors from occurring. Health plans, medical groups, regulators and purchasers need to monitor the care provided to patients and take timely action to ensure that high standards for quality care are met.
The source of consumers' problems frequently appears to be with their medical group or doctor rather than with the health plan. Although the public perception frequently is that health plans are the source of consumers' problems, Hotline counselors have found that consumers' problems more likely stem from an individual physician or medical group. As the relationships between health plans and medical groups have changed, medical groups have become increasingly responsible for decisions that were once made by health plans.
Recommendations: Purchasers and policymakers need to give consumers objective information about choices among medical groups. In addition, medical groups should be monitored for the quality of care provided, their tracking of consumer complaints and their financial capabilities to pay for needed care.
Consumers in Network Model HMOs report problems at a significantly higher rate than do consumers in other types of health plans. Overall the rate at which consumers in Network HMOs report problems is three times higher than for consumers in a Group HMO or a PPO. Consumers' problem experience is not simply with "managed care," but with how care is managed. All too often there is poor coordination between HMOs and the medical groups with which they contract.
Recommendations: Network Model HMOs and their contracted medical groups need to better coordinate their activities. Consumers' problems should be handled at the first point of contact - whether it's the HMO or the medical group - rather than being passed back and forth. Health plans and medical groups need to educate consumers about how their choice of medical group can limit their care options. In addition, HMOs specifically must ensure that in the event a contracted medical group goes bankrupt, consumers are not billed for services.
Insured consumers frequently do not know what to do when they have a problem. While the health care system has gotten more complicated, many consumers do not know where to turn for help. Over sixty percent (61%) of health plan members who were directly assisted by the Health Rights Hotline had not contacted their health plan prior to calling the Hotline. Of these callers, nearly half (46%) said that they had not called their health plan because they didn't know what to do or they didn't think it would do any good.
Recommendations: Health plans and medical groups need to improve their communication with enrollees and make information about grievance and appeals processes easily available to members. The new Department of Managed Care should refer consumers to local independent assistance programs around the state and not just back to their health plans. By establishing clear referral protocols and tracking its referrals, the Department will be positioned to assess the benefit provided by its own efforts and those of local independent assistance programs.
Consumers who try to resolve issues with their health plans often disagree with the plan, find the plan to be unhelpful, or want independent verification of information provided by the plan. For those consumers who did try to resolve problems with their health plans prior to calling the Hotline, nearly two-thirds (64%) disagreed with the plan's decision or found the plan to be unhelpful.
Recommendations: Health plans should follow up with written information after contacts with enrollees over the phone. In addition, they should provide clearer explanations of their decisions and detailed information on the steps that consumers can take if they disagree with the plan.
Health plans and medical groups generally do a poor job communicating with consumers about decisions to deny, delay or modify care. The Hotline analyzed hundreds of health plan and medical group letters to consumers and found that neither health plans nor medical groups provide much information regarding how denial decisions are made and what consumers can do when they disagree.
Recommendation: The new Department of Managed Care must ensure legislation is effectively implemented that clarifies health plan obligations to communicate clearly the basis for denial decisions. The Department should work with health plans, medical groups and consumer organizations to develop letters and notices that are easy to understand and provide sufficient information regarding the basis for plans' decision, explains consumers' rights and specifies next steps consumers can take.
Medicare beneficiaries enrolled in HMOs report problems at a much higher rate overall than Medicare beneficiaries who receive their care on a fee-for-service basis. Overall, Medicare beneficiaries in HMOs reported problems at more than three times the rate of Medicare beneficiaries who are not enrolled in HMOs (e.g. those who get care on a fee-for-service basis). It appears that health plans have had a much higher success rate enrolling Medicare beneficiaries than they have in explaining how seniors can navigate the health care system.
Recommendations: Health plans need to educate Medicare beneficiaries more adequately about how to use the health care system and they need to educate providers about Medicare coverage issues. In addition, the Health Care Financing Administration and the California Department of Health Services need to significantly improve their coordination of benefits for Medicare beneficiaries who also have Medi-Cal coverage.
Consumers report problems at significantly different rates depending on their type of health plan and their source of coverage. Medicare beneficiaries in HMOs reported problems to the Hotline at over five times the rate of commercially enrolled HMO members (45.3 per 10,000 enrollees compared to 8.4) and Medi-Cal beneficiaries in HMOs reported problems at a higher rate than commercial HMO members (13.3 per 10,000 enrollees compared to 8.4).
Recommendation: The Health Care Financial Administration (HCFA), the California Department of Health Services (DHS), the California Department of Corporations (DOC) (and its successor the Department of Managed Care), and the health plans themselves, should compare the experiences of consumers based on their type of plan and their source of coverage. Regulator and purchaser oversight of health plans needs to use data from a variety of sources, including consumer surveys, performance data and complaint data from internal and multiple external entities. The California Department of Corporations, in particular, needs to deepen its analysis and presentation of complaints received on its hotline to distinguish health plans performance based on their commercial, Medi-Cal and Medicare enrollees.
Consumers want better information on how to make health care choices. Many Hotline callers wanted informational tools that would help them make better choices. The top two inquiries that were not "problems" related to how to choose a health plan or medical group and how to understand a health condition.
Recommendations: Employers need to engage their employees in decisions about what coverage will be offered and small employers should consider offering multiple coverage options. Public and private purchasers, together with the Department of Corporations, should develop and distribute comparative information about health plans and medical groups. Beyond providing information on how consumers can choose between health plans and medical groups, doctors, medical groups and health plans should work with health condition organizations to make available information about treatment options (regardless of whether a particular course of treatment is a covered benefit) for a wide spectrum of health conditions.
Many Hotline callers without health coverage report problems trying to obtain coverage because they do not understand or qualify for public programs, cannot afford coverage, or because they have a pre-existing condition. While the Hotline can and does assist those who need help getting enrolled in programs such as Medicare, Medi-Cal and Healthy Families, for many callers there is not an easy resolution. Daily, the Hotline hears the voices of consumers who represent the seven million Californians who do not have health coverage because they cannot afford it, are precluded from getting it, or do not understand how complex application processes work.
Recommendations: Improving the health care system must include making the system work better both for those who have coverage today and for those we hope will have coverage tomorrow. Private employers, as well as government at the local, state and federal levels need to expand coverage opportunities to reach those who currently are not insured.
Below please find the Summary of Health Plan and Medical Group Problem and Consumer Education Rates Reported in the Sacramento Area, July 1998 - June 1999.*
* These files are available in PDF format. You will need Acrobat Reader in order to view them. If you need to download a free copy of Acrobat reader, click here.
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