Health insurance provider rating

Q

In an article in the December 15 issue of Newsweek, health maintenance
organization (HMO) plans nationwide are listed and evaluated. I was
distressed to learn that out of 88 plans ranked, PacifiCare of Colorado
(formerly FHP) came in at number 59. Its overall HMO ranking was only a C,
and to my greater distress, I found that "kids' care" earned straight D's!
Since this is my health care provider (and provider to many others at UCAR
also), I wonder what, if anything, UCAR will do about this. Isn't it
logical to look around for another plan that will perform better for our
work force? At the very least, shouldn't PacifiCare be notified that UCAR
has a corporate concern about this dismal showing and asked how it will
clear up its deficiencies? Although I'm not a subscriber to Kaiser, I have
to say I was pleased to note that the Kaiser Foundation Health Plan of
Colorado scored 11 out of 88, with an overall ranking of A. While I'm not
totally loath to consider switching to Kaiser, I'm aware of its limitations
and concerned about the number of chronic, preexisting conditions my family
members deal with, and the difficulty and delicacy of starting all over
again with a whole new batch of doctors.

Answered on December 16, 1997

A

The writer brings up questions that all consumers of medical services
(that is, all of us, sooner or later) should consider. We should all take
an interest in the quality of medical care and look at alternatives that
will address our individual needs.

The Newsweek ranking is a new one for me. We use different tools to
measure the quality and cost of health care providers, such as the Health
Plan Employer Data and Information Set. HEDIS reports are prepared under
terms established by the National Committee for Quality Assurance. Nearly
all HMOs prepare HEDIS reports, and we get one each year from PacifiCare.
NCQA has a Web site which has information about PacifiCare and its
accreditation by NCQA.

Reading the article in Newsweek, I see they used many of the ratings
found in the HEDIS report. For young and growing families, Newsweek used
prenatal care during the first trimester, cesarean-section rates, and
childhood immunization percentages. A summary of Newsweek's interpretation
of each category and the most recent HEDIS data on PacifiCare follows.

o Prenatal care. Newsweek says an HMO should show a rate of
prenatal care provision for pregnant patients of 87.5% or higher. For the
total population covered by PacifiCare's Colorado HMO, the rate among
pregnant patients is 81.3%.

o C-section rates. Newsweek says a rate of no more than 15% is
appropriate. PacifiCare's rate is 17.5%. Newsweek says an HMO should track
the rate of vaginal deliveries for women who have had an earlier C-section;
PacifiCare does.

o Childhood immunization percentage. Newsweek says 65% or higher.
PacifiCare's HEDIS number is 60.1%, and this number is a bit misleading,
because when you look at the percentage by type of immunization, PacifiCare
runs 77% to 88%. The methodology in the HEDIS report downgrades the average
if children do not have all recommended immunizations by their second birthday.

Now what do these statistics mean to employees at UCAR?
Unfortunately, our population of employees covered by the HMO is too small
to get statistics on our group only. But I would guess that most of our
folks who need prenatal care get it, and all families who want their
children immunized have done so. Based on the plan experience, we do not
think surgeries are being overutilized under PacifiCare EPO/HMO, so this is
probably not an issue for UCAR, either.

Why does Kaiser rate higher than PacifiCare? Both plans provide about
the same level of benefit (for example, both pay for immunizations), yet
Kaiser has better statistics. My guess is that this is due to the makeup of
the two HMOs, which are designed very differently. The Kaiser model is
clinic-based (a staff model) and participants use Kaiser doctors for most
care, especially for routine medical care. The PacifiCare model uses
individual physicians or physician groups and participants may select from
a list of primary care physicians. Obviously, Kaiser has much more
supervision over its own physicians so it can ensure that procedures such
as immunizations by the second birthday are better controlled. Kaiser also
maintains strong relationships with patients and actively works on
preventive care. If you look down the Newsweek ratings, Kaiser rates high
in many parts of the country. We feel Kaiser offers high-quality care and
believe it is a very good option for UCAR employees, especially those who
are looking for a group-based HMO.

Employees who select PacifiCare as an HMO have more flexibility in
picking physicians. With flexibility comes responsibility. All the
physicians on PacifiCare's list have met quality standards but maintain
their own practices. There is less of a consistent practice plan among
these physicians than would be found under a Kaiser-type plan. Employees
need to select physicians carefully and be involved with their treatments.
We believe PacifiCare has a network of high-quality providers and is
another very good option for UCAR employees, especially those who want to
select their own primary care physician.

After saying all this, I should note that PacifiCare has a plan to
raise its HEDIS ratings. In all cases, PacifiCare's goals are higher than
the levels in the Newsweek rating. We will continue to monitor the HEDIS
report for PacifiCare, and we hope to eventually have a custom UCAR report
so we can monitor the effectiveness of our own group plan.

When it comes down to it, each of us needs to ask if we are happy
with the care we are getting from our physicians. Kaiser's plan works for
some employees, PacifiCare's HMO for others, and many of our employees opt
for the PPO plan, which provides a great deal of flexibility and
responsibility.

--Bob Roesch, Manager, Human Resources