Health Plan Options Research Articles

Moving to Personalized Medicine Requires Personalized Health Plans.

When individuals, families, and employers select health plans in the United States, they are typically only shown the financial structure of the plans and their provider networks. This variation in financial structure can lead patients to have health plans aligned with their financial needs, but not with their underlying nonfinancial preferences. Compounding the challenge is the fact that managed care organizations have historically used a combination of population-level budget impact models, cost-effectiveness analyses, medical necessity criteria, and current medical consensus to make coverage decisions. This approach to creating and presenting health plan options does not consider heterogeneity in patient and family preferences and values, as it treats populations as uniform. Similarly, it does not consider that there are some situations in which patients are price-insensitive. We seek to highlight the challenges posed by presenting health plans to patients in strictly financial terms, and to call for more consideration of nonfinancial patient preferences in the health plan design and selection process.

Medicaid's Public Health Plan Options.

Medicaid's Public Health Plan Options.

The ACA's Choice Problem.

The Affordable Care Act (ACA) is in many ways a success. Millions more Americans now have access to health care, and the ACA catalyzed advances in health care delivery reform. Simultaneously, it has reinforced and bolstered a problem at the heart of American health policy and regulation: a love affair with choice. The ACA's insurance reforms doubled down on the particularly American obsession with choice. This article describes three ways in which that doubling down is problematic for the future of US health policy. First, pragmatically, health policy theory predicts that choice among health plans will produce tangible benefits that it does not actually produce. Most people do not like choosing among health plan options, and many people-even if well educated and knowledgeable-do not make good choices. Second, creating the regulatory structures to support these choices built and reinforced a massive market bureaucracy. Finally, and most important, philosophically and sociologically the ACA reinforces the idea that the goal of health regulation should be to preserve choice, even when that choice is empty. This vicious cycle seems likely to persist based on the lead up to the 2020 presidential election.

More intelligent designs: Comparing the effectiveness of choice architectures in US health insurance marketplaces

We examine the effectiveness of alternate choice architectures for health plan choice in US marketplaces under the Affordable Care Act (ACA) using three experiments based on the Health Reform Monitoring Survey: two experiments tested how choice architectures used in presenting information on health plans influenced plan choices and how existing designs could be improved; the third experiment checked the robustness of the choice architecture effects to more naturalistic choice scenarios in which consumers select plans when future medical spending is uncertain. More vulnerable consumers (e.g., worse health, lower literacy) experienced the largest relative improvements when ACA marketplace plans were displayed and sorted by total expected costs for the year rather than premiums (Experiment 1). The benefits of sorting plans by total expected costs was not improved further by making the importance of total expected costs more salient or by providing just-in-time education about such costs (Experiment 2). However, just-in-time education increased the likelihood consumers did not choose a plan, suggesting they may be in the process of updating their plan selection strategy given the new information. Broadly, these results were consistent across alternative scenarios where total expected costs were subject to uncertainty and consistent with expected patterns of consumer behavior under risk aversion (Experiment 3). Thus, a policy-feasible mechanism—sorting health plan options by and highlighting total expected costs—may improve health plan choices, saving money for consumers and the government.

How Common are Dominated Health Plan Options? Evidence from Employer Health Benefits with High-Deductible Plans

We analyze detailed data on plan designs from the Kaiser Family Foundation Employer Health Benefits Survey for 331 firms that offered employees both a qualifying high-deductible health plan and a lower-deductible option. For an employee at these firms selecting the lower-deductible option will decrease the deductible by $1,300 on average. However, the cost of that additional coverage for the employee, from increased employee premiums and forgone firm contributions to health savings accounts, is nearly as large, averaging $1,100. In 65% of firms the high-deductible option would result in lower maximum possible spending for the employee for the year. Further, we estimate based on simplified plan representations that the high-deductible plan financially dominates the lower-deductible option for employees at roughly half of the firms. Employees facing a range of possible medical-spending distributions would save on average over $500 per year with the high-deductible option, often with no additional annual financial risk. While we cannot pin down the mechanism behind these patterns conclusively, the evidence is consistent with firms passing through lower average costs for high-deductible plans generated by adverse selection patterns to the employees choosing those plans. These results raise questions about the net effect of offering employees choices over plans with different coverage levels. Rather than creating a classic trade-off between risk and expected spending, at many firms plan options generate disparities in overall benefit value for employees who opt into different levels of coverage.

The accuracy of dermatology network physician directories posted by Medicare Advantage health plans in an era of narrow networks.

IMPORTANCE Insurers are increasingly deploying “narrow networks” with fewer contracted physicians both in health plans offered in new state exchanges under the Affordable Care Act and in Medicare Advantage (MA) plans, which are commercial alternatives offered to Medicare beneficiaries. Patients choosing health plans rely on the accuracy of network directories posted by insurers. The MA plans must meet network adequacy requirements,and inaccurate directories of participating physicians might prejudice those determinations.OBJECTIVE To determine the accuracy of MA plan directories of participating dermatologists,and the appointment availability of listed physicians.DESIGN, SETTING, AND PARTICIPANTS Scripted telephone calls were placed to every dermatologist listed in directories for the largest MA plans in 12 US metropolitan areas. The caller sought an appointment on behalf of his fictitious father who had severe itch for several months, asked whether the dermatologist accepted the relevant plan, and asked for the next available appointment date.MAIN OUTCOMES AND MEASURES Appointment availability and wait time.RESULTS Among 4754 total physician listings, 45.5%represented duplicates in the same plan directory. Among the remaining unique listings, 48.9% of physicians were reachable,accepted the listed plan, and offered an appointment for our fictitious patient. Many of the dermatologists listed had incorrect contact information, were deceased, retired, or had moved, were not accepting new patients, did not accept the insurance plan, or were subspecialized. The mean (range) wait time for appointments among the remaining listings was 45.5 (1-414) days. Both the accuracy of network directories and the appointment wait times varied substantially by health plan and metropolitan area. For 1 plan, our caller was unable to obtain an appointment with any listed dermatologist. CONCLUSIONS AND RELEVANCE Medicare Advantage physician directories for dermatology in many areas substantially overestimate the number of in-network physicians available to treat patients with medical skin conditions. These inaccuracies occurred in areas with long appointment wait times and where plans are terminating selected physician contracts. This suggests a lack of capacity that would be exacerbated by further network narrowing.Accurate physician directories are essential for proper oversight of network adequacy, and for patients who rely on these listings to evaluate health plan options during open enrollment.

Consumer‐Oriented Health Care Reform Strategies: A Review of the Evidence on Managed Competition and Consumer‐Directed Health Insurance

For many years, leading health care reform proposals have been based on market-oriented strategies. In the 1990s, a number of reform proposals were built around the concept of "managed competition," but more recently, "consumer-directed health care" models have received attention. Although price-conscious consumer demand plays a critical role in both the managed competition and consumer-directed health care models, the two strategies are based on different visions of the health care marketplace and the best way to use market forces to achieve greater systemwide efficiencies. This article reviews the research literature that tests the main hypotheses concerning the two policy strategies. Numerous studies provide consistent evidence that consumers' health plan choices are sensitive to out-of-pocket premiums. The elasticity of demand appears to vary with consumers' health risk, with younger, healthier individuals being more price sensitive. This heterogeneity increases the potential for adverse selection. Biased risk selection also is a concern when the menu of health plan options includes consumer-directed health plans. Several studies confirm that such plans tend to attract healthier enrollees. A smaller number of studies test the main hypothesis regarding consumer-directed health plans, which is that they result in lower medical spending than do more generous plans. These studies find little support for this claim. The experiences of employers that have adopted key elements of managed competition are generally consistent with the key hypotheses underlying that strategy. Research in this area, however, has focused on only a narrow range of questions. Because consumer-directed health care is such a recent phenomenon, research on this strategy is even more limited. Additional studies on both topics would be valuable.

The “Choose With Care System”—Development of Education Materials to Support Informed Medicare Health Plan Choices

People aging into Medicare need to choose a health plan. Several challenges exist for consumers in choosing a Medicare health plan, including limited knowledge of Medicare, limited experience in using comparative health plan quality information, and limited experience and ability to pull together and use plan information from different sources like employers and the Medicare program. The Choose with Care System was developed to help consumers aging into Medicare make informed Medicare health plan choices. Choose with Care is an innovative decision support tool for employers to use to assist people approaching age 65 to learn about their Medicare health plan options and how to incorporate information on the quality of care and services offered by health plans into their choices. Employers are the targeted channel for distributing the Choose with Care materials because they are one of the most recognized and accessible formal intermediaries for information about health insurance. We used multiple methods to test the Choose with Care products. Product testing showed that the Choose with Care materials increase older consumers' knowledge of Medicare and how it relates to retiree health insurance and improves their comprehension and use of comparative quality information when choosing a health plan.

Assessing the new medicare prescription drug law.

The Medicare Modernization Act (MMA) is the product of a political compromise to attract moderate Republicans and enough Democrats without losing Republican conservatives. The compromise offered more private health plans to beneficiaries while maintaining and improving traditional Medicare's benefits. This compromise did not settle the debate over the legislation, which is a major issue in the 2004 elections. Voters poorly understand the law because of its complexity. In this paper, I explain how the policy decisions made by the U.S. Congress have contributed to the law's complexity and controversy. I examine the new private health plan options that will be offered to beneficiaries, improvements made to traditional Medicare, and the impact of introducing income-based determinations into Medicare. I also discuss the impact of the drug benefit on beneficiaries in different income and assets categories and Congress's decision to prohibit the federal government from directly negotiating prices with drug manufacturers. I conclude by assessing the major claims made by critics and proponents. Both might be more circumspect in their assessments of the law's impact, since it is impossible to predict how a law of such complexity, with so many human variables, will work out in the end. The MMA is a worthwhile but imperfect effort to extend drug coverage to seniors who are most in need. It deserves neither condemnation nor indiscriminate praise but instead a commitment to help it succeed.

Early experience with employee choice of consumer-directed health plans and satisfaction with enrollment.

To assess the initial impact of offering consumer-defined health plan (CDHP) options on employees. A mail survey of 4,680 employees in the corporate offices of Humana Inc. in June 2001. The study was a cross-sectional mail survey of employees aged 18 and older who were eligible for health care benefits. The survey was conducted following open enrollment. The primary outcome is the choice of consumer-directed health plan or not; the secondary outcome is satisfaction with the enrollment process. Important covariates include sociodemographic characteristics (age, gender, race, educational level, exempt or nonexempt status, type of coverage), health status, health care utilization, and plan design preferences. A six-page questionnaire was mailed to the home of each employee, followed by a reminder postcard and two subsequent mailings to nonrespondents. The response rate was 66.2 percent. Seven percent selected one of the two new plan options. Because there were no meaningful differences between employees choosing either of the two new options, these groups were combined in multivariate analysis. A logistic regression modeled the likelihood of choosing the novel plan options. Those selecting the new plans were less likely to be black (odds ratio [OR] 0.46), less likely to have only Humana coverage (OR 0.30), and more likely to have single coverage (OR 1.77). They were less likely to have a chronic health problem (OR 0.56) and more likely to have had no recent medical visits (OR 3.21). They were more likely to believe that lowest premiums were the most important plan attribute (OR 2.89) and to think there were big differences in the premiums of available plans (OR 5.19). Employees in fair or poor health were more likely to have a difficult time during the online enrollment process. They were more likely to find the communications very helpful (OR 0.42) and the benefits information very understandable (OR 0.38). They were less likely to feel that they had enough time to make their enrollment decision (OR 0.47). Employees who were attracted to the new CDHP plan options valued the attributes that distinguished these plans from other choices. The shift to consumer-defined plans and to the electronic provision of information, however, requires a significant increase in the communication support for all employees, but particularly for those in fair or poor health whose information needs are the most complex and individualized.

Risk segmentation related to the offering of a consumer-directed health plan: a case study of Humana Inc.

To determine whether the offering of a consumer-directed health plan (CDHP) is likely to cause risk segmentation in an employer group. STUDY SETTING AND DATA SOURCE: The study population comprises the approximately 10,000 people (employees and dependents) enrolled as members of the employee health benefit program of Humana Inc. at its headquarters in Louisville, Kentucky, during the benefit years starting July 1, 2000, and July 1, 2001. This analysis is based on primary collection of claims, enrollment, and employment data for those employees and dependents. This is a case study of the experience of a single employer in offering two consumer-directed health plan options ("Coverage First 1" and "Coverage First 2") to its employees. We assessed the risk profile of those choosing the Coverage First plans and those remaining in more traditional health maintenance organization (HMO) and preferred provider organization (PPO) coverage. Risk was measured using prior claims (in dollars per member per month), prior utilization (admissions/1,000; average length of stay; prescriptions/1,000; physician office visit services/1,000), a pharmacy-based risk assessment tool (developed by Ingenix), and demographics. Complete claims and administrative data were provided by Humana Inc. for the two-year study period. Unique identifiers enabled us to track subscribers' individual enrollment and utilization over this period. Based on demographic data alone, there did not appear to be a difference in the risk profiles of those choosing versus not choosing Coverage First. However, based on prior claims and prior use data, it appeared that those who chose Coverage First were healthier than those electing to remain in more traditional coverage. For each of five services, prior-year usage by people who subsequently enrolled in Coverage First 1 (CF1) was below 60 percent of the average for the whole group. Hospital and maternity admissions per thousand were less than 30 percent of the overall average; length of stay per hospital admission, physician office services per thousand, and prescriptions per thousand were all between 50 and 60 percent of the overall average. Coverage First 2 (CF2) subscribers' prior use of services was somewhat higher than CF1 subscribers', but it was still below average in every category. As with prior use, prior claims data indicated that Coverage First subscribers were healthier than average, with prior total claims less than 50 percent of average. In this case, the offering of high-deductible or consumer-directed health plan options alongside more traditional options caused risk segmentation within an employer group. The extent to which these findings are applicable to other cases will depend on many factors, including the employer premium contribution policies and employees' perception of the value of the various plan options. Further research is needed to determine whether risk segmentation will worsen in future years for this employer and if so, whether it will cause premiums for more traditional health plans to increase.

Disruption of a Managed Competition Environment by Low-Ball Premium Bids

This paper reviews the movement among multiple health plan options between 1994 and 1998 for Minnesota state employees whose work site was located in the Minneapolis/St. Paul metropolitan area. During this period the employer contribution was based on the lowest family premium bid from a qualified plan in the county of the employee’s work site. In 1995 the largest individual practice association model HMO in the state, Medica, reduced its state premium by 25%, becoming the lowest-priced option. This resulted in massive transfers of enrollees between plans. The point of this study was to estimate the risk changes that resulted from these movements between plan options. We obtained enrollment data by age and gender from Blue Cross Blue Shield of Minnesota (Blue Cross) and applied age/gender risk weight factors derived from actuarial rate tables to the Blue Cross cells. Annual changes in risk weights by 10-20% were common in a number of Blue Cross subpopulations, and in one case, by more than 50%. The Blue Cross POS plan experienced increases in risk and went into a death spiral, while a second Blue Cross plan with a more restrictive provider network started with low risk, but experienced increases in risk when the Medica plan was withdrawn. Similar demographic data were not available from other plans offered by the state and claim costs were confidential, so the results pertain only to Blue Cross risks. The question is raised as to whether managed competition can work without some means of adjusting premium rates to the expected cost level of the enrollees of a particular health plan. All carriers seemed reluctant to guarantee premium rates after the 1994-1998 experience, and the state soon became self-insured.

Health plan options at fortune 100 companies: available coverage for mental health care consumers.

tions in their industries, exert substantial influence on employer-sponsored mental health benefits (7). When these companies change their benefit options, other companies in their industries, which are competing for employees and market share, have an incentive to follow suit (8). Competition may thus produce industryspecific trends in employee medical benefits, resulting in substantially different plan options for mental health care in different industries and similar options within an industry. The presence of differences in coverage options by industrial sector implies that workers’ risk of incurring high out-of-pocket expenses for mental health services depends on which industry they work in, even if the workers have similar skills and experience and they all work for large companies.

Health Benefits for Federal Employees

You have accessThe ASHA LeaderBottom Line1 Dec 2002Health Benefits for Federal EmployeesPromoting Direct Access for Audiologists Maureen Thompson Maureen Thompson Google Scholar More articles by this author https://doi.org/10.1044/leader.BML.07122002.3 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In The Federal Employees Health Benefits Program (FEHBP)—the world’s largest employer-sponsored insurer—provides health insurance for nearly 9 million federal employees and annuitants, as well as current and former spouses and employees. FEHBP licenses health plans to compete for federal employee premium dollars. Currently, more than 350 health plan options are offered nationally, with up to 15 only available in local areas. As you’ll note in the following set of questions and answers, a recent law permits—but does not require—direct payment to audiologists by FEHBP plans. Audiologists need to advocate for their inclusion as direct-care providers with FEHBP plans. Read on for more information, Web sites, and grassroots strategies to build support for the expanded autonomy of audiologists treating the nation’s large population of federal workers. Who are considered “covered providers” with FEHBP plans? A. The list of FEHBP-covered providers includes physicians, clinical psychologists, qualified clinical social workers, optometrists, nurse midwives, and nurse practitioners. Audiologists are not specifically listed in the “covered provider” section of most health plans participating in the FEHBP. In 2002, three of the seven nationwide fee-for-service (FFS) plans available to enrollees reimburse audiologists directly. Those plans and their Web sites are: American Postal Workers’ Union Health Plan Blue Cross/Blue Shield Service Benefit Plan Mail Handlers Benefit Plan Of the six FFS plans that are open only to specific groups (e.g., Secret Service), two reimburse audiologists directly: Special Agents Mutual Benefits Association Secret Service Health Plan How does the Federal Employees Health Protection Act of 1998 affect audiologists? A. Before enactment of the Federal Employees Health Protection Act (P.L. 105–266), the only covered professional services for hearing care under FEHBP were those rendered by physicians. With the passage of P.L. 105-266, FEHBP plans are permitted to provide direct access, direct payment, or reimbursement to health care providers such as audiologists. The law does not specify, however, that particular health services be covered or excluded. Thus, the law does not mandate direct reimbursement to audiologists. As a result, four of the nationwide FFS plans participating in the FEHBP still require that audiology services be billed through a physician and deny reimbursement claims submitted directly by independently practicing audiologists. Such actions prevent FEHBP-covered consumers from having direct access to audiologists. Audiologists need to become direct-access providers under FEHBP. How can we achieve that goal? A. Audiologists must advocate for their inclusion as direct-care providers with FEHBP plans. To achieve this goal, it is critical that audiologists contact the U.S. Office of Personnel Management (OPM) and FEHBP plans about the quality and cost-effectiveness of direct audiologic care. Adding audiologists to the list of covered providers is congruent with the basic thrust of the FEHBP—having reasonable minimum standards for health benefits plans and ensuring direct access to specific health professionals. How can we advocate for direct access with individual FEHBP plans? A. Until the FEHBP mandates audiology services, audiologists must advocate for direct reimbursement of their services with individual FEHBP plans. To help you lobby effectively, ASHA has prepared a new technical information packet, FEHB Plans: Expanding Direct Access for Audiologists. This free product offers an overview of the FEHBP and ASHA’s legislative efforts to date. It also offers sound advice on which FEHBP plans to target, what FEHBP plan administrators want to know about audiologists and the people they serve, issues to address when advocating with FEHBP plans, suggested strategies and timelines, and suggested monthly “To Do” lists. How can I learn more about the FEHBP program? A. For an overview, visit the OPM’s Web site. For a copy of the free ASHA materials, call the Action Center at 800-498-2071 or fax your request to 301-897-7358. Request item #0804265. For more information on FEHBP, contact Maureen Thompson through the Action Center at ext. 4431, by fax at 301-897-7356, or by e-mail at [email protected]. Author Notes Maureen Thompson, is ASHA’s director of private health plans advocacy. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 7Issue 12December 2002 Get Permissions Add to your Mendeley library History Published in print: Dec 1, 2002 Metrics Downloaded 93 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2002 American Speech-Language-Hearing AssociationLoading ...

Aging and decision‐making competence: an analysis of comprehension and consistency skills in older versus younger adults considering health‐plan options

AbstractOlder adults need to maintain strong decision‐making capabilities as they age. However, we know little about how age‐related physical and psychological changes affect older adults' judgment and decision processes. This paper reports the results of research comparing older versus younger adults' performance on evaluation and choice tasks about health‐plan options. In particular, comprehension and consistency in judgments (across separate versus joint evaluation contexts) were examined. Results indicated that increasing age was related to greater comprehension errors and inconsistent preferences, even when covariates (education, income, gender, self‐perceived skill and health, decision style, and attitude toward delegation) were taken into account. Discussion of the results emphasizes difficulties in interpreting the meaning of age differences in performance on decision tasks and the need for research that ascertains the seriousness of the consequences of age differences in real‐life tasks. The implications for providing decision‐aiding interventions for older adults are highlighted. Copyright © 2002 John Wiley & Sons, Ltd.

Providing Information to Help Medicare Beneficiaries Choose a Health Plan

Many Medicare beneficiaries have limited knowledge of the Medicare program and related health insurance options. This is due in part to the complexity of the Medicare program and supplemental health insurance market. A recent congressional mandate through the Balanced Budget Act of 1997 called for broad dissemination of information to educate beneficiaries about their health plan options and to encourage informed health plan decision-making. In response, the Health Care Financing Administration (HCFA) launched the National Medicare Education Program (NMEP) to support the educational objectives of the BBA. This paper provides an overview of the components of the NMEP information campaign. We also review lessons learned from our experience in designing and testing a prototype consumer handbook that explains the different health plan options to Medicare beneficiaries. Through our discussion of the handbook, we highlight several ways to communicate information effectively about a complex publicly funded program to an older adult population.

Medicare reform: foundations respond to federal policy changes.

Medicare reform: foundations respond to federal policy changes.

Medicare's Choice explosion? Implications for beneficiaries.

Medicare+Choice was established under the Balanced Budget Act of 1997 to expand the range of health plan options available to beneficiaries and to encourage plans to compete on the basis of price and quality, with potential savings to beneficiaries and the program. However, it is unclear whether the envisioned positive outcomes will occur. This paper reviews the rationale for expanding choices under Medicare. It considers how the rapidly changing health insurance market poses uncertainties for beneficiaries and concludes with a discussion of safeguards that may be necessary to assure that the program continues to work well for beneficiaries with diverse needs and circumstances.

Paying more fairly for Medicare capitated care.

The 1997 Balanced Budget Act (Public Law 105-33) not only balanced the federal budget for the first time in decades but also mandated major changes in Medicare. One important goal of these changes was to expand the choice of health plans for Medicare beneficiaries, both to encourage the provision of high-quality care and to control aggregate program costs through competition and risk sharing. Under the new provisions, health-plan options include traditional fee-for-service care, high-deductible medical savings accounts, provider-sponsored organizations, and capitated plans, such as health maintenance organizations. However, questions arose about whether all beneficiaries would have these choices. In particular, . . .

Consumer's information needs: results of a national survey.

A national survey conducted in 1995 found that a disturbingly high percentage of Americans do not understand the basic elements of health plans and that people want much more information, particularly about the physicians in the plans and the range of services that are covered. Their most important concern when selecting a health plan is the quality of physicians in the plan, followed by the courtesy of doctors and staff and the freedom to choose their own doctors and hospitals.