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What HMO’s Won’t Tell You

| Articles | September 28, 2013

When a company enters into a contract with an HMO, employee satisfaction as well as company money is on the line. Health costs are rising annually, and employee health care is a major expense for most businesses. The following tips will help you select the best health plan for your business.

When companies out-source services, they usually monitor the supplier to ensure that it consistently supplies the goods or services which are specified in the contract. When dealing with HMOs, however, many companies ignore this basic business practice. At least once a year, compare your HMO with nationwide HMO performance measurements.

To compare HMOs, use the Health Plan Employer Data Information set, or HEDIS, available from the National Committee on Quality Assurance (NCQA) in Washington, D.C. This database has guidelines for comparing HMO performance in approximately 60 categories. Nearly all HMOs provide their own HEDIS data to prospective clients. If an HMO refuses, this is a sign of inferior performance.

Check to be sure the HMO is accredited by either the NCQA or the Joint Commission on Accreditation of Health Care Organizations in Oak Brook Terrace, Illinois. Both of these organizations have rigorous standards for HMOs. While evaluations are paid for by participating HMOs, one in eight tested so far by the NCQA has received a failing grade.

If you are still confused by the parameters of the HEDIS report, it may be worthwhile to hire a healthcare consultant to teach company managers how to evaluate health plans. This usually costs $5,000 to $10,000.

Several important criteria are used to compare HMOs. The first is the medical-loss ratio, which refers to the ratio of HMO medical expenses to the total premiums collected. A ration of less than 80% denotes an inefficient health plan which spends too much on marketing or administration. Also, be wary of an HMO with a medical-loss ration which fluctuates widely from year to year. A sudden decrease may mean that the health plan has started to market itself more aggressively, perhaps due to a sudden loss of members. A sudden upward surge may mean that the HMO has incurred unexpected medical expenses which may lead to insolvency. However, new HMOs generally have slightly more unstable medical-loss ratios than those which have been in business for many years.

Disenrollment ratios refer to the percentage of employees who have discontinued the health plan. Some turnover always occurs as employees change jobs or move away; however, higher than average losses may indicate customer dissatisfaction. Disenrollment rates of greater than 10%, or a steady rise in disenrollment rates, invite further investigation.

The best medicine is preventative medicine. Be sure to check for such services as childhood immunizations, prenatal care, mammography and screening for high cholesterol. A lack of coverage for these services can lead to higher costs in the future. Also, ask whether the plan covers any alternative therapies, which are becoming increasingly popular with the public.

Find out what access the HMO offers patients seeking primary care physicians. Don’t be impressed by a long list of affiliated physicians; the key is to check for practitioners who are actively accepting new patients. Many HMOs have a large provider directory of family physicians, internists and pediatricians, most of them with full practices. A plan which confines patients to a few available doctors is likely to generate patient complaints. Many employees may already have personal physicians who are familiar with their medical histories, and will resent being forced to switch to an HMO-approved doctor.

Check whether the available physicians are close by, whether they provide services in evenings or on weekends, and what percentage are board-certified.

Get references from existing customers. Widespread dissatisfaction, despite good statistics, is a sign that you will probably be unhappy with the HMO as well. HMOs frequently conduct customer-satisfaction surveys, which should be done by an independent organization so the results can be verified. Sometimes “inessential” features, such as a live receptionist rather than automated voice mail system, or a good patient-education resource center, bring a great increase in customer happiness.

The best HMO isn’t necessarily the cheapest, but rather the one which most closely matches a company’s needs.

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