Consumer Bill of Rights and Responsibilities
Choice of Providers and Plans
Statement of the Right
Consumers have the right to a choice of health care providers that is
sufficient to ensure access to appropriate high-quality health care.
To ensure such choice, health plans should provide the following:
Provider Network Adequacy: All health plan networks should provide access to sufficient numbers and types of providers to assure that all covered services will be accessible without unreasonable delay -- including access to emergency services 24 hours a day and seven days a week. If a health plan has an insufficient number or type of providers to provide a covered benefit with the appropriate degree of specialization, the plan should ensure that the consumer obtains the benefit outside the network at no greater cost than if the benefit were obtained from participating providers. Plans also should establish and maintain adequate arrangements to ensure reasonable proximity of providers to the business or personal residence of their members.
Access to Qualified Specialists for Women's Health Services: Women should be able to choose a qualified provider offered by a plan -- such as gynecologists, certified nurse midwives, and other qualified health care providers -- for the provision of covered care necessary to provide routine and preventative women's health care services.
Access to Specialists: Consumers with complex or serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers. Authorizations, when required, should be for an adequate number of direct access visits under an approved treatment plan.
Transitional Care: Consumers who are undergoing a course of treatment for a chronic or disabling condition (or who are in the second or third trimester of a pregnancy) at the time they involuntarily change health plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their current specialty providers for up to 90 days (or through completion of postpartum care) to allow for transition of care. Providers who continue to treat such patients must accept the plan's rates as payment in full, provide all necessary information to the plan for quality assurance purposes, and promptly transfer all medical records with patient authorization during the transition period.
Public and private group purchasers should, wherever feasible, offer consumers a choice of high-quality health insurance products. Small employers should be provided with greater assistance in offering their workers and their families a choice of health plans and products.
The ability of consumers to exercise choice in the health care marketplace is associated with several desirable characteristics of a health care system.
- First, choice is associated with increased consumer satisfaction. In a survey of consumers receiving health care in both indemnity and managed care plans, individuals with a choice of health products report greater satisfaction with their plan and tend to rate both their health insurance product and their individual physicians of higher quality (Davis and Schoen, 1997).
- Second, the ability of consumers to choose among competing products is a hallmark of a healthy marketplace. Individual consumers are responsible for 34 percent of all direct expenditures for health care in the United States (Cowan et al., 1996). As the science of measuring and generating accurate and valid information on the quality of health plans, providers and facilities advances, consumers can wield their purchasing power to create incentives in the marketplace for improvements in health care quality.
- Third, consumers who have a role in the selection of their caregivers are likely to have greater confidence in those practitioners and are, therefore, more likely to seek appropriate care in a more timely fashion and follow agreed-upon care regimens.
- Fourth, having a choice of providers allows consumers to take action to preserve continuity of care within the health care system by selecting products and providers that allow them to continue provider relationships when continuity of care is especially important (e.g., prenatal care, care of individuals with complex chronic or disabling conditions).
Thus, a health care marketplace that promotes satisfied consumers, continuity of care, and continuous improvements in quality requires that an array of choices be available to consumers. Without consumers' ability to have and exercise choice, greater activities may need to be undertaken by group purchasers and regulators to ensure that the health care marketplace responds appropriately to consumers' health care needs.
Consumer Choice of Health Plans or Products
During the last decade, there has been a marked increase in the number and types of health insurance products available in most geographic markets. Prior to the widespread development of managed care plans, most Americans had limited choice of health insurance products. Indemnity products dominated the market with HMO and PPO products available primarily in certain metropolitan areas. The past 10 years have seen a significant increase of insurance products with the expansion of many health plans into new geographic markets and the development of multiple insurance product lines by indemnity insurers and managed care organizations. As a result, with the exception of sparsely populated areas, most communities now have available HMO, POS, PPO, and indemnity products offering consumers a variety of options in terms of benefits, premiums, copayments, and health care delivery systems.
At the same time, there has been a steady migration from traditional indemnity plans to various managed care products in both the public and private markets. Between 1991 and 1995, the percentage of American workers enrolled in indemnity plans decreased from 59 percent to 35 percent (EBRI, 1997). In 1997, more than 5 million Medicare beneficiaries were enrolled in 336 managed care plans, an increase of more than 100 percent since 1993. Under Medicaid, 13 million, or 35 percent, of all beneficiaries have been enrolled in managed care plans, an increase of more than 170 percent since 1993. The Balanced Budget Act of 1997 will increase those trends by expanding the types of products available to beneficiaries of those two public programs.
Although there is greater choice of health insurance products available in most markets, it is important to note that this choice often is exercised at the level of the group purchaser instead of by individual consumers. Between 1988 and 1997, health plan offerings by moderate- and large-sized employers declined (Gabel, 1997). Those offering three or more plans declined from 35 percent to 32 percent, while those offering only one plan climbed from 41 percent to 44 percent over that period. Notably, the percentage of employees in firms with 200 or more workers who were offered coverage of PPOs and POS plans increased from 12 percent in 1988 to 58 percent in 1997 (Gabel, 1997).
There also is evidence of variation in consumer preferences for various product characteristics. In the Kaiser-AHCPR survey (1996), 70 percent of survey respondents would prefer a high-cost product with a wide range of benefits over a low-cost product with a more limited range of benefits (26 percent). Respondents were more divided over other health product decisions. Fifty-three percent said they would pay more for unrestricted choice of physicians, while 43 percent would opt for a lower-cost product that limited choice to a list of physicians. Forty-six percent would pay more to have direct access to any specialist, whereas more than half (51 percent) would choose a lower-cost plan that requires a visit to the family physician for a referral (Robinson and Brodie, 1997).
The Commission is troubled by the limited choice of insurance products made available to many consumers through their employer group purchasers. Some of the reduction in choice of plan and product has resulted from conscious decisions by employers to select high-quality products at the best price in the market. In other instances, employers may be seeking to minimize administrative costs associated with multiple offerings. Affording consumers greater choice of plans would allow consumers to select the product that best meets their individual preferences and would encourage health plans to be responsive to consumers' expressed needs. However, the Commission recognizes that, for many consumers, the availability of one plan is better than no plan at all.
The Commission was unable to achieve consensus on creating a "right" to a consumer choice of health plan or product but it is determined to find ways to encourage and assist employers and other group purchasers in providing consumers with a meaningful choice of health plans and products. Consumer choice of health plans is important and should be provided whenever possible and in a way that is affordable both to employers and consumers. In its final report, the Commission will address policy options to provide greater choice of health plans and products, including encouraging the development of purchasing coalitions and alliances to assist small employers who encounter the greatest difficulty in offering multiple options.
Consumer Choice of Physicians and Other Health Care Providers
The shift from indemnity coverage to managed care arrangements can affect consumers' choice of physicians and other health care providers. In a 1995 study, 41 percent of managed care enrollees who changed health plans over the prior 3 years also changed physicians (Davis et al., 1995). However, nearly all covered workers can now choose a health plan that covers non-network providers. In some cases, however, the additional cost of these products or of the option to go out of network effectively puts such choice out of the reach of some consumers.
It also is clear that consumers value some degree of choice of physicians. The 1997 Kaiser/Commonwealth National Health Insurance Survey found that respondents with a choice of physicians registered the highest level of satisfaction with their plans (Davis and Schoen, 1997). A Kaiser-AHCPR survey of consumers identified four reasons why consumers prefer a greater choice of physicians and other health care professionals:
- "So you can see whatever doctor you think is best qualified to treat a particular medical problem" (43 percent).
- "So you can change doctors if you become dissatisfied with the one you're seeing" (24 percent).
- "So you can continue seeing your regular doctor" (20 percent).
- "So it's easier to see someone else if your doctor is not available for an appointment" (9 percent).
The most frequently cited reasons speak to consumers' desire to use choice of physicians as a way to obtain quality care. The third is directed toward maintaining relationships with physicians with whom consumers have an existing relationship. In other words, 63 percent of consumers surveyed wanted a choice of physicians so that they can develop and maintain a relationship with a physician they trust to provide them high-quality care.
Therefore, it is important for all health plans and products to maintain an adequate network of physicians and other health care providers, to provide for continuity of care when consumers change plans, and to allow consumers with special health care needs to have adequate choice of physicians and other health care providers. This can lead to higher consumer satisfaction with providers and their health plans without undermining the efforts of provider groups and health plans to develop organized delivery systems.
The Commission's recommendations seek to build on these trends toward providing greater choice by taking several steps to ensure (1) network adequacy; (2) greater access for women to qualified specialists for women's health services; (3) ease of access to specialists for consumers with complex and serious conditions; and (4) greater continuity of care for consumers who enroll in new health plans or see their provider dropped from a plan for other than cause.
Provider Network Adequacy
When appropriately structured, a plan using a network of providers can improve the quality and coordination of care delivered to consumers through careful selection and credentialing of providers and through coordination of care by primary care physicians and those with specialty training. The National Association of Insurance Commissioners (NAIC, 1996) has developed standards for provider network adequacy that have been adopted by several States. The Commission believes universal adoption of these standards will improve both the quality of care and consumers' satisfaction with their health plans and their care. Because of its strong desire to maintain the integrity of health plan networks, the Commission has rejected approaches to mandate the inclusion of providers into networks (i.e., "any willing provider" laws) or to require plans to allow enrollees to go out of plan networks at will (i.e., "freedom of choice" laws).
Access to Specialists
Consumers with ongoing health needs often require regular access to physicians and other health care professionals who are specially trained to serve those needs (Bernstein, Dial, and Smith, 1995). This is especially true of those consumers who have disabling or terminal conditions. In such cases, the traditional "gatekeeper" approach used by some health plans can be an impediment to access to quality care and result in unnecessary inconvenience to consumers. The Commission's recommendations are designed to promote consumers' access to appropriately trained specialists while maintaining the integrity of network models of care. Consumers with complex and serious medical conditions who require frequent specialty care should have direct access to a qualified specialist of their choice within a plan's network of providers. Authorizations, when required, should be for an adequate number of direct access visits under an approved treatment plan.
Access to Qualified Specialists for Women's Health Services
Morbidity and mortality associated with breast cancer, cervical cancer, ovarian cancer, and sexually transmitted diseases in women can be significantly reduced through the provision of preventive and routine gynecological services. The U.S. Preventive Services Task Force has issued recommendations pertaining to the provision of Pap smears, mammograms, and other preventive services for women. Women should be able to choose a qualified provider offered by a plan -- including gynecologists, certified nurse midwives, and other qualified health care providers offered by a plan -- for the provision of routine and preventive women's health care services.
Finally, consumers who are undergoing an extensive course of treatment (e.g., chemotherapy or prenatal care) at the time they join a new health plan should be able to continue to see their current providers for a period of up to 90 days (or through completion of postpartum care). Similarly, such consumers should be able to continue to see a provider who is terminated from a plan's network for reasons other than cause. Sudden interruption of care can compromise the quality of care and patient outcomes. Continuity of care has been shown to increase the likelihood that patients receive appropriate preventive services (O'Malley et al., 1997). Appropriately transitioning of care can protect the quality of that care and improve consumers' satisfaction with a new health plan or product. The Commission's recommendations are designed to ease the impact of these transitions from one health insurance product to another and changes in the composition of health plan networks while maintaining the integrity of network models of care. Consumers who are undergoing a course of treatment for a chronic or disabling condition (or who are in the second or third trimester of a pregnancy) at the time they involuntarily change health plans or at a time when a provider is terminated by a plan for other than cause should be able to continue seeing their current specialty providers for up to 90 days (or through completion of postpartum care) to allow for transition of care.
Implications of the Right
Health plans will need to comply with network adequacy standards. Because these changes are primarily to be carried out within existing networks, there should not be a significant increase in costs to health plans or enrollees. Many licensed plans already meet these requirements as laid down by the National Association of Insurance Commissioners (NAIC) in its Managed Care Plan Network Adequacy Model Act. Plans also will need to develop processes to comply with requirements regarding continuity of care and ease of access to specialists within their network of providers.
Consumers will need to exercise their right to choice by using good judgment and providing direct feedback to plans about their level of satisfaction with the network provided for them.
Quality Oversight Organizations will need to incorporate network adequacy standards into their review activities.
References and Selected Reading
Bernstein AB, Dial TH, Smith MD. "Women's Reproductive Health Services in Health Maintenance Organizations." West J. Med 1995; 163[suppl]:15-18.
Cowan, CA, Braden, BR, McDonnell, PA, et al. "Business, Households and Government: Health Spending, 1994." Health Care Finance Rev; Summer 1996; 17(4):157-178.
Davis K, Collins KS, Schoen C, et al. "Choice Matters: Enrollees' Views of Their Health Plans." Health Affairs; Summer 1995; 99-112.
Davis K, Schoen C. testimony before the Advisory Commission on Consumer Protection and Quality in the Health Care Industry; June 25, 1997.
Employee Benefits Research Institute. EBRI Databook on Employee Benefits, Washington DC, 1997.
Gabel JR (KPMG Peat Marwick LLP). testimony before the Advisory Commission on Consumer Protection and Quality in the Health Care Industry; June 23, 1997.
Kaiser Family Foundation and the Agency for Health Care Policy and Research (AHCPR). Americans as Health Care Consumers: The Role of Quality Information. Princeton Survey Research Associates; October 1996.
KPMG Peat Marwick, Health Insurance Association of America. Sourcebook of Health Insurance Data. Washington, DC; 1996.
O'Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. "Continuity of Care and the Use of Breast and Cervical Cancer Screening Services in a Multiethnic Community." Arch Intern Med 1997; 157(13):1462-70.
National Association of Insurance Commissioners. Managed Care Plan Network Adequacy Model Act. Model Regulation Service; October 1996.
Robinson S, Brodie M. "Understanding the Quality Challenge for Health Consumers: The Kaiser/AHCPR Survey." Journal on Quality Improvement, May 1997; 23(5):239-244.
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