America's Best Health Plans
Managed care doesn't have to be cold and uncaring. The highest-ranking plans have a positive attitude.
How is it possible that some people never seem to get sick? Good genes, good fortune, good karma? Whatever it is, Lori Rittenhouse wouldn't mind having some. The 35-year-old mother of three has had asthma since childhood. Three years ago she was diagnosed with diabetes and a month later discovered she was pregnant. That called for a drug and diet high-wire act to harness her blood sugar without harming or undernourishing her fetus. Hypertension and high cholesterol round out her litany of health problems.
Without careful monitoring and regular medical attention, Rittenhouse could easily wind up in a hospital near her suburban Wilkes-Barre, Pa., home with flare-ups or complications. But she's lucky: She's a member of Geisinger Health Plan, which covers much of central Pennsylvania. It's one of the biggest rural plans in the nation and among the top 20 commercial plans in new rankings assembled by U.S. News and the National Committee for Quality Assurance, the major accrediting body for managed-care plans.
Keeping tabs. One of Geisinger's distinctions is its disease-management program, which monitors and assists members like Rittenhouse with chronic health conditions. A nurse in the program has been keeping close tabs on her for four years. After helping her quit smoking, now the nurse focuses on making sure she's taking her medications and keeping up with regular blood tests and eye and foot exams for her diabetes.
If Rittenhouse has a question for her primary-care doctor, she logs into the Geisinger system from home and sends her an E-mail, eliminating the telephone tag they used to play. And she can view her patient record online, including test results and weigh-ins, which she charts in graph form on her password-protected page. "They keep so on top of me, it makes me feel more comfortable," she says. "I don't worry as much."
These days, a satisfied managed-care member seems about as rare as a flattering hospital gown. Faced with rising premiums, employers continue to shift healthcare costs onto their employees' shoulders, and workers are scrambling to pay the bills. In 2005, premiums rose 9.2 percent, slightly less than in previous years but more than three times the growth in employee earnings, according to the Kaiser Family Foundation's annual Employer Health Benefits Survey, released last month. Workers paid $2,713 on average in premiums for family coverage in 2005, nearly $1,100 more than five years ago. And that represented only about 26 percent of the total cost; their employers picked up the rest. Deductibles, copayments, and coinsurance have climbed.
If managed care today seems more about managing costs than providing care, consumers are at least partly to blame, say health policy experts. When managed care first became widely popular, in the late 1980s and early 1990s, it offered consumers a trade-off: In exchange for richer benefits (such as full coverage of preventive care) and much lower out-of-pocket costs ($5 or $10 copayments), consumers agreed to allow plans to coordinate and sometimes limit the care they received. People liked the cheap, comprehensive benefits. But by the late 1990s, managed care's "gatekeeper" function had provoked a huge backlash among patients--and doctors, who felt their authority had been usurped and their expertise challenged.
The price of choice. Under pressure from employers, health plans backed off. Today nearly two thirds of people covered by employer plans belong to preferred provider organizations, which generally give members access to a wide network of doctors and services without requiring gatekeeper approval. Five years ago just 42 percent of workers belonged to PPOs. Meanwhile, the number of workers in traditional health maintenance organizations, which impose stricter controls, has fallen to 21 percent.
Consumer choice, however, comes at a cost. Yearly premium increases, which had dipped below 1 percent in 1996, peaked at 13.9 percent in 2003."Consumers now have less restrictions on their care, but they're paying a lot more for it," says Paul Ginsburg, president of the Center for Studying Health System Change, a nonpartisan think tank based in Washington, D.C.
The most workable solution, some experts argue, is to turn back the clock. In surveys, a majority of consumers say they would trade less choice of healthcare providers for lower out-of-pocket costs. "When we finally come to our senses, we'll go back to tighter managed care," says Donald Berwick, president and CEO of the Institute for Healthcare Improvement in Cambridge, Mass. But most health industry experts and employers these days are betting on a different remedy to cure our healthcare ills: consumer-driven healthcare.
If PPOs let consumers nibble at making their own healthcare decisions, consumer-driven healthcare lays out an all-you-can-eat banquet. The most-cited model is based on a tax-free health savings account, or HSA. Individuals or plan members open an HSA in which they or their employer sets aside pretax money to cover deductibles and other out-of-pocket medical expenses. Withdrawals for medical expenses are untaxed, and unused funds roll over year to year. An HSA must be tied to a high-deductible health plan--at least $1,000 a year for individuals or $2,000 for families--that kicks in for catastrophic coverage. Twenty percent of employers providing insurance now offer a consumer-driven plan, up from 5 percent just two years ago.
Critics maintain that consumer-driven plans are just the latest employer effort to push healthcare costs onto their employees and that the plans mostly benefit healthy, affluent workers. Advocates argue that if consumers have a bigger financial stake in their healthcare choices, they'll spend their healthcare dollars more prudently.
With the healthcare system in flux, consumers have more of a challenge than usual trying to pick a good plan this fall (nuts and bolts advice, Page 52). There are many ways to judge a plan, and the rankings on Pages 60 and 62 (and with more detail at www.usnews .com ) offer valuable information. But some areas where top-notch plans excel may not be obvious from a performance ranking or a benefits handbook. With consumers being handed more responsibility for managing their own care, not to mention picking up more of the tab, these indicators of quality care merit close attention.
Putting medical records online. Online access to medical records isn't essential--only about 15 to 25 percent of hospitals and doctors' offices have taken that step, according to a recent Rand study--but it has the potential to substantially improve patient care, reduce errors, and enhance patient communication and information. At Geisinger Health Clinic, all 750 staff physicians rely on electronic records, and the plan recently began allowing nonstaff doctors affiliated with the plan to view records online. When a doctor or nurse pulls up a patient's chart, in addition to the patient's medical history, the display shows any preventive tests or screenings that are due and, with a keystroke, lists all medications patients are currently on or have been on in the past and whether it's time for a refill.
Patients have access to their medical records online as well. Jodie Danowsky, 35, was able to confirm last year that she was pregnant--with Emma, now 3 months old--by checking her results online even before the Geisinger nurse had a chance to call. Winifred Reakes, 59, logs into her patient record to help her remember the details of a recent doctor's visit. "Sometimes when they explain stuff in the office, you forget," she says.
Coping with chronic illness. Care for people with chronic conditions--ongoing illnesses such as diabetes, heart failure, asthma, and hypertension--accounted for 83 percent of all healthcare spending in 2001, according to a recent Johns Hopkins University study. By 2030, half the population will have one or more of these illnesses, the study found. A good disease management program teaches patients how to monitor their condition and prods them to manage it themselves. For 15 years, Charles Coffman was able to control his diabetes through diet alone. But when that strategy began to fail four years ago, the 57-year-old mayor of Bloomsburg, Pa., started working with a disease management nurse at Geisinger. Coffman knew chocolate cake wasn't good for him, but through his nurse he learned that potatoes and bread could make his blood sugar spike, too. The nurse also worked with his wife to develop healthful meals she could cook for them both. Now Coffman sees his nurse every six weeks for a check of his blood sugar, blood pressure, and weight and to look over his feet for sores. The results have been gratifying. "I'm not on insulin right now, and I probably still have my legs because of this program," he says.
Managing medication. An oft-cited Institute of Medicine 1999 report charged that medication errors cause up to 100,000 in-hospital deaths each year. Harvard Pilgrim Health Care believes outpatient errors may cause even more. So the plan offers to send a pharmacist to doctors' offices to sit down with patients on more than five medications to review their prescriptions and talk about side effects, drug interactions, and the like.
The transition back home after a hospital stay can be confusing, so the health plan also routinely calls patients three days after discharge to review their medications. Judith Frampton, the plan's vice president of clinical quality programs, cites a patient who was found to be taking not only the drugs she'd been prescribed when she was discharged but those she was on before she was admitted as well. "That's a very dangerous situation, and who knows when it would have been discovered," she says.
Informing consumers. The rise of consumer-driven healthcare has prompted health plans to intensify their efforts to make information more available to consumers about the cost of services and help them evaluate the quality of care provided by doctors and hospitals. Cost information has been particularly elusive. But in a pilot project now underway in Cincinnati, Aetna plan members can go online and find out the cost of their medical care for 25 common office procedures.
On the quality side, the flow of information is building. Many health plans also contract with private vendors to provide members with more in-depth information about hospital--and in some cases physician--performance. That allows consumers to push for providers with the best track records for procedures like coronary bypass, for example.
Now health plans are taking data mining to the next level to measure providers' efficiency at handling an "episode of care" --calculating the resources a physician uses to treat a case of pneumonia, for example, relative to his peers. Coupled with quality information, this efficiency quotient can be a powerful information tool for newly price-conscious consumers. "If a doctor is 20 percent more efficient, with equal quality outcomes, then you have a good notion of value," says David Gregg, a principal and senior consultant with Mercer Human Resource Consulting.
Whether such initiatives will take root and Americans will take to consumer-driven healthcare is an open question. But even critics applaud the notion of consumers' taking charge and agitating for better care. "Consumer power is crucial," says Berwick. "It's the only thing that will change the system: frustrated consumers demanding change." And melding a few of those changes just might make healthcare better--and more affordable--for more people.
This story appears in the October 10, 2005 print edition of U.S. News & World Report.