Choosing a Managed Care Option: How Do You Control Health Care Costs without Compromising Quality?

By West, Kathryn Z. | Risk Management, March 1996 | Go to article overview

Choosing a Managed Care Option: How Do You Control Health Care Costs without Compromising Quality?


West, Kathryn Z., Risk Management


The health care provider market continues to expand. Managed care options--HMOs, PPOS, point of service and out of network programs--have been augmented by more recent hybrids including Preferred Hospital Organizations (PHOs), Physician Organizations (POs) and Integrated Delivery Systems.

These health care benefit alternatives can be attractive to employers, aiming to hold down employee benefit costs. "This is the primary motivation of employers," says Russ Sherlock, chief executive officer of Acordia Health Care Solutions in Indianapolis. But there's more to these programs than cost.

Some of the newest alternatives in the market aren't regulated and require very careful review. The National Committee for Quality Assurance (NCQA) is a governing body established to evaluate managed care entities. Unfortunately, the NCQA review and accreditation process is a long one. "Knowing a company has applied demonstrates a level of initiative and commitment to quality," says Mr. Sherlock. Approximately 50 percent of HMOS today have been reviewed for this quality accreditation.

Employers should be reminded that any managed care options should be carefully scrutinized. The quality of alternatives also needs to be considered. "There have to be incentives to employees to take an active interest in the benefit program to mitigate the cost," says Mr. Sherlock.

Before Signing Up

For many employees, quality of a health care plan may come down to a simple question of access. "Are the participating providers accessible? That's a basic element of quality in the mind of the employee," says Mr. Sherlock. He recommends that employers compare a list of their employees' primary physicians with the list of providers a managed care entity is offering and see if there is enough of a match.

"Good managed care organizations should have the ability to map out access for your employee population," Mr. Sherlock continues. Are the doctors in the plan conveniently located? Are they accepting new patients? "That's an important question to ask," he says.

Will a lot of staff have to change doctors? "It doesn't mean you shouldn't select that option," says Mr. Sherlock. "It just gives you more information." For instance, if staff would have to change doctors, employers may want to offer a dual option plan or a point of service plan with out of network benefits. …

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