A health plan report card for informed choice of insurance.

• Author: Zika, Kari Jo

Member satisfaction surveys assess the performance of each of the 26 health care plans offered to participants of the State of Wisconsin's Group Health Insurance Program.

Each year the Government Finance Officers Association bestows its prestigious Award for Excellence to recognize outstanding contributions in the field of government finance. The awards stress practical, documented work that offers leadership to the profession and promotes improved public finance. This article describes the 1997 winning entry in the communications and reporting subcategory of the pensions and benefits category.

The Wisconsin Department of Employe Trust Funds (ETF) administers the State of Wisconsin Group Health Insurance Program under the direction of the Group Insurance Board ("the Board"). This health care program covers approximately 66,000 state, university, and other public employees, and more than 16,000 retirees. Taking into account eligible dependents, the insured population totals more than 200,000 members. Participants are allowed to choose from 26 different plans, including health maintenance organizations (HMOs), preferred provider plans (PPPs), and fee-for-service indemnity plans. More than 80 percent of the insured group belong to either an HMO or PPP.

Each year in October, already-insured participants are given an opportunity to change health plans. Participants are provided with information concerning the health plans that are available in their area, as well as the employe share of the premium. HMOs and PPPs are offered as alternative health care plans to help hold down health care costs and to give individuals some latitude in selecting their health care benefits. There is standardization in benefit levels, known as a uniform benefits schedule, which is intended to simplify the plan selection process for participants.

The Need for Report Cards

While many of the factors considered in health plan selection are readily available to consumers (e.g., cost, benefits, provider network), there is little reliable information produced on the quality of the health care and services that a plan provides. When health plans compete for subscribers solely on cost or their provider network, purchasers and participants are not getting a true picture of the product value.

ETF member surveys have shown in the past that people consider five basic factors when selecting health insurance plans: 1) out-of-pocket expense; 2) the benefits - what is covered and what is not. This is less of a consideration with uniform benefits for HMOs and PPPs; 3) plan policies, such as referrals, out-of-area care, and changing primary care physicians; 4) access to care, including choice/location of providers and ability to see a doctor when needed; and 5) quality of care - the knowledge and assurance that medical problems are treated appropriately and successfully.

Of the above factors, quality of care was the most important to members. Traditionally, it had been thought that quality of care was assured through competition, which is true for the most part - if care is poor, people go elsewhere. Bad publicity or lawsuits damage a plan's reputation and the plan will subsequently see a...