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BOSTON -- Employers should consider replacing point-of-service health plans with open-access plans, because workers are dissatisfied with POS plan administration and gatekeepers, a researcher suggests.
Employees especially report trouble with POS plan billing and administration of claims for non-network providers and low satisfaction with primary care physicians, the researcher found.
Under POS plans, members typically can choose at the time service is needed whether to go to a primary care physician, who serves as a gatekeeper for access to network specialists, or see a non-network provider or specialist, with higher out-of-pocket expenses.
Open-access plans essentially lack the gatekeeper function, with plan members visiting specialists of their choice inside or outside the network, though employee costs typically are higher if they go out of the network.
Employers cannot ignore growing employee dissatisfaction with restrictive managed care plans that fail to demonstrate "concern for members' well-being," contends Dr. Tod D. Cooperman, president of New York-based CareData Reports Inc.
During the annual conference of the American Assn. of Health Plans in Boston last month, Dr. Cooperman discussed the results of a recent survey he conducted.
"Employers seem to like the POS option but are really becoming more and more troubled by the administrative problems that the members are having," he said.
"We do hear (employers) interested in considering more open-access products and even PPO (preferred provider organization) products."
Dr. Cooperman's survey received 23,000 responses from employees at 131 large employers nationwide. The survey was conducted last year in the top 26 managed care markets in the nation.
"In terms of their satisfaction, it was clearly higher with open-access plans over HMOs and (also) over point-of-service plans, which traditionally and always in our studies had the lowest levels of satisfaction of these products," Dr. Cooperman said.
Actually, the majority of employees in open-access plans apparently had not made a conscious decision to join them because of the absence of gatekeepers, the researcher said. Only one-third of those in these plans said they joined for easy access to specialists, while most pointed instead to the inclusion of their physicians in the plans' preferred networks; financial issues, such as copayments; and prescription drug coverage.
Regardless of why they chose an open-access plan, the survey clearly found that these members were happiest with both administrative service and medical treatment, Dr. Cooperman said. Open-access plan members said they were highly satisfied with their programs 65% of the time, compared with 58% for HMO members and 48% for POS plan members.
Open-access plan participants also were more likely to say they would remain in their plans -- 82%, as opposed to 72% for POS plans.
"Even a 1% increase or decrease in retaining members means millions of dollars if you have a large plan," he said.
Open-access plan members were more likely than those in other types of plans to: recommend their plans to others; perceive that their plans have value; and like their primary care doctors. With this level of loyalty, open-access plans are in a much better position to decrease their marketing expenses and increase margins, Dr. Cooperman said.
The key issues driving consumer satisfaction for all kinds of managed care plans were the plan's display of concern for its members, satisfaction with service, happiness with medical care, and satisfaction with primary care physicians, he said.
POS plans received the lowest marks for customer satisfaction, with poor handling of out-of-network claims one of the most frequent complaints, Dr. Cooperman's survey found.
Employees, dissatisfied with the administrative side of the POS plans, appeared to carry the blame over to their primary care physicians and gave them relatively poor marks, he said.
An exception appeared to be cases when a managed care plan permits female members to choose obstetrician/gynecologists as their primary care physicians. In such instances, plan members had high satisfaction and lower levels of plan utilization because they often relied on the Ob/Gyn instead of a specialist for treatment, he said.
Pointing to a specific market as an example, Dr. Cooperman said United Healthcare Corp.'s POS plan in Houston achieved a 56% overall satisfaction level in the survey, compared with 67% in its local open-access plan.
But one problem managed care companies and employers face, if they introduce open-access plans, is differentiating them from similar programs that lack a gatekeeper, such as PPOs, according to the researcher.
"A good number of members don't know what kind of plan they're really in, let alone the name of the plan they're really in," he said, adding that defining exactly what is unique about open-access plans in today's market will be a continuing challenge for the plans and their sponsors.
Nonetheless, every HMO should be offering an open-access plan, he said. It also should not charge members "self-referral" fees when they venture outside the provider network, he said.
As for dissatisfaction with the traditional POS plan, Dr. Cooperman was pessimistic, saying it "either requires a tremendous correction in systems -- or maybe it's just an inherent problem that can never be fully solved."