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To help eliminate health plan administrative problems encountered by its employees, PROMUS Hotel Corp. relies on a service that sometimes uses a stealth approach to check up on managed care company performance.
A benefit consultant contends, however, that looking only at the operational efficiency of a managed care plan, and not also reviewing the quality of its medical decisions, provides employers with an incomplete picture.
In 1997, PROMUS Corp. began using a product called Health Plan CheckUp, offered by Minneapolis-based Network Management Service Inc., to continually test the ease of employee access to managed care services.
PROMUS has about 20,000 employees enrolled in health plans nationwide, said Todd Creasy, director of benefits planning. PROMUS owns and operates the Embassy Suites Hotel chain and recently acquired DoubletreeHotels.
As part of the service, NMS uses PROMUS' employee health plan eligibility data to assure that the HMOs PROMUS has contracted with are accurately loading the employee information into their enrollment systems. NMS does so by contacting the health plans by phone and comparing the plan's records with the employer's data. In that way, things such as the accurate and timely issuance of health plan identification cards can be tracked.
NMS also helps PROMUS track such things as how long it may take for employees to arrange a doctor visit or how long it might take them to actually reach someone in customer assistance departments, Mr. Creasy said.
NMS also will make telephone contact with HMOs without alerting the plan that it is really a vendor calling and not an employee using the system. That way it gets a more accurate picture of how the health plan really treats plan enrollees, NMS says.
PROMUS has been using the NMS service for 6,000 covered lives, but next year it will expand use of the service to serve the additional 14,000 covered employees that came with the acquisition of Doubletree.
"It's a great way for us to pre-emptively see where problems are cropping up and try to correct them before they become a problem on a mass scale," Mr. Creasy said.
With employees and HMOs in several states, PROMUS relies on NMS report cards to gauge the quality of service in different geographical areas, Mr. Creasy said. A particular HMO may be good in some states but weak in others, he explained.
"Some of the national carriers will be very strong here and somewhat weaker there, and as a result of these reports, they will make changes or adjust their operations, and if they don't do it, then we certainly take that into consideration during the rebidding process," Mr. Creasy said. "It is causing them to perform."
The additional clout the performance data brings during the negotiating process can be helpful to the employer.
"When I am talking to our account manager, I am talking about these issues and saying, 'Hey, you're wanting this fee and that fee for this, that and the other,' and this gives me some ammunition other than just the number of covered lines that I am representing," Mr. Creasy said.
As interest in health plan quality continues to build, employers are increasingly turning to two types of auditing practices, albeit with some overlap, explained Lonny Reisman, a doctor and principal specializing in health care system re-engineering and evaluation for William M. Mercer Inc. in New York.
Some employers focus on the quality of clinical care delivery. Others look more at health plans' administrative sides, as the NMS CheckUp service does.
While both sides are getting more attention, Dr. Reisman argues that it is pointless to assure the administrative or operational side is operating smoothly if the clinical side is failing.
"Obviously, you can't do the clinical piece if the operations stuff isn't going well," he said. "But I would argue that if the operational side is going well and the clinical care is poor, then perhaps you haven't really accomplished much."
To test the quality of care at managed care companies for employer clients, Dr. Reisman said Mercer presents HMOs with scenarios of simulated health cases and then evaluates their process for handling them. The attention needed to treat the hypothetical cases can vary greatly, with some needing only nurse attention while others may have complications or call for specialist referrals.
"We get a sense of the orientation, the focus, what the priorities of the plan are with regard to evaluating different types of clinical situations," he said.
An employer could also have Mercer check up on a health plan without revealing that the consultant is actually testing the service.
"If the employer wanted it to be done blind to the managed care organization, then we basically add a few names to the (plan) eligibility tapes that are sent to the plan every month and say, "We hired this new guy; here is the Social Security number,' " Dr. Reisman said.
The health plan can then be contacted openly to see how it has handled the enrollment service or prepared for the potential care of someone they thought was a real employee with a particular condition, not just a test case.
Most employers, however, prefer to conduct the testing openly in a cooperative spirit, alerting the HMO of their intent, according to Dr. Reisman. That method works just as well, even though the HMO has an additional incentive to put its best foot forward when it knows it is being tested, he added.
Measuring a plan's health care quality is important, and NMS does provide that service for clients, said Mike Bingham, president of the company in Minneapolis. The CheckUp product it offers is designed to only measure service quality, not to be a comprehensive evaluation including quality of medical care, he noted.
Along with checking the health plan's access records, postcard-size satisfaction surveys also are sent to employees who have recently used an HMO's services. NMS send results of those satisfaction surveys to the employer.
"Not every client will buy the service," Mr. Bingham said. "It's not cheap. It is fairly labor-intensive to have people on the phone. We think a lot of clients will buy it for HMOs that they are having a problem with and focus on them.'