Health Insurance Exchange Stakeholders Conference - Panel 1: Meeting Consumer Needs (08/30/2010)

Our first panel is titled ensuring consumers needs are met.
And will be moderated this morning by Karen Pollitz, the director of consumer information
in the office of consumer information and insurance oversight here at the department
of health and human services. The panelists this morning include Dr. William
J. hall, who is member of the board of Board of Directors at AARP.
Dr. Hall serves on their governance an compensation committee and the AARP insurance trust.
He is a professor of medicine at the university of Rochester school of medicine where he directs
the center for healthy aging. Our next panelist is Dania Palanker, healthcare
policy coordinator at the service employees international union.
Dania has been with SEIU since 2001 and prior to that she worked at the center for handgun
violence. Our third panelist is Jason Helgerson, Wisconsin's
medicaid director and senior health policy adviser to Wisconsin's governor Doyle for
nearly six years. Jason serves as project lead for the development
of the health insurance exchanges in Wisconsin. Finally, Steven Finan, health economist and
senior director of policy at the American cancer society action network, the advocacy
affiliate of the American cancer society. Previously Steven was senior economist in
the office of economic policy at the department of treasury and prior to that Steven worked
here at the department of health and human services, also in the office of management
and budget. And finally office of senator David prior.
Please join me in welcoming our panelist this is morning and Karen, I'll turn it over to
you.
[Applause]
-- Thank you, Ann. Good morning, everybody.
I just can't say how pleased and proud I am that this panel on consumer needs leads the
day today. I think that symbolic of the importance of
organizing health insurance markets and plans to meet consumer needs and we have a lot of
issues to discuss in that regard. So let me kick it off by starting at the end
with Steve Finan. Steve, I have heard you sum up the priorities
that we need to adopt in order to make insurance and markets work for consumers and you use
a list of four As. Can you tell us about those?
-- Yes. The American cancer society when we into healthcare
reform, it was a new issue for us. We traditionally focused on cancer.
So we try to figure out how to approach something asthmasive as healthcare reform.
And at the end of the day we came to what we call the four As, many others have adopted
as well which are the availability of coverage, adequacy of coverage, affordability and administrative
simplicity. Those principles still are extremely relevant
to exchanges. The adequacy will probably be fine first and
foremost by the benefits package, the availability, adequacy and administrative simplicity are
made operational, those principles are made possible by decisions you make on the decisions
you make.
-- Terrific. Let me use that as a jumping off point for
the whole panel. The point of exchanges is to organize health
insurance marketplaces and change the balance of market clout so that the exchange will
bargain with all health insurers and plans in order to provide better value, better customer
service for the best price, in essence to meet the four As.
For all of our panel members I would like you to just jump in and let's talk about this
for a little while. From the consumer perspective, what issues
should we consider in terms of selecting or allowing plans to participate in the exchange
and what kinds of plans, standards or bidding procedures will help facilitate getting the
best value for consumers and taxpayer? Anyone like to take a crack at that one?
-- You summed up the whole complexity of the situation, that I think we're all facing.
In terms of -- the four As that Steve mentioned, accessibility comes forward as one of the
really key points. But it's not just accessibility at the first
point of entry, but it's accessibility over some period of time and the population that
we are -- we think we're going to be dealing with is probably going to be a population
that will fall within many cases that less than 400% of the poverty level.
This means some of these people will be moving in and out of jobs, maybe moving in and out
between individual coverage, employer coverage, a concern that we have is there be some mechanism
to ensure stability and continuity of plans for the families.
This is going to require an immense amount of coordination but also I think will be simplified
if that's the right word, facilitated by much more involvement of the entire consumer pool,
not just the individual but the insurers, federal agencies, state agencies, so in the
planning process up front I think we need to put this very much into the forefront.
Let's get the large group of consumers very much involved in the planning and facilitation.
-- I would add, when we're looking at what plans to have involved, it's the thinking
about the same population but the plans themselves that beyond just looking for the plans that
hit the essential benefit package, remembering that that group between 250 and 400% of poverty
that has subsidized out of pocket maximum but not other subsidized cost share, it's
still a group where it's hard for many to afford to go to the doctor to get an MRI or
blood test above that preventative care if they have to pay the full cost of it.
So I think if exchanges can think of ways to encourage creativity whether it's through
the medical home, value-based and other ways possibly even working with safety net providers
to have plans that don't have deductibles then what that maximum deductible is.
-- Another major challenge we have is health insurance is a complex good.
In order for markets to work well, consumers need to have information and be able to understand
information. I think at least an experience we're going
through now with 100,000 families in Wisconsin through the medicaid program, we fine it's
very difficult to present information to a diverse set of consumers in ways that's easy
for them to understand, that doesn't overwhelm them, that allows them to make informed choices.
We're learning a lot from the experiences we have going on in Wisconsin today but that's
a major challenge for all the states is how do we summarize information, how do we present
a series of options in ways that consumers can understand so they can make informed choices
and if we don't do that very effectively the exchanges won't be the transformative force
that many of us want them to be.
-- Can I pick up on Jason's point, which is educating consumers.
It is absolutely critical personally I believe there is such a thing as competitive market
but we have never seen it in this country because of 60 years or so that we have had
real insurance, a group or individual market has been price driven.
The consumer is ignorant about the quality of care that is available.
So we have a tremendous job to do, to begin to teach people what real coverage means.
Karen did a study a few years ago looking at some of the Massachusetts plans and she
took quote unquote typical cases of heart disease, diabetes and cancer.
And found that the quality of care actually didn't line up very well with the bronze,
silver, gold structure that they had in Massachusetts which we're going to have an exchange.
That's a very serious problem because ultimately we want consumers to know what the real coverage
means if you get a serious condition. So it won't happen quickly an easily.
We have a population basically I will literate in terms of what insurance is so bring them
along and creating a learning curve will be a tremendous challenge but if we want the
exchange to work, if we want constructive competition to exist, educating consumers,
providing them with useful information is a tremendous by essential challenge.
-- Bill, I know AARP has some concerns about information and how to convey this in a way
that crosses these complex areas. Do you want to talk about that?
-- We're moving suddenly from a piece of paper to a web-based Internet system of making choices
ultimately. For the population we're talking about a corn
earn -- concern we have is you can put a list of plans available.
But there needs to be a universal standard that people can say plan A is somewhere on
the scale versus the standard as opposed to just comparing plans themselves.
There's room for a fair am of confusion as -- amount of confusion though it seems on
the surface simple, just go to the Internet and pick the plan.
In many community, many states we probably are going to have to look at who are going
to be the omsbudsmen, the go to people that can help interpret and translate some of these
difficult decisions making sure we have taken into account literacy levels, language competencies
and age, very different interest for the very young, I think we call them, we call them
the inVincable, the inVincable, I'm more concerned about the older Vincibles, the where they're
going have substantial problems and there needs to be a common source that people can
go for information. -- Jason, you're experimenting with some new
models in Wisconsin. Do you want to talk a little bit about how
these challenges have been addressed so far in your model?
-- Sure. We went through a new procurement for Medicare
managed services in the south eastern part of our state, 100,000 families.
In Wisconsin the coverage is expansive, basically for all children regardless of presential
income if they don't have access to employer sponsored insurance so we have individuals
making a new set of managed care choices. Hopefully that's note a bad sign.
But so I think it is somewhat instructive, not only for us but other stages because we
have folks coming from all across the income spectrum.
In essence they have four different choices, the benefit is standard, but what we're attempting
to do is try to take information, preference, what's most important from the consumer and
their family and try to use that information to inform their choices and so we have built
a new web-based tool and we have a call senor to use that tool to give preferred physician
or physicians your preferred hospital, other types of information about health status.
We then based on information the individual gives about themselves and their family, we
rank healthcare plans for them. An algorithm runs and gives choices in their
area and our thought with that is it was an initial effort to sort of give information
to people in ways that was easily consumed and understood but one thing we're finding
out is the consumption of healthcare services is more complex than anticipated.
A number of people were finding don't know who their actual doctor's name is but they
do know the clinic. And we today don't have a standard list of
clinics. Meaning they have a standard name.
So what we're finding is as we go through this process in three waves of 33,000 families
each wave, we're having to modify our approach and we're putting together a list of clinics,
popular clinics to assist people and better understanding which providers are in which
networks, they can make informed choices. I think if anything that's sobered us to challenges
we have, and in Wisconsin we're learning from the experience so when we do get to the big
time when the exchange comes an you have even more consumers going through, that we'll have
better information that's timely and important and valuable to people when they make these
choices.
-- How much help do people get from the ombudsman program?
Do people need additional talking one on one? Hand holding as they kind of process all this
information?
-- Good question. We spend time training the staff at the 1-800
number and we staffed up much higher than I think we would have in otherwise because
we wanted to make sure we were answering calls quickly.
So hold times were less than a minute. So people do get to talk to a real human being,
if they want to make a choice they can go through an IVR system, if they know what health
plan and not wait on hold for anyone. But what we're finding is the average call
time is about five minutes which indicates some people come in, know exactly what it
is but some people on the phone 10, 15 minutes in length asking fairly detailed questions.
But that -- but you can have a well-trained conference call people but we have also found
sometime it is phone isn't the best way either. We deployed 20 outstation workers spread across
the community who are available for in person interviews.
We found that not a majority but minority of individuals want that one on one touch
which is a lesson we learned from the experience of part D which is particularly with the older
individuals they really do want to be able to sit down across someone they trust and
get their question answered so I think a wide array of strategies are going to be necessary
to make it successful.
-- Definitely a generational thing. My son will go online and click around and
make all kinds of life decisions but I find I need to talk to a person if it's something
really important. I think not only getting the right plan but
staying well covered in ways that works for you is another challenge.
Dania, working people are used to getting their health insurance through work but we
change jobs, we leave jobs, circumstances change.
How do exchanges need to take into account the fact that people have different work statuses
and that that can change?
-- First is the information and actually going off what Jason said, having people to talk
to because one of the groups that will have biggest changes are people who are lower income
who are on the subsidies where they maybe on a subsidy, get a new job then lose the
subsidy. And, or going back and forth from subsidies
to medicaid depending on their job status, their incomes through their job or even marital
status or whether they have a new child and having someone being able to explain that
to people because that's something that a footnote disclaimer is not something people
truly understand they need to check back to make sure they don't lose that subsidy if
they don't get that new raise or new job. The other aspect is having a way to coordinate
people going between medicaid and the exchange plans and back and forth whom they have their
children on a chip plan if there's a way some of those plans can coordinate so the networks
are the same so they don't lose their provider and there isn't a drop in coverage during
that period of time. As well as just trying to create ways that
the employers can provide the information about the exchange if they're not providing
insurance, or provide enough information about their plan to work with people to make that
transition period if they're moving off the exchange on to a new plan.
And then what their rights are within that.
-- Absolutely. When my son was born I worked for the Federal
Government, left that job, covered briefly under my husband's plan and switched to coverage
under my new job plan. All of that in the space of three months,
my son had three pediatricians in three months because we had to keep changing in order to
keep up. We don't always think about what kinds of
disruption in the continuity of care. May come along with changes in coverage.
-- This brings up another point. That has to do with where does marketing come
in in all of this? In a logical world you say let's set standards
for enrollment which I know HHS is doing. Let's put the infrastructure together and
worry about marketing. In this case maybe marketing should be a essential
element of the role-out of the plans not in 2014 but for the planning to start right now.
This is going to be an important point. You learn by your mistakes but you can't live
long enough to make all the possible mistakes that can be made so we should take advantage
of the experience that's out there but put marketing a little higher up on the order
of priority.
-- Steve, I know the cancer society has run a call center for people with questions and
concerns about health insurance. What are kinds of concerns that consumers
run into when they become patients?
-- Virtually every problem you can imagine they run into, from the biggest problem we
see is one of affordability. Sometimes the premium, sometimes it's the
cost sharing. But it is also going back to the earlier discussion
about consumer information. Is that very often patients don't realize
what's in their insurance plan until they're in treatment.
Then they discover there are limits or barriers to access to care.
Which at that point becomes too late. It's therefore I think -- it's the need for
information and demand is going to just change extraordinarily.
Even back to discussion we were basically having about Internet versus personal interaction,
fortunately the act does recognize this need and does create patient navigator program
but it's not well defined. As we're suggesting here, in today's market
you have brokers and agents that fill part of that role but in the new exchange, the
needs are going to be perhaps significantly different.
Because you've got the every day needs of consumers and some extent brokers and agents
deal with that today but with the lower population, the lower income population and the kind of
population shifting say between medicaid and exchanges, their needs are probably very different
and much greater than the general population. And we're going to have to have people who
are capable of dealing with that population both income but also the cultural variations
that differ. To make this work that's going to be -- has
to be a very important focus of the consumer information and exchange program going forward.
-- Sounds like new kind of information beyond the kinds of stuff published today.
These are doctors in the network, this is the deductible, this is the co-insurance for
this service. But additional kinds of information about
how plans really work for people when they're using the coverage, when they're making claims.
How important is it -- that was softball, it's important.
We have already agreed. But what kinds of benchmarks, what kinds of
measure, new measures do we need to develop so that consumers can get a really good glimpse
of how their plan can be expected to work for them when they actually need to go to
the doctor, take care kid in for treatment and so forth, what -- complaints, effective
payment rates, what things do we need to look at?
-- I think that's going to be an interesting challenge because a lot of times consumers
in the market oftentimes unless they work for a large employer like state governments
or federal government or other large employers they don't have choices in terms of insurance
company. Asking for recommendations, may have a preferred
physician but when it's evaluating insurance companies versus insurance companies that's
a thing where focus groups an additional discussion is necessary because that's a challenge we
have is to the extent to which trying to communicate to at least the medicate population showing
it in getting letter grades for performance in certain areas, the extent to which people
respond to those things, we do our surveys, we find people overwhelmingly support health
plans and give their health plans good results. But when we look at the performance in terms
of measures and other health outcome data we find that though the variance is large
in those measures, we don't see it in terms of customer satisfaction.
So that's going to be one of the challenges we have is to make sure when people are making
choices they understand that not all health mans are the same, not all insurance companies
are the same and they need to understand how to best use these measures.
I think there's still a lot of work and lessons to be learned running up to 2014.
-- I think probably two general categories of complaints.
One will be about cost. And or denial of -- whether it's cost sharing
or premiums and so forth. Those are fairly straight forward.
Second area is probably the benefits themselves. Right now we at our call center get a fair
number of complaints about denial of coverage and whether something is covered, presumably
with essential benefits package those questions will become a little more straight forward.
But I think it's important to track in more detail what the benefit problems are, is it
truly because one of the big sources of competition going forward maybe provider networks.
And the quality of provider networks. So we have to be able to I think you need
to be able to track both is a service actually being denied and what kinds of service or
is it a network problem? There are a wide range of potential benefit
issues. I suspect no one is set up to track those
issues now. If we want to make this work in the sense
we know what essential benefits are, we truly providing them, how are we going to change
that going forward, understanding the problems that consumers have on a day-to-day basis
with the current system will be critical to understanding what changes really need to
be addressed.
-- Oftentimes, looking through the literature analogy is made it's just like the airline
industry, now you go on the web, you don't go through a travel agent.
Look how wonderful travel is these days in the United States.
[LAUGHTER]
-- Healthcare is different. Healthcare is tragedy, it's elation, it's
joy. I think that has to be one of our operative
principles here. Talking about real lives that are unpredictably
affected so when people call in an complain, I don't like X, Y and Z it's important to
take that into consideration but as has been alluded to, it's not the whole story.
The whole story is, is there a standard,a national standard that plans have to live
up to and how adequately are are they living up to that standard over time.
-- I think we need to know that standard varies per different illnesses or conditions or types
of coverage. And I am sure underwriters would be horrified
by the idea of actually letting people know how a plan is for diabetes versus arthritis
versus asthma. But I know that a plan could be incredible
at providing coverage for people who are managing chronic diabetes but it may fail me with my
arthritic condition. That's what the consumers and what the patients
of chronic illness want to know. They want to know is this plan going to cover
my condition and if they look at the co-pays and co-insurance and turns out that somehow
their illness doesn't end up covered in that same way because of the exclusion that's where
-- that's the information they need to get somehow.
-- And need to be sensitized to. Most of us are healthy most of the time.
So it's easy to shop for the plan that will meet your sort of predictable and anticipated
healthcare needs. We do buy health insurance to protect us against
the unknown of the unforeseen illness. As Steve said earlier, that's a heck of a
time to find out the plan doesn't do a good job with cancer or heart attack if that's
what happened to you.
-- One other thing that is critical to put on the table is the risk adjustors because
ultimately if the plans are to provide high-quality care to chronically ill people, the risk adjustors
need to work because that is the way that the funds will get reallocated and if one
properly you begin to create a constructive incentive for plans to take on high risk people.
Because then there's a real incentive for them to figure out how to provide quality
integrated care, something like cancer which is 200 different diseases is just enormously
complex and diverse. But one sees if the risk adjustors work properly,
plans have an incentive figure out how to provide good integrated care for cancer in
a way that we don't do today. But that risk adjustor is enormously important
in the long run to make this work.
-- I think one of the other exciting opportunities with national reform is with these tax credits
being as large and substantial as they are, by our estimates in Wisconsin we estimate
for people in the middle of the income spectrum here, the 200, 300 range you're talking lowering
premiums by 80%. When you do that, and also if the market structures
within the exchange and the -- truly transformative you see premiums begin to sort of also at
the risk adjustors premiums to consolidate or the range narrows a bit.
When you take -- I'm just looking for the cheapest premium I can get and forget everything
else, hope I never get sick or hope I don't get one exclusion, I don't look at the fine
detail of the option, when you get to that point then maybe consumers then move to the
next most important decision which is what doctors in the network, what coverage, how
do they perform, what's their customer service like, are there any exclusions, those kinds
of things. That's part of the challenge here is that
for a lot of people the non-group an small group markets, price is King and if the premium
is becomes the dominant issue and if we can get beyond that being the single issue that
dictates the choice, then we're getting somewhere in terms of trying to make sure people are
making choices best for themselves and for their families, and also that in turn creates
the right set of incentives in terms of health insurance markets.
-- There are lots of ways you could be the lowest price plan, you could never pay claims.
That would make you cheaper but not necessarily good value.
People want choice and health insurance coverage, how much choice?
What's the balance between you have a thousand choices, everything soup to nuts, good to
bad, we pick out the best thing for you.
-- There's a large literature how people make decisions.
One thing that screams out, there's too many choice it is usual result is no choices made
or default choice is made. So I think it's a balance between representing
good plans that want to compete in this marketplace, versus such a panorama of plans that people
won't be able to do anything without not only just a whole Army of people helping them out.
I don't know the answer except to say there is a happy medium and it will start to level
out after a couple of years where in fact the number of carriers will probably be reduced
quite a bit.
-- Steve.
-- We saw in part D what happens when you have choice.
It was overwhelming. And the market eventually shook it out and
I gather there are far fewer plans today. I don't think quantity in terms of plans in
and of itself represents competition or is necessarily good as Bill is saying.
There can be too much choice. Back to the problem of consumer ill literacy,
if they have 10 or 20 choices, if they don't know anything, no background other than price,
that's not necessarily going to do well. I think therefore I think it's really more
incumbent to set how the exchange is set fairly high standards for plans to enter.
So consumers know at a minimum no matter what they choose they're going to get something
relatively good. It's important exchanges be flexible enough
that newed biers and competitors can enter the market.
You don't want to create a barrier to entry but on the other hand quantity alone will
not and is not inherently a good thing.
-- This is fundamentally a a trade-off with regard to exchange.
Want to be a transformative force an realign sense within the healthcare delivery system
and bend the cost curve versus unfettered choice meaning exchange is nothing more than
aggregator of existing health insurance options, people have almost unlimited sets of choices
in terms of obviously that's a standard benefit but there's still flexibility allowed in terms
of cost sharing arrangements. I think that's a key decision that states
if they're going to implement exchanges are going to have to make.
Where do they fall on that continuum? In Wisconsin we're inclined to think we want
to be transformative because to us this huge investment by the Federal Government in healthcare
coming through exchanges in the form of these tax credits is this -- in our view, once in
a lifetime opportunity to really get at some of the inefficiencies in healthcare delivery
system. If we done set that up from the being meaning
we try to use change in these criteria for determining which plans are allowed to play
an which aren't, effectively which inherently will limit choice but if we don't go that
route we'll spend a lot of money helping some people get health insurance that don't have
it today but at the same time really missed the boat when it comes to trying to bend the
cost curve in the healthcare system.
-- Very important. Bill, go ahead.
-- We concentrated a lot on covering catastrophe. That's obviously very, very important.
But another important advantage and opportunity that we have in this once in a lifetime opportunity
is to start to realign the healthcare system much more toward prevention and avoidance
of risk factors, particularly in the population that we're going to be dealing with, it's
well known that adherence to any sort of common established scientifically verified preventative
measures is very low. So maybe another part of the plan that needs
to be plan needs to be emphasized making choices is which plan really has a some sort of idea
how preventative services are going to roll out.
That's the only way the cost containment is going to take place ultimately anyway.
-- I want to add to that that considering in their preventive not just preventive that
regulations are defining but the chronic disease management that present people who already
have a disease from ending up in the hospital or people at risk from getting that disease.
-- Absolutely. How are we going to get exchanges to stay
focused on these kinds of consumer information needs, these kinds of standards?
How can we engage as consumers to make sure that these things are bill in at the planning
level. Jason, you mentioned focus groups.
What efforts have been started -- A beg concern I have nationally with implementation,
no one in Massachusetts and Connecticut and other states who have done parts of this,
no one has ever done this. So one concern that I have is just if we don't
begin piloting, testing, doing thing, trying to learn from the experiences of maybe not
full fledge implementation but elements of implementation, sooner rather than later and
start trying to share that both lessons learned, we're in for a world of a challenge.
Medicare part D was a small microcosm of what we're actually about to go through.
While -- I sat in meetings with HHS and Dr. McClellan speaking how they had 15 backup
plans and there wouldn't be problem or issues, I learned well that day never say there won't
be problems with implementation. But to the extent that I think we need to
pilot these things, we need to put up websites that allow consumers to tell us themselves
what things work, what information is important this them, to begin to get a feel how these
things work in the real world. If you have 50 states in territories turning
on these things on the same day, without having gotten lessons learned that's going to be
very challenging.
-- One thing we have been working on here at HHS is a new website, you're probably familiar
with healthcare.gov which has been an enormous undertaking first as we launch this summer
just showing all of the plans that are for sale to individuals.
Then later this year we'll add some information about the prices shortly thereafter, we're
working on developing other kinds of plan performance measures, how happy are people
in these plans what are the kinds of complaints that come in and how are they resolved, how
often are claims paid and how often are they slow opted or deniedch these are important
measures, many of them new. So gathering these data, making sure they
are meaningful is going to be, you're exactly right, a big challenge but very important.
-- Dania, what else are working people looking for in health insurance?
-- I think a big thing for the working people who don't have employer provided health insurance
is a lot of them have never had health insurance. So I think there really -- they may not be
looking for it now, but many of them are, many of them have figured out how to access
care and I think we're going to have to come up with a way to actually let people know
about the importance of health insurance, a large number of them are from different
countries and it's cultures where health insurance doesn't exist.
You go to the clinic when you need healthcare. And the subsidies will be bringing in recent
immigrants and people who may not be eligible for medicaid because they have only been for
five years eligible for the subsidy so it it's getting the information out and recognizing
we can't depend entirely on private navigators to do that because that will create its own
discrepancies. And this really is inherently public work
and the government does know how to get word out about government programs and getting
people access to social programs. So I think they're looking for that help.
-- The ultimate measure is outcomes. Ultimately when we buy health insurance we
want coverage that allows us to become healthy again.
Again, we have dysfunctional system that's basedically fee for service, regarding volume,
not outcomes. In certain areas, disease areas and health
areas we have begun to make real problem in measuring outcomes.
But much, much more needs to be done. This probably I'm raising the issue probably
that goes first an foremost to the essential benefits package, how do we structure that.
Ultimately we want to be able to have in the exchange information for consumers that says
this plan with its network is successful in treating these kinds of conditions whether
heart disease or diabetes or autism or cancer. We have to think about how do we measure
-- how do we measure outcome an performance? What is successful treatment of heart disease,
what is successful treatment of cancer. Those are -- a lot of that information exists
but it's -- or measures are there but it's not organized.
We have to figure how to better organize that and make it available in a readily comprehensible
accessible way.
-- We promised to save the last 15 minutes of our panel to open this discussion up to
everybody who is here in the room for any questions or comments that you will like to
direct to the room at large or to any panelists. So let us know who you are and go ahead, we'll
go back and forth between the two mics.
-- Mitchell Stein with consumers affordable healthcare in Maine.
Thank you all. I'm cureious the hear what the five of you
think about the two different options of outlining the standard medal plans, actual or value
or we can go with the standard benefits package and Massachusetts have the experience of starting
out one and having to move to the other because of the consumer of confusion of consumers.
If you would comment on that.
-- Folks know what actuarial value is. That's a measure, if I can -- at the risk
of oversummarizing of on average what percent of a population's covered claims would be
paid by a particular plan. In Massachusetts, Mitchell, you're talking
about the gold, silver, bronze tiers set of plans that are -- will cover a higher percentage
of your claims as you come in. Steve referenced some research that I worked
on before coming here. That showed that the average may not be meaningful
to a given consumer. When we examine plans we found in some instance
it is bronze plan would pay the lowest level plan would pay the highest level of claims
of the highest percentage of claims for someone with diabetes but lowest percentage for someone
with cancer because within that policy, the structure of the prescription benefit was
different than the structure of the outpatient medical benefit and the inpatient hospital
bench so while the averages are good benchmarks they don't necessarily tell a person who may
or may not be average ha that plan would do for them.
-- That is an issue we're thinking about grappling with as well.
We went in with this idea that you would allow all this choice and variation one lesson learned
is that variation causes complexity. And consumers think they're getting something
when they're not. They think they're choosing a plan and a tier
and it ends up being a different result. I think it's certainly makes the case for
greater standardization, the flip side of that is when you standardize more and more,
there's a point at which you may get to a point where you'll maybe take away some of
the innovation in the market or potentially also limit some choices to people who actually
would like maybe have a slightly higher deductible plan or things like that. We have been sobered
from talking to the Massachusetts experience about the need to consider seriously a much
higher degree of standardization than we initially thought.
-- Over here.
-- Sara Thomas with the national committee for quality assurance.
This has been a great discussion. We have been excited about potential for exchange
to really drive high-quality as well as reducing cost and competing based on premium.
So I think quality in three buckets. The quality of coverage, do you get the coverage
for your care when you need it which is really important.
Customer experiences, do you get your claims paid on time and people answer the phone and
do people respond to your complaints. Then there's the dimension of clinical qualities
which is do you do a good job taking care of diabetes, do people get their eyes examined,
their feet examined, that sort of thing. These are all important.
I would urge you to think about three options for driving people toward plans that do a
good job on all three dimensions which is one on limiting the choice which is an option,
who is in the exchange, only good plans that do all three of these things well, another
option is create bright flashing lights around the good plan, sort of with the AARP folks
are thinking this is a great plan for you and every other plan could be compared to
it. Another option would be incorporated into
the bidding, some extra credit for high quality plans.
Those are three ideas that we're sort of chewing around on to steer people because it is really
hard to look at all these dimensions of quality as well as cost for a consumer.
Three ideas.
-- Great comment. Thank you.
-- NCUA has done a wonderful job defining parameters.
Distilling them in a way the population irregardless of literacy can understand.
So you have a position of leadership there, hands-down.
-- The call of
the herb hue is always going to be was. This is a once in a generation opportunity
to start to drive a system, not just a question of accepting what the insurance industry puts
forward, we are now in a position through the exchanges to actually demand a higher
level of accountability. In many areas, not the least of which is quality.
At the same time almost certainly bend the cost curve.
That's what we have to keep in mind, not just the matter of adjudicating.
But providing the leadership. My sense is that our organization does a lot
of this has to come from the federal level.
-- I'm Jennifer nandi with the national council of -- we are a national organization, head
quartered in DC but we have five regional offices and serve as umbrella group or approximately
300 independent community based organizations. I have one quick comment and one question.
We have seen already the good work that SOIO is doing in healthcare.gov is amazing and
we're excited for the imminent introduction of the Spanish language website as well.
One thing to keep in mind is there needs to be consistency in consumer information versus
with that of -- that which people are receiving from insurance companies.
Most people especially people who are getting into the system and are new may not know in
common insurance terms so there needs to be as little room as possible if you're simplifying
the terms that go out to consumers so they can unction them.
With that -- understand them. As Dania pointed out there's a lot of varied
eligibility within the Latino immunity in part due to immigration status.
And we have seen that we do need community-based navigators at the ground level really helping
to connect people with coverage. So my question really goes to Mr. Helgerson
which is in Wisconsin what was your -- you mentioned that you employed community-based
workers on the ground. What was your use of non-governmental community-based
organizations and then maybe just speak to how do they plan to engage folks at the ground
level. With consumer information.
Thanks.
-- In terms of using -- when we launched -- which was our effort to ensure every child
in the State of Wisconsin had access to healthcare; we tried to build up an Army of community
based partners. Our thought was that there's a lot of people
who are very wary going to county based welfare offices or aren't comfortable using the Internet
or making using 1-800 number but wanted to go to trusted community organizations.
So we have 200 community-based partners we work with on a daily basis across the state.
when we went through the new every in the southeast we tried to build upon that and
bring in additional groups so they -- the challenge here is twofold.
One, we have a lot of groups fantastic to work with and we have trained and provided
with resources but the one challenge you have with community based partners, some of them
have -- are better trained to have more information than other triesing to maintain a consistency
of different groups is challenging. If government tries to pursue this answer
on its own it's going to have very significant problems, particularly in Latino community
or in some of the other ethnic communities in our state and country, it's a community
based partners far more trusted than government is and having those groups being fully deployed
is extremely useful and so far for us been a great strategy.
-- We have a funding announcement out right now to support consumer ombudsman programs,
we'll hear from states about applications in the next couple of week.
One thing we even encouraged state agentsises can partner with community based organizations
to provide this direct connection to people as well.
So we're very excited about that.
-- Thanks. I'm Gerry Shea from the CIO, thank you very
much for this thoughtful panel to start us off.
I agree with no better place to start than the consumer interests an issues.
You talked a lot about the information people need and some about how they actually get
it in the kind of assistance they need to get.
I want to second that point and make a specific suggestion.
Based on our experience talking with union members about the quality of care and how
to find out where good quality care is or distinguish.
A lot of evidence points to the primary care setting.
The emphasis on primary care strengthening primary care practices runs throughout this
legislation, I think it is applicable here too.
I think we have a look at plan, some of the standards for certifying plans ought to be
how well do they incentivize primary caregivers for providing information and playing a role
in this. A lot of our experience, all of us is when
we need information we talk to our primary care clinician if we have one.
And that's an important vehicle so all the information can be made available in every
way is great but unless we embed it in the patient clinician relationship, at least based
on our experience we have done 30 years, report cards on health plans.
Sara from NCQA knows about this. The reaction is humbling.
We have to get it to the physician or clinician patient relationship.
We have a great opportunity to do that here.
-- Well said.
-- Jumping off that on to another role for primary care physicians, is to think of them
also possible as other primary care gives as a rule to get information out about exchanges
and plans. we used to work for a gun prevention organization
and it was pediatricians we worked with to educate parents about dangers and pediatricians
can be seen to not just get the children covered but to find out do those -- that young inVincable
25-year-old mother and father F they have health insurance, if they don't reminding
them and helping them get access and finding and connecting both within a primary care
system and also a role for hospitals when people end up when they're getting to the
doctor, into the health system to get that connection.
-- Anthony, state of California have anything to say in
-- I'm executive director of health access California the consumer advocacy coalition
in California. We passed our exchange bills week out of our
legislature. That ear heading to the governor now.
And the issue we try to grapple with in California, they're very good bills.
I have copies. But is the issue how the get good information
to consumer? One was cultural linguistic competency, that
was prioritized in these bills not only for the exchange but insurers in the exchange,
the demographic of who is going to be in this exchange is different, not going to be your
mothers individual insurance market. We have that knowledge from the healthy San
Francisco program, which -- where the new folks who came in just had a very different
profile than folks and had specific needs that needed to be addressed.
But I wanted to get broad tore the question of one thing we try to bet around we couldn't
quite figure out a way to operationalize it is how to make consumers feel like the exchanges
they place for trusted information, one way we did that is governance by making sure nobody
from the industry -- that providers or insurers were not part of the governance not on the
board. This was seen as independent entity.
But I'll curious about steps to go further to make people feel like they're members of
an exchange, they have that relationship with exchange, trust of information separate from
the insurers. In California and other places insurers send
communications about market trends, about politics and policy to their subscribers and
how can the exchange be a place of objective information about what's going on in healthcare
and providing guidance to them and how to operationalize that in a DNA now.
-- At the state level there's a wonderful opportunity here for actually engaging consumer
at large in the actual planning an governance of the exchanges.
There's no reason that can't happen and if it does, that will establish much more basis
for trust F it isn't something that some external agency is inflicting on us but it's something
we in our localE have had a role looking at and governing.
All the way across the board.
-- Janet, last question then we have to wrap up.
-- I'm Janet trout with the national association of health underwriters.
I would be remiss if I didn't make a comment that my member whose are insurance agents
brokers and consultants work with consumers every day to help them understand the coverage
that they have. One thing that we see -- we're very concerned
about the quality issues related to the exchange in both outside the exchange as well.
One thing I wanted to add to what Steve said, we're dealing with people that are eligible
for subsidies that may not have had access to coverage before but one thing I want to
point out is that people will be eligible for subsidies up to a fairly high income level.
Many of these are the same people that we're already dealing with.
Some of the most common questions that we see are never covered on any report card.
Things that consumers really are caring about are that we often see minimum wage workers
asking for example, which doctors speak my language.
I'm not talking about people undocumented. Just regular people that are working on the
assembly line and this question is very common for hourly workers who may not have sick pay
benefits which offices are open late. It takes -- this information is not readily
available to them and these are the types of things that they consider to be quality
on their plan if they can get to a doctor that understands what they're saying, if they
can get to a doctor at all because they can afford to do it after the working hours.
Those are things important to real people out there so I hope as you -- as we talk more
about quality that we can address those things that matter to real folks out there that need
to access healthcare.
-- Well said. I'm sorry, it's 10 and we need to wrap up
so we can keep going. I'm happy to talk to you later about your
question if I can please put you off, I apologize. What we talked about today is that it's complicated
as health insurance maybe, consumers are very complicated.
We really do need to begin at the outset with understanding what it is that people need
in terms of their care and in terms of their coverage, in terms of the information in terms
of is insistence for understanding this new world of health exchanges and making choices
that makes sense for them. If we can build that in at the outset through
new information sources, through new kinds of assistance and through the design of the
health plans that we include in these exchanges then I think we will have done a great service
for everybody. So I want to thank our panelists for joining
us today and the organizers of this event for beginning with consumer perspectives.
With that, we will pause, take a little break, then get ready for the next panel.
Thank you very much.