Consumer Health Care Information: Many Quality Commission Disclosure
Recommendations Are Not Current Practice (Letter Report, 04/30/98,
GAO/HEHS-98-137).

Pursuant to a congressional request, GAO reviewed the Advisory
Commission on Consumer Protection and Quality in the Health Care
Industry's recommendations for improving information disclosure,
focusing on the: (1) Commission's recommendations regarding information
to be provided to consumers and comparing them with the information
currently provided to employees of large public and private health care
purchasers; (2) available evidence from purchasers and researchers
concerning the extent to which consumers are able to make use of this
information; and (3) potential cost of bridging any existing information
disclosure gap between the Commission's recommendations and existing
purchaser practices.

GAO noted that: (1) the Quality Commission's Consumer Bill of Rights and
Responsibilities recommends that consumers have access to a broad range
of information regarding the policies, characteristics, and performance
of health plans, professionals, and facilities; (2) under the Consumer
Bill of Rights, each of these components of the health care system would
have responsibility for routinely providing a set of specific
information to consumers, either directly or through plan sponsors, and
making other information available on request; (3) taken together, the
large purchasers in GAO's review, and their associated health plans,
currently provide over half of the data elements the Commission
recommended be routinely provided to consumers; (4) the information
covering conventional health insurance issues, such as covered benefits
and cost-sharing, is typically provided by health plans; (5) in
addition, performance measures reflecting plans' clinical quality and
enrollee satisfaction are generally collected and disseminated by large
purchasers; (6) on the other hand, information that the Commission
recommended be provided about the business relationships and financial
arrangements among health professionals, health care facilities, and
health plans, as well as measures of service performance, are among the
items not routinely reported to consumers; (7) to be responsive to
consumers' information needs, large purchasers disseminate information
through a variety of media; (8) written materials, generally used during
open season to assist consumers in their health plan selection, are
highly accessible but can become quickly outdated; (9) regardless of the
format used, however, both the purchasers GAO interviewed and consumer
surveys indicate that many enrollees do not use the health care
information made available to them because it is difficult to
understand; (10) according to an analysis performed for the Commission,
meeting the Consumer Bill of Rights information disclosure
recommendations would add $0.59 to $2.17 per enrollee per month to
current information-related expenses, depending on the level of detail
provided and the time allowed for implementation; (11) the cost
increases would initially be borne by physicians, hospitals, health
plans, and dissemination sources and could ultimately be passed on to
purchasers and consumers; and (12) despite the potential increase in
cost associated with providing more and better information, large
purchasers indicated that they intend to continue expanding their
information development and disclosure efforts because of the value
gained through informed choice.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-98-137
     TITLE:  Consumer Health Care Information: Many Quality Commission 
             Disclosure Recommendations Are Not Current Practice
      DATE:  04/30/98
   SUBJECT:  Federal advisory bodies
             Health maintenance organizations
             Consumer education
             Health insurance
             Employee medical benefits
             Health care planning
             Consumer protection
             Information disclosure
IDENTIFIER:  Federal Employees Health Benefits Program
             NCQA Health Plan Employer Data and Information Set
             HCFA Consumer Assessments of Health Plans Study
             
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Cover
================================================================ COVER


Report to Congressional Requesters

April 1998

CONSUMER HEALTH CARE INFORMATION -
MANY QUALITY COMMISSION DISCLOSURE
RECOMMENDATIONS ARE NOT CURRENT
PRACTICE

GAO/HEHS-98-137

Consumer Health Care Information

(108358)


Abbreviations
=============================================================== ABBREV

  CAHPS - Consumer Assessments of Health Plans Study
  FEHBP - Federal Employees Health Benefits Program
  HEDIS - Health Plan Employer Data and Information Set
  HHS - Department of Health and Human Services
  HMO - health maintenance organization
  JCAHO - Joint Commission on Accreditation of Healthcare
     Organizations
  NAIC - National Association of Insurance Commissioners
  NCQA - National Committee for Quality Assurance
  PBGH - Pacific Business Group on Health

Letter
=============================================================== LETTER


B-279867

April 30, 1998

The Honorable Larry E.  Craig
United States Senate

The Honorable Paul D.  Coverdell
United States Senate

The Honorable William V.  Roth, Jr.
Chairman
Committee on Finance
United States Senate

The rapid changes in the health insurance industry have increased
calls for greater information dissemination to enable consumers to
make more informed choices.  Purchasers of health care, such as large
employers and agencies responsible for government employee health
plans, have become more active in the information movement as they
have adopted "value-based" purchasing strategies.  For both
purchasers and their employees--who are the ultimate consumers of
care--information is considered critical in choosing the highest
quality health plan for the dollar and in promoting efficiency and
responsiveness in the provision of health care services. 

Growing public concern about health care quality has elevated the
discussion of health plan information to the national level.  As a
result, on September 5, 1996, the President created the Advisory
Commission on Consumer Protection and Quality in the Health Care
Industry and charged it with recommending measures to promote and
ensure health care quality and to protect consumers and workers in
the health care system.  The Commission released its initial
recommendations--The Consumer Bill of Rights and Responsibilities--in
November 1997.\1 Since then, some Members of the Congress have called
for the Consumer Bill of Rights to be adopted into federal law. 
Others argue that such an increase in regulation would result in
higher insurance premiums and increase the number of people unable to
afford health insurance.  With these issues in mind, you asked us to

  -- review the Commission's recommendations regarding information to
     be provided to consumers and compare them with the information
     currently provided to employees of large public and private
     health care purchasers,

  -- review the available evidence from purchasers and researchers
     concerning the extent to which consumers are able to make use of
     this information, and

  -- discuss the potential cost of bridging any existing information
     disclosure gap between the Commission's recommendations and
     existing purchaser practices. 

To respond to your request, we reviewed the information disclosure
chapter of the Consumer Bill of Rights and Responsibilities and
transcripts of Commission meetings where this issue was discussed. 
To compare Commission recommendations with current large purchaser
practices, we drew from an extensive body of our work over the last
few years focusing on managed care in general, as well as on large
purchaser management strategies and quality initiatives.  In
addition, we contacted officials at, or reviewed health benefits
material from, a group of nine large public and private health care
purchasers, a purchasing coalition, and a business group.  The
purchasing coalition and the business group together represent
approximately 190 large employers.  (For a list of these purchasers
and groups, see app.  I.)

In making the comparison, we assumed that if a purchaser provided
information that only partially fulfilled a recommendation, it did
not meet the recommendation.  For example, many health plans
distribute provider directories during plan selection periods, but
few of the directories we reviewed included all of the data the
Commission recommended be included, such as whether the providers
were accepting new patients, what languages the providers spoke, or
whether interpreter services were available.  On the other hand, in
cases in which the Commission did not elaborate on the level of
detail that should be disclosed, we assumed that any information
provided regarding a specific data element was equivalent to the
Commission's recommendation.  For example, the Commission recommended
that health plans provide "information about circumstances under
which primary care referral is required to access specialty care." We
assumed that health plan information was consistent with this
recommendation if it simply stated that a referral from the primary
care physician was required for specialty care. 

To address health care consumers' ability to make use of information,
we discussed the issue with health benefits managers and reviewed
recent studies on health plan information and consumer choice.  Our
review of the potential cost of meeting the Commission's information
disclosure recommendations was based on an analysis by The Lewin
Group, Inc.\2 We also discussed the cost implications of the Consumer
Bill of Rights with large purchasers' benefits managers. 

The firms we included in our review were large--having more than
10,000 employees--and offered a choice of health plans to their
employees.  We selected these purchasers in part on the basis of our
previous work and in part because of their reputations as innovators
in the health care purchasing arena.  Given that a large percentage
of employer-sponsored health care coverage is offered by small- and
medium-sized firms, commonly with a single health plan option, the
information available to employees of purchasers in our group should
not be considered representative of that provided to all insured
consumers.  Rather, the information disclosure practices discussed in
this report represent the leading edge in information collection and
dissemination in the nation. 

We conducted our review between January and April 1998 in accordance
with generally accepted government auditing standards. 


--------------------
\1 Advisory Commission on Consumer Protection and Quality in the
Health Care Industry, Consumer Bill of Rights and Responsibilities,
Report to the President of the United States (Washington, D.C.:  Nov. 
1997).  The Consumer Bill of Rights and Responsibilities is also
referred to as the Consumer Bill of Rights and the Patient Bill of
Rights. 

\2 In 1997, the Quality Commission contracted with The Lewin Group,
Inc., to analyze the benefits and costs of the information disclosure
and external appeals provisions of the Consumer Bill of Rights. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

The Quality Commission's Consumer Bill of Rights and Responsibilities
recommends that consumers have access to a broad range of information
regarding the policies, characteristics, and performance of health
plans, professionals, and facilities.  Under the Consumer Bill of
Rights, each of these components of the health care system would have
responsibility for routinely providing a set of specific information
to consumers, either directly or through plan sponsors, and making
other information available on request.  Taken together, the large
purchasers in our review, and their associated health plans,
currently provide about half of the data elements the Commission
recommended be routinely provided to consumers.  The information
covering conventional health insurance issues, such as covered
benefits and cost-sharing, is typically provided by health plans.  In
addition, performance measures reflecting plans' clinical quality and
enrollee satisfaction are generally collected and disseminated by
large purchasers.  On the other hand, information that the Commission
recommended be provided about the business relationships and
financial arrangements among health professionals, health care
facilities, and health plans, as well as measures of service
performance, are among the items not routinely reported to consumers. 

To be responsive to consumers' information needs, large purchasers
disseminate information through a variety of media.  Written
materials, generally used during open season to assist consumers in
their health plan selection, are highly accessible but can become
quickly outdated.  Electronic dissemination via the Internet
overcomes the timeliness problem by rapidly reflecting changes in
health plan information, but not all consumers have access to the
Internet.  Regardless of the format used, however, both the
purchasers we interviewed and consumer surveys indicate that many
enrollees do not use the health care information made available to
them because it is difficult to understand. 

According to an analysis performed for the Commission, meeting the
Consumer Bill of Rights information disclosure recommendations would
add $0.59 to $2.17 per enrollee per month to current
information-related expenses, depending on the level of detail
provided and the time allowed for implementation.  The cost increases
would initially be borne by physicians, hospitals, health plans, and
dissemination sources and could ultimately be passed on to purchasers
and consumers.  Despite the potential increase in cost associated
with providing more and better information, large purchasers
indicated that they intend to continue expanding their information
development and disclosure efforts because of the value gained
through informed choice. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Information disclosure has attracted increased attention because of
the desire to protect consumers and the important role information
plays in helping consumers make informed choices.  Current
information disclosure practices have been shaped largely by
employers, private accrediting agencies, and governments. 

In response to the double-digit increases in the cost of health
insurance in the late 1980s, many large purchasers opted for an
approach to buying health care that demands more analysis on the part
of the purchaser to secure the greatest value for its health care
dollar.  Using the leverage conferred by their size, many large
purchasers pushed health plans to improve their data collection and
reporting capabilities, so the purchasers could perform the necessary
analysis.  For example, together with health plans, large purchasers
developed the Health Plan Employer Data and Information Set
(HEDIS)--a standardized set of performance measures--as a tool with
which purchasers could compare health plans.\3 In some cases,
purchasers passed this information and analysis on to their employees
to assist them in deciding among competing health care options. 

In addition, accreditation agencies such as the National Committee
for Quality Assurance (NCQA) and the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) evaluate health
care organizations' clinical and administrative systems and make the
results of these evaluations available to employers and the general
public.\4 There is some commonality between the standards for
accreditation and the Consumer Bill of Rights information disclosure
recommendations.  For example, both JCAHO and the Consumer Bill of
Rights require the dissemination of information on the scope of
covered benefits.  But in many other cases, the Consumer Bill of
Rights' recommendations are more extensive than accreditation
standards.  For instance, JCAHO does not require disclosure of state
licensure status, federal certification, and private accreditation
status, as called for in the Consumer Bill of Rights. 

The Congress, in addition to the executive branch, has been active in
encouraging greater disclosure of health plan information to
consumers.  The Balanced Budget Act of 1997 (P.L.  105-33) contains a
list of information disclosure requirements for Medicare+Choice
plans.\5 These requirements include an explanation of benefits,
premiums, plan service area, quality and performance indicators, and
supplemental benefits.  On February 20, 1998, the President
instructed the Departments of Defense, Health and Human Services,
Veterans Affairs, and Labor, as well as the Office of Personnel
Management, to bring their various plans and programs (which serve
over 85 million people) into agreement with the Consumer Bill of
Rights. 

At the state level, the California Managed Health Care Improvement
Task Force recently recommended that "health plans be required to
make available and accessible to consumers significant additional
information including the following:  a `standard product
description' to facilitate direct comparison of plans by consumers,
up-to-date and specific information on provider access, information
on referrals to specialty centers, and plan and medical group
independent practice associations' written treatment guidelines or
authorization criteria."\6 The National Association of Insurance
Commissioners (NAIC) has also addressed the issue of health plan
information disclosure in a series of model laws that are being
incorporated, to varying degrees, by states as they pass
comprehensive consumer protection legislation.\7


--------------------
\3 The current version of HEDIS measures--HEDIS 3.0/1998--includes 86
reporting and testing measures in eight areas:  effectiveness of
care, access/availability of care, satisfaction with the experience
of care, health plan stability, use of services, cost of care,
informed health care choices, and health plan descriptive
information.  Over 90 percent of health maintenance organizations
(HMO) use HEDIS at the request of the Health Care Financing
Administration, state governments, and large commercial employers. 

\4 NCQA is an independent, nonprofit organization that reviews and
accredits managed care organizations.  More than half of the HMOs in
the nation have been reviewed by NCQA, and they account for
approximately 75 percent of all Americans enrolled in HMOs.  JCAHO is
an independent, nonprofit organization that accredits health care
providers and networks (including health plans). 

\5 A Medicare+Choice plan can be any of the following types of health
insurance plans:  a coordinated care plan--such as an HMO, a
provider-sponsored organization, or a preferred provider
organization; a combination of a medical savings account plan and
contributions to an associated medical savings account; or a private
fee-for-service plan. 

\6 The California Managed Health Care Improvement Task Force was
created in 1996 to inform the state's leaders about the current
health care industry in California, including the impact of managed
care on specific segments of the industry and components of special
concern to consumers, and to make recommendations regarding the
state's oversight and regulatory role related to managed care.  See
California Managed Health Care Improvement Task Force, Executive
Summary (Sacramento, Calif.:  California Managed Health Care
Improvement Task Force, Jan.  5, 1998). 

\7 NAIC first developed a Health Maintenance Organization Model Act
in July 1995.  Since then, NAIC has developed model laws covering
health care quality assessment and improvement, health care
professional credentialing verification, managed care plan network
adequacy, utilization review, and health carrier grievance
procedures. 


   COMMISSION INFORMATION
   DISCLOSURE RECOMMENDATIONS GO
   BEYOND CURRENT HEALTH PLAN AND
   PURCHASER PRACTICES
------------------------------------------------------------ Letter :3

In the Consumer Bill of Rights and Responsibilities, the Commission
has recommended that consumers receive a broad array of information
about health plans, professionals, and facilities.\8 The rationale
given by the Commission is that "active and informed decision making
by consumers will improve the performance of the health care system,
as providers seek to enhance their quality and reduce their costs in
order to be more attractive to value-seeking consumers." Under the
Consumer Bill of Rights, health plans, professionals, and facilities
would have responsibility for routinely providing a set of specific
information to consumers and making other information available on
request.  The information routinely provided to employees of the
large purchasers in our review covered about half of the data
elements that the Commission recommended and focused on health plan
benefits and network characteristics.  The areas of information
disclosure on which the purchasers and the Commission were furthest
apart generally pertained to the business relationships and financial
arrangements that health professionals and health care facilities
have with health plans. 


--------------------
\8 The Commission used the term "health plan" to refer broadly to
indemnity insurers, managed care organizations (including HMOs and
preferred provider organizations), self-funded employer-sponsored
plans, Taft-Hartley trusts (union-organized health plans), church
plans, association plans, state and local government employee
programs, and public insurance programs.  The term "consumers" refers
to the users of health care, including beneficiaries of public
programs, government employees, individuals who purchase their own
health insurance, and employees who work for firms that sponsor
self-funded plans or provide health insurance products. 


      COMMISSION RECOMMENDS
      EXTENSIVE DISCLOSURE OF
      INFORMATION ON HEALTH PLANS
      AND PROVIDERS
---------------------------------------------------------- Letter :3.1

The Commission's recommendations pertaining to information disclosure
are divided into three sections:  health plans, health professionals,
and health care facilities.  Among other things, health plans would
be required to provide information on specialty referral rules,
professionals would be required to provide information on their board
certification status, and facilities would be required to provide
information on their experience in performing specific procedures and
their accreditation status.  For each of the three sections, the
Commission made the distinction between those data elements that
consumers should receive routinely and those that should be available
upon request.  Following are the Commission's recommendations for
specific components of health plan, professional, and facility
information.\9


--------------------
\9 The elements included in this list would not necessarily apply to
all types of health plans; for example, the recommendation for
disclosure rules regarding out-of-network services would not apply to
a standard fee-for-service indemnity plan. 


         ROUTINELY PROVIDED
         INFORMATION
-------------------------------------------------------- Letter :3.1.1

Health plan benefits, cost-sharing, and dispute resolution

  -- general limits on coverage

  -- preventive services coverage

  -- drug formulary operations

  -- how drugs, devices, and procedures are deemed experimental

  -- enrollee cost-sharing

  -- dispute resolution procedures

Health plan characteristics and performance

  -- state licensure status, federal certification, and private
     accreditation status

  -- consumer satisfaction measures

  -- clinical quality performance measures

  -- service performance measures

  -- disenrollment rates

Health plan network characteristics

  -- aggregate information on the numbers, types, board certification
     status, and distribution of providers

  -- each primary care provider's board certification status,
     location, availability, languages spoken, and accessibility

  -- provider compensation methods

  -- rules regarding out-of-network coverage

  -- circumstances under which primary care referral is required to
     access specialty care

  -- options for 24-hour coverage and access to urgent care centers

Health professional information

  -- ownership or affiliation arrangements with a provider group or
     institution that would make referral to a particular specialist
     or facility more likely

  -- how the provider is compensated

Health care facility information

  -- corporate form of the facility

  -- accreditation status

  -- specialty programs' compliance with established guidelines

  -- volume of certain procedures performed

  -- consumer satisfaction measures

  -- clinical quality measures

  -- service performance measures

  -- complaint process

  -- availability of translation or interpretation services

  -- number and credentials of providers of direct patient care

  -- affiliation that would make it more likely that referrals would
     be made within a provider network

  -- whether facility has been excluded from any federal health
     program


         INFORMATION TO BE MADE
         AVAILABLE ON REQUEST
-------------------------------------------------------- Letter :3.1.2

Health plan characteristics and performance

  -- number of years in existence

  -- corporate form of the plan

  -- whether the plan meets federal and state requirements for fiscal
     solvency

  -- whether the plan meets federal, state, and private accreditation
     standards that ensure confidentiality of medical records and
     orderly transfer of caregivers

Health plan network characteristics

  -- detailed list of names, board certification status, and
     geographic location of all contracting specialists and specialty
     care centers; whether they are accepting new patients;
     language(s) spoken and availability of interpreter services; and
     whether facilities are accessible to people with disabilities

  -- detailed list of names; accreditation status; and geographic
     location of hospitals, home health agencies, and rehabilitation
     and long-term care facilities; whether they are accepting new
     patients; language(s) spoken and availability of interpreter
     services; and whether they are accessible to people with
     disabilities

Health plan care management

  -- preauthorization and utilization review procedures followed

  -- whether the plan has special disease management programs or
     programs for people with disabilities

  -- qualifications of reviewers at the primary appeals level

  -- use of clinical protocols, practice guidelines, and utilization
     review standards pertinent to a patient's clinical circumstances

  -- whether a specific prescription drug is included in a formulary
     and procedures for considering requests for patient-specific
     waivers

Health professional information

  -- education, board certification, and recertification status

  -- years of practice as a physician and as a specialist if so
     identified

  -- consumer satisfaction measures

  -- service performance measures

  -- corporate form of practice

  -- names of hospitals where physicians have admitting privileges

  -- experience with performing certain medical or surgical
     procedures, adjusted for case-mix severity

  -- clinical quality performance measures

  -- accreditation status (if applicable)

  -- availability of translation or interpretation services for
     non-English-speakers and people with communication disabilities

  -- any cancellation, suspension, or exclusion from participation in
     a federal program or sanction from a federal agency; any
     suspension or revocation of medical licensure, federal
     controlled substance license, or hospital privileges


      CONSUMERS RECEIVE
      INFORMATION ON HEALTH PLANS,
      BUT LESS ON PROVIDERS
---------------------------------------------------------- Letter :3.2

Employees have access to a considerable amount of information on
health plans, but to more limited information on health professionals
and facilities.  The information is made available by a variety of
sources, including health plans, purchasers (including purchasing
coalitions), state agencies, accreditation agencies, and the media. 
Much of the information is required to be disclosed by state
insurance laws and regulations. 

The health plan data routinely provided to the large purchasers in
our review included information on covered benefits and enrollee
cost-sharing.  Health plan brochures explain general limits on
coverage, deductibles (if applicable), and copayments for office
visits, and outpatient and inpatient care.  Although managed care
plans frequently provided lists of their network participants, in
some cases this information simply indicated the names and addresses
of associated providers; in other cases, it included additional
details, such as the physician's training, language(s) spoken, and
ability to accept new patients.  Information on certain health plan
procedures, such as how consumers obtain referrals to specialists,
how consumers access after-hours care, how products are included in
drug formularies, and the grievance process, was also generally
available.  However, only 2 of the 10 purchasers we reviewed
indicated that their plans provided a detailed explanation of how
they deemed drugs, devices, or procedures as experimental (and,
therefore, not covered).  None explicitly indicated their federal
certification and state licensure status, although they did provide
information on their private accreditation status. 

To augment the information provided by individual plans, large
purchasers have compiled and reported to their employees comparative
information on plan characteristics and performance.  Specifically,
these purchasers have informed consumers about consumer satisfaction
measures, plan performance on selected clinical quality indicators,
and rates of disenrollment from each plan.  Generally absent from
these comparisons were service performance measures (such as waiting
times to obtain an appointment). 

Enrollee satisfaction is the most common type of performance
information provided by purchasers in our group.  Purchasers'
satisfaction surveys ranged from a single aggregate measure to a
five-part survey, with each part containing at least four measures. 
For example, the Federal Employees Health Benefits Program (FEHBP)
reported satisfaction for each plan as a whole by showing the
percentage of federal enrollees who were extremely satisfied, very
satisfied, and somewhat satisfied.\10 For HMOs, FEHBP also reported
on satisfaction in several specific areas, including plan coverage,
amount of time to get an appointment when sick, seeing the same
doctor on most visits, quality of care, thoroughness and competency
of the provider, and explanations and results of care. 

The most widely used comparative indicator of plan clinical quality
is preventive care measures.  Some of the purchasers in our review
collect HEDIS data from their health plans and issue report cards to
their employees on a subset of measures.  For example, purchasers
reported on the rates of immunizations, cholesterol screening,
cervical cancer screening, caesarean sections, and retinal exams for
people with diabetes for each available health plan. 

The Pacific Business Group on Health (PBGH) also makes report cards
on providers available.\11 For example, the coalition uses a series
of patient surveys to measure satisfaction with medical groups'
service and quality of care.  It reports data on overall patient
satisfaction with particular physician groups, satisfaction with
specific preventive care services, and satisfaction ratings for
patients with high blood pressure or high cholesterol.  PBGH has also
developed hospital report cards showing success rates for and overall
volume of certain complex procedures, such as organ transplants, as
well as utilization rates for more common procedures, such as
caesarean sections. 

The areas of greatest difference between the Commission
recommendations for information to be routinely provided and that
which is currently available to consumers involved characteristics of
health professionals and health care facilities.  Explanations of
physician compensation arrangements--including financial incentives
for physicians to be conservative in providing services--were not
included in any of the information provided to consumers that we
reviewed.  Information on ownership interests that a provider could
have with a hospital or medical group that would make it more likely
that a patient would be referred to a particular physician or
facility was also unavailable to consumers.  Other facility-specific
information recommended by the Commission but not routinely
disseminated by our large purchasers included data on service
performance, complaint filing and resolution procedures, availability
of translation or interpretation services, number and credentials of
providers of direct patient care, and whether a facility has been
excluded from any federal health program.  Table 1 summarizes the
information that is routinely provided by most large purchasers in
our review or is publicly available in some regions. 



                                         Table 1
                         
                         Comparison of Information the Commission
                          Recommends Be Routinely Provided With
                          Information Commonly Provided by Large
                                        Purchasers

                                                                                 Commonly
                                                                                 provided
Commission-recommended information                                            information
--------------------------------------------------------------------------  -------------
Health plan benefits, cost-sharing, and dispute resolution
-----------------------------------------------------------------------------------------
General limits on coverage                                                              X
Preventive services coverage                                                            X
Drug formulary operations                                                               X
How drugs, devices, and procedures are deemed experimental
Enrollee cost-sharing                                                                   X
Dispute resolution procedures                                                           X

Health plan characteristics and performance
-----------------------------------------------------------------------------------------
State licensure status, federal certification, and private accreditation
 status
Consumer satisfaction measures                                                          X
Clinical quality performance measures                                                   X
Service performance measures
Disenrollment rates                                                                     X

Health plan network characteristics
-----------------------------------------------------------------------------------------
Aggregate information on the numbers, types, board certification status,                X
 and distribution of providers
Each primary care provider's board certification status, location,
 availability, languages spoken, and accessibility
Provider compensation methods
Rules regarding out-of-network coverage                                                 X
Circumstances under which primary care referral is required to access                   X
 specialty care
Options for 24-hour coverage and access to urgent care centers                          X

Health professional information
-----------------------------------------------------------------------------------------
Ownership or affiliation arrangements with a provider group or institution
 that would make referral to a particular specialist or facility more
 likely
How the provider is compensated

Health care facility information
-----------------------------------------------------------------------------------------
Corporate form of the facility
Accreditation status                                                                    X
Specialty programs compliance with established guidelines
Volume of certain procedures performed                                                  X
Consumer satisfaction measures
Clinical quality measures                                                               X
Service performance measures
Complaint process
Availability of translation or interpretation services
Number and credentials of providers of direct patient care
Affiliation that would make it more likely that referrals would be made
 within a provider network
Whether the facility has been excluded from any federal health program
-----------------------------------------------------------------------------------------
Large purchasers were not in agreement about the feasibility--at
least in the near term--of providing all the information recommended
in the Consumer Bill of Rights.  Some benefits managers we
interviewed expressed concerns about the amount and quality of
information to be made public.  A public purchaser told us that it
does not currently provide plan-level clinical quality data to
consumers because the data it receives from health plans are not
consistent.  A private firm's manager said that provider-level
quality indicators do not exist and, while she believes they would be
valuable, she thinks such information is still 5 to 7 years away.  A
PBGH member firm told us that its health plans were currently
providing all the data they were capable of providing.  Another
reason given for not providing certain information was the difficulty
plans have explaining technical or medical concepts.  For example,
descriptions of compensation arrangements for individual providers
can be very difficult to understand because they involve complex
concepts, such as percentage of charges, risk-adjusted capitation,
risk pools and withholds, bonuses, case rates, and fee schedules. 
Similarly, a description of how plans determine whether a drug,
device, or procedure is deemed experimental can involve complex
technical and medical concepts.  One benefits manager told us she had
never seen an explanation of this process that could be easily
understood. 

Other purchasers were more positive.  One human resources executive
said that the Commission's recommendations "reflect a realistic set
of consumer healthcare standards." Moreover, this firm publicly
announced that it was committed to implementing the recommendations. 
Similarly, an FEHBP official recently testified that the program
substantially complies with the broad principles of the Consumer Bill
of Rights and that all participating carriers are expected to fully
comply by 2000.  (See app.  II for a comparison of the Commission's
information disclosure recommendations and the information currently
provided by FEHBP.)


--------------------
\10 FEHBP is the largest employer-sponsored health benefit program in
the United States, including 350 carriers and covering 9 million
individuals. 

\11 PBGH is a coalition of 33 member firms, covering approximately
2.5 million people. 


   CONSUMER INFORMATION MAY BE
   DIFFICULT TO OBTAIN AND
   INTERPRET
------------------------------------------------------------ Letter :4

The Commission recognized that for consumers to benefit from
information disclosure, health care information must be accurate,
easy to understand, and available when needed.  It also acknowledged
that consumers' capacity to understand health care information may be
taxed by the volume disclosed--that too much information becomes
overwhelming.  Furthermore, the Commission stated that some consumers
require assistance in making informed decisions and should be
supported by plan sponsors.  Some of the purchasers in our review
found that consumers often have difficulty interpreting much of the
information provided, a view that appears to be supported by research
on this issue.  Believing that their employees may lack the time or
knowledge to make sense of the information, some of the purchasers in
our review are taking steps to reduce the amount and level of detail
in the data they disseminate. 


      PURCHASERS PROVIDE
      INFORMATION IN A VARIETY OF
      FORMATS
---------------------------------------------------------- Letter :4.1

Most purchasers that offer a choice of health plans use a variety of
means to help individual consumers make better decisions about which
health plan and providers to select.  Health care information is
commonly disseminated in written materials distributed once each year
during health benefits open season.  The purchasers in our review
provided documents comparing consumers' options in a report card
format, and the associated health plans provided standard information
about benefits, costs, and provider networks. 

Because written materials do not remain up-to-date, however, some
purchasers have expanded their information dissemination efforts to
include additional formats, such as the Internet.  There are
times--other than during annual enrollment periods--when enrollees
may need specific health plan information.  For example, consumers
may want to change primary care physicians or require a specialist
and need current information on which physicians participate in the
plan's network and who is accepting new patients.  At this point, the
provider directory that consumers received at open season may already
be out-of-date.  To keep consumers current about changes in the
network and other newly available information, some purchasers are
taking advantage of the flexibility inherent in electronic formats,
such as company intranets and the Internet.  One purchaser links The
Health Pages--an Internet site specializing in local provider and
health plan information--to the company intranet, so its employees
can access information when needed about particular physicians
affiliated with their health plan.  But these formats also have their
drawbacks; for example, not all consumers have access to the Internet
or the skills necessary to use it. 

PBGH puts its health plan, physician group, and hospital report cards
as well as satisfaction survey results on a web site.\12 Figure 1
shows a "page" from the PBGH Internet site containing information
about the availability of prescription drugs for consumers with
diabetes across various health plans.  Recognizing that not all
consumers have access to the Internet, PBGH also makes an abbreviated
printed version of its comparative characteristics and performance
information available upon request. 

   Figure 1:  Sample Health Plan
   Drug Information Provided by
   PBGH on the Internet

   (See figure in printed
   edition.)

Source:  PBGH Internet site. 


--------------------
\12 PBGH produced this web site with the support of the Henry J. 
Kaiser Family Foundation. 


      INFORMATION IS NOT ALWAYS
      TRANSLATED INTO A FORM
      USEFUL TO CONSUMERS
---------------------------------------------------------- Letter :4.2

Providing consumers with information to compare health plans and
providers presupposes that individuals have the resources to make
sense of it.\13 Some information is not easy to translate from
technical or legal terminology to consumer-friendly language.  To
help consumers interpret the information disclosed, some purchasers
try to educate consumers about health care in general and managed
care in particular.  For example, one purchaser's open enrollment
brochure included an explanation of the role of a primary care
physician in a point-of-service plan or HMO.  Another purchaser
explained the different levels of NCQA accreditation and the HEDIS
quality measures included for comparison. 

Consumers appear to be interested in comparative health plan
information, but purchasers need to learn more about how to adjust
the information to meet consumers' needs.\14 One PBGH member told us
that the coalition is considering streamlining the information
provided on its Internet site because there may be too many layers. 
One large public purchaser has revised its health plan report card
format three times in the last 3 years in an attempt to make it
easier to use.  After watching employees "struggle" with the
information they receive, a private benefits manager told us her firm
has adopted a strategy of concentrating on employee education and
incremental increases in the amount of information provided, to allow
employees to become more comfortable with making decisions on the
basis of comparative data. 

A review of recent literature on quality information supports much of
what officials from the purchasers in our group told us.  In choosing
a health plan, consumers say that quality of care is their greatest
concern, but they ultimately make their decisions on the basis of
personal recommendations rather than quality data.\15 When screening
health plans for participation in their programs, the purchasers
frequently consider comparative performance measures like HEDIS, but
consumers do not appear to find these same measures particularly
useful.\16 One study found that more than three-quarters of its
respondents would choose to see a surgeon they knew instead of one
they didn't know but who had much higher ratings.\17 One explanation
for the apparent contradiction between the information consumers say
they want and what they actually use is that information on quality
may not be clearly presented.\18 Moreover, consumers lack a
fundamental understanding of how managed care works.\19

Among the information that purchasers provide, consumers find details
on cost, benefits, and the availability of providers most useful;
performance measures are more difficult to understand and, as a
result, may be used less often.\20


--------------------
\13 Marc A.  Rodwin, "Managed Care and Consumer Protection:  What are
the Issues?" Seton Hall Law Review, Vol.  26:1007 (1996), p.  1033. 

\14 Jack Meyer, Elliot Wicks, Lise Rybowski, and others, Report on
Report Cards:  Initiatives of Health Coalitions and State Government
Employers to Report on Health Plan Performance and Use Financial
Incentives (Washington, D.C.:  Economic and Social Research
Institute, Mar.  1998). 

\15 Henry J.  Kaiser Family Foundation, "New National Survey:  Are
Patients Ready to Be Health Care Consumers?" Press Release (Menlo
Park, Calif.:  Kaiser Family Foundation, Oct.  28, 1996). 

\16 Anne Tumlinson, Hannah Bottigheimer, Peter Mahoney, and others,
"Choosing a Health Plan:  What Information Will Consumers Use?"
Health Affairs, Vol.  16, No.  3 (1997), pp.  236-37. 

\17 "New National Survey:  Are Patients Ready to Be Health Care
Consumers?" Kaiser Family Foundation. 

\18 Anne Tumlinson and others, "Choosing a Health Plan:  What
Information Will Consumers Use?"
p.  237. 

\19 Judith H.  Hibbard and Jacquelyn Jewett, "Will Quality Report
Cards Help Consumers?" Health Affairs, Vol.  16, No.  3 (1997), p. 
226. 

\20 Judith H.  Hibbard and Jacquelyn Jewett, "Will Quality Report
Cards Help Consumers?" p.  226. 


   PURCHASERS CONTINUE TO EXPAND
   INFORMATION DISCLOSURE EFFORTS
   DESPITE POTENTIAL COSTS
------------------------------------------------------------ Letter :5

An analysis done for the Commission concluded that developing and
disseminating the recommended information would increase premiums by
a relatively small amount.  While none of the purchasers in our group
met all the Commission's recommendations for information disclosure,
they reported that the cost of complying did not appear to be a major
obstacle.  Moreover, some purchasers told us that they see pursuit of
health care information as a process requiring continuous improvement
and that they plan to continue with their efforts. 


      INFORMATION DISCLOSURE COSTS
      ESTIMATED TO ADD ABOUT 1
      PERCENT TO PREMIUMS
---------------------------------------------------------- Letter :5.1

The Lewin Group has estimated that the additional cost of developing
and disseminating information needed to fully implement the
Commission's recommendations would range from $0.59 to $2.17 per
enrollee per month, or about 1 percent of premiums.\21 While we did
not perform an independent cost assessment, some important aspects of
this analysis were consistent with the information we obtained from
the purchasers in our review.  For example, the Lewin analysis
explains that the most expensive component of information disclosure
is the cost of obtaining quality and satisfaction information
regarding individual physicians, largely because of the sheer number
of physicians and the labor intensity of collecting the information. 
Some of the purchasers in our group said that individual
provider-level data have been and will continue to be among the most
difficult to obtain. 

In developing its estimates, The Lewin Group made various assumptions
regarding the level of detail in the information to be provided.  For
example, the Commission recommends that health plans and providers
report service performance measures, but it does not specify how
detailed these measures should be.  A long, complicated survey,
possibly involving several areas of health plan operations, would be
expected to be more expensive than a single-indicator survey.  To
account for such variation, Lewin offered three estimates of cost: 
low, mid-point, and high.  Lewin also assumed that costs would be
lower if health plans were allowed to meet the recommendations over a
longer period of time.  Table 2 summarizes the Lewin cost estimates. 



                          Table 2
          
           Information Disclosure Cost Estimates
            for Two Implementation Periods, per
                  Insured Person per Month

                                Implementation time frame
                                --------------------------
                                               3-to 5-year
                                      1 year      phase-in
------------------------------  ------------  ------------
Low estimate                           $0.80         $0.59
Mid-point estimate                      1.49          0.84
High estimate                           2.17          1.10
----------------------------------------------------------
Source:  The Lewin Group, Inc. 

Although the burden of providing the recommended information would
initially fall on health plans and providers, how these costs would
ultimately be financed is uncertain.  Plans, for example, could pass
costs on to purchasers through premium increases.  Alternatively,
plans could absorb the increased costs or recoup the additional costs
by lowering reimbursements to providers.  While acknowledging that
pursuing more and better information might lead to an increase in
premiums, some of the purchasers we interviewed said they would
continue their efforts. 


--------------------
\21 Allen Dobson, Caroline Steinberg, Ray Baxter, and others,
Consumer Bill of Rights and Responsibilities Costs and Benefits: 
Information Disclosure and External Appeals (Fairfax, Va.:  The Lewin
Group, Inc., Nov.  18, 1997).  We calculated the incremental cost as
a share of health insurance premiums assuming purchasers' cost of
$160 per member per month.  Cost estimates associated with federal
legislative proposals addressing some of the Commission's
recommendations are currently being developed by the Congressional
Budget Office.




      PURCHASERS CONTINUE TO SEEK
      IMPROVEMENTS IN HEALTH CARE
      INFORMATION
---------------------------------------------------------- Letter :5.2

In making its recommendations, the Commission has recognized the
importance of continuous improvement in health care information
quality and disclosure.  According to the Commission, there is a need
for greater standardization in definitions as well as in clinical
quality, service performance, and customer satisfaction measures. 
Several of our purchasers identified improvement in the
standardization and quality of data as critical to improving
value-based purchasing. 

Current initiatives designed to address the issue of consistency in
data collection and dissemination include an Employers' Managed
Health Care Association\22 project to encourage large purchasers to
eliminate unique elements within their requests for health plan
proposals at contracting time.  The health plans and large purchasers
in this project agree that the health care system would benefit from
more consistent data requests from purchasers.  At the same time,
large purchasers are striving to improve the quality and reliability
of data reported by health plans.  For example, PBGH uses
independently verified HEDIS data in its quality reports, and NCQA
plans to incorporate selected HEDIS measures in its accreditation
process in the summer of 1999.  As a result, purchasers who require
private accreditation in order to participate in their health care
programs will have a consistently reported and collected data set at
their disposal. 

Also with consistency in mind, the Department of Health and Human
Services' (HHS) Agency for Health Care Policy and Research developed
and released a new customer survey instrument--the Consumer
Assessments of Health Plans Study (CAHPS)--in March 1998.\23 The
survey covers specific plan features, such as access to specialists
and quality of patient-physician interaction, and includes questions
geared to consumers with special characteristics, such as those with
chronic conditions, children, Medicaid recipients, and Medicare
beneficiaries.  The Agency for Health Care Policy and Research is
working with NCQA to merge CAHPS and the HEDIS 3.0 Member
Satisfaction Survey, currently used by many health plans, to arrive
at a single, standard set of survey instruments for national use in
making health plan comparisons.  HHS and the Agency for Health Care
Policy and Research have begun using CAHPS with beneficiaries in
Medicare managed care plans, and the Office of Personnel Management
has adopted it for use with FEHBP enrollees in 1999. 


--------------------
\22 The Employers' Managed Health Care Association is an organization
of more than 100 large employers. 

\23 The new Agency for Health Care Policy and Research-sponsored
instrument was developed by a consortium of Harvard Medical School,
RAND, and Research Triangle Institute researchers and involved the
participation of health plans, purchasers, and accreditation
agencies. 


   CONCLUSION
------------------------------------------------------------ Letter :6

The calls for health care information disclosure are not new.  The
movement among large employers and health plans has already produced
standardized data on a number of measures important to purchasers. 
The Consumer Bill of Rights and Responsibilities would extend these
efforts by adding information that is not typically provided, even by
large purchasers.  The ability of consumers to use the information
already being provided, as well as any additional data, will continue
to require attention. 


   COMMENTS AND OUR EVALUATION
------------------------------------------------------------ Letter :7

We provided copies of a draft of this report to officials of the
President's Advisory Commission on Consumer Protection and Quality in
the Health Care Industry as well as to officials of the Office of
Personnel Management for review.  These officials generally agreed
that the report was accurate and suggested a few technical revisions,
which we incorporated where appropriate. 


---------------------------------------------------------- Letter :7.1

As arranged with your office, unless you publicly announce its
contents earlier, we plan no further distribution of this report
until 30 days after its issue date.  At that time, we will send
copies to interested parties and make copies available to others on
request.  Please call me on (202) 512-7119 if you or your staff have
any questions.  Staff who contributed to this report include Rosamond
Katz and Mark Ulanowicz. 

Bernice Steinhardt
Director, Health Services Quality
 and Public Health Issues


LARGE HEALTH CARE PURCHASERS
INCLUDED IN THIS REVIEW
=========================================================== Appendix I

In conducting our review, we examined samples of employee health
benefits materials or contacted health benefits officials at the
following organizations.\24

PRIVATE FIRMS

Chevron

General Motors

IBM

PepsiCo

Southern California Edison

Xerox

PRIVATE PURCHASING COALITION

Pacific Business Group on Health

PUBLIC HEALTH BENEFITS ADMINISTRATORS

Federal Employees Health Benefits Program

Minnesota Department of Employee Relations


--------------------
\24 We also consulted with the Washington Business Group on Health,
an organization that includes large public and private employers.  In
addition, the purchasers in our review included a private firm that
asked that we not use its name. 


INFORMATION DISCLOSURE UNDER THE
FEDERAL EMPLOYEES HEALTH BENEFITS
PROGRAM
========================================================== Appendix II

The Federal Employees Health Benefits Program (FEHBP) is the largest
employer-sponsored health benefits program in the United States.  The
program covers approximately 9 million enrollees and includes 350
health insurance carriers.  Through FEHBP, federal employees have a
choice of fee-for-service plans, preferred provider organizations,
point-of-service plans, and health maintenance organizations.  FEHBP
currently provides information consistent with several components of
the Commission's recommendations for routine disclosure, particularly
those pertaining to health plan benefits, characteristics, and
performance.  However, neither FEHBP nor its associated health plans
provided detailed information on specific health professionals or
facilities, such as disclosure of financial incentives.  Table II.1
indicates which of the Commission's information disclosure
recommendations we found to be routinely provided by FEHBP or its
participating health plans in 1997. 



                                        Table II.1
                         
                         Comparison of Information the Commission
                          Recommends Be Routinely Provided With
                         Information Provided by FEHBP and Plans

                                                                              Information
                                                                              provided to
                                                                                    FEHBP
Commission-recommended information                                              enrollees
--------------------------------------------------------------------------  -------------
Health plan benefits, cost-sharing, and dispute resolution
-----------------------------------------------------------------------------------------
General limits on coverage                                                              X
Preventive services coverage                                                            X
Drug formulary operations                                                               X
How drugs, devices, and procedures are deemed experimental
Enrollee cost-sharing                                                                   X
Dispute resolution procedures                                                           X

Health plan characteristics and performance
-----------------------------------------------------------------------------------------
State licensure status, federal certification, and private accreditation
 status
Consumer satisfaction measures                                                          X
Clinical quality performance measures
Service performance measures
Disenrollment rates

Health plan network characteristics
-----------------------------------------------------------------------------------------
Aggregate information on the numbers, types, board certification status,
 and distribution of providers
Each primary care provider's board certification status, location,
 availability, languages spoken, and accessibility
Provider compensation methods
Rules regarding out-of-network coverage                                                 X
Circumstances under which primary care referral is required to access                   X
 specialty care
Options for 24-hour coverage and access to urgent care centers

Health professional information
-----------------------------------------------------------------------------------------
Ownership or affiliation arrangements with a provider group or institution
 that would make referral to a particular specialist or facility more
 likely
How the provider is compensated

Health care facility information
-----------------------------------------------------------------------------------------
Corporate form of the facility
Accreditation status
Specialty programs' compliance with established guidelines
Volume of certain procedures performed
Consumer satisfaction measures
Clinical quality measures
Service performance measures
Complaint process
Availability of translation or interpretation services
Number and credentials of providers of direct patient care
Affiliation that would make it more likely that referrals would be made
 within a provider network
Whether the facility has been excluded from any federal health program
-----------------------------------------------------------------------------------------
RELATED GAO PRODUCTS

Health Insurance:  Management Strategies Used by Large Employers to
Control Costs (GAO/HEHS-97-71, May 6, 1997). 

Medicare Managed Care:  HCFA Missing Opportunities to Provide
Consumer Information (GAO/T-HEHS-97-109, Apr.  10, 1997). 

Medicare HMOs:  Potential Effects of a Limited Enrollment Period
Policy (GAO/HEHS-97-50, Feb.  28, 1997). 

Medicare:  HCFA Should Release Data to Aid Consumers, Prompt Better
HMO Performance (GAO/HEHS-97-23, Oct.  22, 1996). 

Medicaid:  States' Efforts to Educate and Enroll Beneficiaries in
Managed Care (GAO/HEHS-96-184, Sept.  17, 1996). 

Health Care:  Employers Urge Hospitals to Battle Costs Using
Performance Data Systems (GAO/HEHS-95-1, Oct.  3, 1994). 


*** End of document. ***