Questions and Answers about Managed Care

1. What is Managed Care?
Managed care is a system of health insurance characterized by a network of contracted providers providing health benefits to a defined population for a fixed payment. Health care services are typically controlled in a managed care plan through a network of primary care physicians often referred to as "gatekeepers."

2. How Many Americans are Enrolled in Managed Care Plans?
In the last decade, managed care has become the dominant form of health insurance in the United States. Most Americans are enrolled in some type of managed care plan. One in five Americans (51 million) are enrolled in health maintenance organizations (HMOs) - the most organized form of managed care.

3. How is Quality Health Care Affected by Managed Care?
The quality of health care delivery varies from plan to plan, depending on the expertise, commitment, and resources of each plan sponsor. However, by definition, managed care plans provide a full range of services in the face of stringent resource constraints. The incentive is likely to underserve people, particularly for the sickest individuals and other at-risk populations. The potential for managed care plans to impede access to needed services and providers is the leading consumer concern under managed care and is why the independent monitoring of the quality of care is imperative.

4. Can Consumer Access to Needed Care be Assured and Monitored Under Managed Care?
This becomes more difficult as corporate restructuring, downsizing and the loss of professional and facility capacity in the health care industry presents increasing barriers to patient care access. To monitor access concerns, uniform data from each managed care plan will need to be collected. Unfortunately, managed care plans have not been required to produce uniform information for each patient encounter because individual financial claims are not routinely generated. Such data, aggregated and profiled on a routine basis by independent quality evaluators, would permit a comprehensive assessment of patient access to health care services. It would also allow a plan's performance to be measured against standardized quality indicators.

5. Do Consumers Have Appeal Rights if Services are Denied by a Plan?
At present, only Medicare and Medicaid beneficiaries have rights to an independent appeal beyond a health plan's own internal grievance and appeals system. Every consumer enrolled in a managed care plan should have the right to an independent, external appeal of benefit and service denials with an expedited time frame for dispute resolution.

6. What Type of Information do Consumers Need to Select Managed Care Plans?
Real competition among managed care plans can only be generated if consumers have easy access to comparative information on plan prices, quality and service. Such information, self-reported by individual health plans, should be externally audited to ensure data accuracy. In addition, each individual health plan should provide enrollees or prospective enrollees with a detailed description of plan benefits, the full credentials of network providers, a description of the grievance and appeals process, and the health plan's procedures for gaining access to specialists and emergency care both in and out of the plan's service area.

7. Who Can Assist Consumers in Navigating the New World of Managed Care?
The transition from traditional health insurance, where consumers enjoyed an unrestricted choice of providers, to managed care is creating uncertainty, confusion, and concern for many consumers, especially vulnerable populations. Health care consumers would greatly benefit from an ombudsman program established in every state that would be responsible for helping consumers choose plans, understand their benefits and rights as plan members, and investigate and resolve consumer complaints.

8. Are Consumer Interests Represented in Managed Care Governance and Policy Making?
The empowerment of consumers in the age of managed care can only become a reality if consumers and front-line health care workers fully participate in decision making at all levels of the health care system. At present, seven states require that enrollees be represented on health plan governing boards and that enrollees be afforded the opportunity to participate in policy decisions that directly affect patient care and enrollee rights. These requirements for consumer and worker participation should be expanded to all fifty states or become a national standard.

9. How Will the Consumer Coalition for Quality Health Care Influence the Quality Agenda Under Managed Care?
The Consumer Coalition believes that assuring and improving the quality of health care for all Americans must be an explicit goal of any health care system - particularly a managed care system so driven by the need to control costs at the potential expense of quality. The Coalition is active at the state and federal levels advocating for policies and programs that assure quality and protect consumers under managed care. Coalition activities include model state legislation, federal legislation, and training for state health care advocates; and the Quality Watchline, 1-800-720-8090, which collects the stories from consumers and health care workers about poor quality health care under managed care.

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