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The majority of Americans are satisfied with their health insurance plan, but most insured adults in the United States have had some problem with their health plan in the last year according to a new survey released by the Kaiser Family Foundation

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MOST CONSUMERS GENERALLY

POSITIVE ABOUT THEIR HEALTH PLAN,

BUT FIFTY-ONE PERCENT REPORT HAVING SOME PROBLEM IN THE PAST YEAR

Few Consumers Are Aware of Mechanisms Available for Resolving Disputes

(Washington, DC) Although Americans report mostly positive experiences with their health insurance plans, one in two say they’ve had a problem with their plan in the last year, according to a new survey released by the Kaiser Family Foundation. Most problems appear minor and easy to resolve, but a significant minority involve serious reported consequences and are difficult to settle.

The survey of 2,500 insured adults ages 18-64 found that most consumers are confused about where to turn for help in resolving problems with their health plans, especially with regard to the right to appeal health plan decisions to an independent expert. The survey was designed and analyzed by Kaiser Family Foundation staff with advice and input from Consumer Reports under a joint project developed to help consumers resolve difficulties with health plans. Highlights from the survey will be featured in the July issue of Consumer Reports.

“When one out of every two people reports having a problem with their health plan, it suggests that the pressure behind the patients’ rights debate is grounded in real patient experiences, not just anecdotes,” said Drew Altman, Ph.D., president of the Kaiser Family Foundation. “But we also need to keep in mind that most of these problems are more hassle than horror story,” he added.

Consumer Experience Influences Satisfaction with Health Plan

Most people (83%) who have had contact with their plan in the last year say that their recent experiences in dealing with their plan have been positive. Even among those who say they have had a problem with their plan, most (71%) report their recent experiences as positive.

In fact, most people appear satisfied with their plan overall — 64% give their plan a grade of A or B. However, those in “strict” managed care plans (with features common in HMOs) grade their plans lower (53% give an A or B) than those in “loose” managed care plans (70% give their plan an A or B) or those remaining in traditional health insurance (of whom 74% give their plan an A or B).

Problems Reported by Consumers

Overall, 51% of insured Americans under age 65 report having some problem with their health plan in the last year. Women, those in “strict” managed care plans, and those who are in fair or poor health or who have a health condition are most likely to report problems.

Types of problems

The types of problems reported involved:

  • Delays or denials of coverage or care (reported by 17% of all people and 32% of people with problems),
  • Difficulty seeing a physician (14% of all people; 27% of people with problems),
  • Billing and payment problems (12% of all people; 23% of people with problems), and
  • Problems related to communication or customer service difficulties (7% of all people; 14% of people with problems).

Consequences of the Problems

More than a third (38%) of people who report problems with their health plan said there was no financial consequence, time lost from life activities, or impact on health status. Forty-three percent of those who reported problems identified moderate overall consequences, while 18% (or 9% of all insured adults) identified more serious consequences.

Financial Consequences: Almost two in five (38%) of people experiencing problems (or 19% of all insured adults) say there was a financial consequence to the problem (i.e., they ended up paying more for treatment or services than they normally would have).

In most cases (53%) where there was a problem that had a financial consequence, the amount at issue was under $200. In 14% of these cases (5% of those with a problem), there was a cost of $1,000 or more.

Lost Time: About one in five (21%) of people experiencing problems say they lost time from work, school, or other major life activities as a result. While most cases involved relatively little time lost, it amounted to at least a week in 28% of these cases.

Health Declines: About one in five (21%) of people with problems say they experienced a decline in health as a result. Most said it was “not too serious,” though a small minority (6% of those with a problem of any kind) said the decline resulted in a permanent or long-lasting disability.

“While many of the problems reported have relatively minor consequences, they clearly cause aggravation,” said Mollyann Brodie, Ph.D., vice president for Public Opinion and Media Research for the Kaiser Family Foundation. Sixty-two percent of people experiencing problems said it caused them stress (28% “a lot,” 34% “some”). In general, people reported similar levels of stress for dealing with their health insurance company as for doing their taxes and dealing with their auto mechanic.

Problem Resolution

The survey showed that most people who had a problem with their health plan sought some means inside their plan to resolve the problem, while few turned to external resources.

  • 73% contacted someone at the plan or their own physician
  • 46% referred to plan documents for information
  • 25% contacted a friend or family member for assistance.

Only 21% of those with a problem contacted someone outside of their plan for help, including 13% who contacted someone at work whose job it is to deal with health insurance issues, just 2% who contacted a state agency and 1% each who contacted a lawyer or an elected official. Six percent filed a formal appeal including 1% who filed with an independent review organization.

Most people are satisfied with the resolution to their problems–nearly half said their problem was resolved to their satisfaction. Twenty-three percent said it was resolved, but not the way they would have liked, and 28% said their problem had not yet been resolved.

More serious problems appear to be more difficult to resolve. Among those whose problems had a high impact (involving financial consequences, lost time, or reported health declines), only 20% said the problem was resolved to their satisfaction, 31% said it was resolved but not the way they would have liked, and 49% said the problem had not yet been resolved.

Many problems are resolved relatively quickly; 40% of those whose problems had been resolved said it took less than a week. However a substantial number take much longer 29% took more than a month to resolve.

When asked what resources would be helpful in resolving health plan problems, people gave the highest marks to appeals to an independent medical expert (87% said it would be “very” or “somewhat” helpful), an independent place to turn for help (84%), and someone at work whose job it is to deal with health insurance issues (81%). Somewhat fewer people identified a state agency (74%), or the right to sue (69%) as helpful.

Consumer Awareness

Most people appear confused about where to go for help if they have a problem with their health plan and whether they have a right to appeal health plan decisions to an independent expert. The vast majority (89%) of people say they do not know the name of the state agency that regulates HMOs and other health plans. Forty percent of people do not know whether they have the right to appeal a health plan decision to the state or to an independent medical expert.

In the 21 states (including DC) where consumers did have that right at the time of the survey (33 states currently offer the right to at least some people), 54% of consumers either said they did not have that right, didn’t know or didn’t answer the question. And in the states that did not provide the right to an independent appeal at the time of the survey, 39% of consumers thought mistakenly that they did have such a right.

“As Congress debates giving patients new rights, the truth is that most people remain in the dark about some they already have. Some states are way ahead of Congress on this issue, but most people who live in these states don’t even know it,” said Larry Levitt, director of The Changing Health Care Marketplace Project for the Kaiser Family Foundation.

For more information about the Consumer Reports Survey, contact Joan Tripi at: (914) 378-2436.

Methodology

The Kaiser Family Foundation National Survey of Consumer Experiences with Health Plans was designed and analyzed by researchers at the Kaiser Family Foundation. Fieldwork was conducted by telephone by Princeton Survey Research Associates between October 20 and December 8, 1999. The survey included a nationally representative random sample of 2,500 adults age 18 to 64 who have health coverage other than Medicare. Interviews were conducted in both English and Spanish. The margin of sampling error for the total sample is plus or minus 2 percentage points. For the 1,278 respondents who experienced some problem with their health plan in the past year, the margin of sampling error is plus or minus 3 percentage points. The margin of sampling error may be higher for some of the other sub-groups as noted in the analysis.

Because many people are unsure of – or don’t know — what kind of health insurance they have, respondents were asked a series of questions about their health plan to establish what type of coverage they actually have. They were asked if they were required to do any of the following by their plan: choose doctors from a list and pay more for doctors not on the list; select a primary care doctor or medical group; and/or obtain a referral before seeing a medical specialist or a doctor outside the plan. Respondents were listed as being in “strict” managed care if they reported their plans had all of these characteristics; listed as being in “loose” managed care if they had some but not all; and were listed as having “traditional” health insurance if they reported their plans had none of these characteristics.

In order to classify respondents into groups based on the overall impact of their problem with their health plan, we developed a scoring system related to the severity of the reported impact of the problem across four dimensions: 1) how long care was delayed, 2) financial impact, 3) health status impact, and 4) time loss from work or other activities.

This survey was produced as part of a joint project between Consumer Reports and the Kaiser Family Foundation designed to improve how consumers resolve problems with their health insurance plans. Under the project, researchers at the Kaiser Family Foundation designed and conducted this national survey of consumers, with advice and input from Consumer Reports staff. Articles appearing in Consumer Reports in conjunction with this project were produced with full editorial control by the magazine.

The Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. Copies of the survey toplines and chartpack publication #3025 are available online at /, or by calling the Foundation’s Publications Request Line at 1-800-656-4533.

The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400
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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.