Physicians: Be picky with health plan contracts

In the scramble for managed care dollars, physicians often contract with as many health plans as they can. But here’s a reason to be more picky: Patients who become unhappy with their health plans may be unhappy with you, too.

An analysis of survey data from more than 11,000 Medicaid enrollees in Oregon found a correlation between patient satisfaction with their health plans and providers.1 "Those who are dissatisfied with various aspects of their plan have lower satisfaction with their physicians," says Daniel M. Harris, PhD, executive director of the Oregon Health Resources Commission, a state agency based in Salem that conducts medical technology assessments.

What matters most to patients in a health plan? They want a wide range of available providers and services, understandable information, and user-friendly gatekeeper procedures, Harris says. Problems in any of those areas could taint their feelings about their overall care or their providers, he says.

"Those aspects of the plan seemed to be the most important for having an impact on the perception of the provider," he says.

The survey, conducted by the Oregon Office of Medical Assistance Programs in Salem, targeted managed care enrollees in the age range of 18 to 64 who were enrolled continuously in the same health plan for at least six months. Of 19,098 randomly selected, 11,591, or 63%, responded.

Harris offers the following advice to physicians considering which health plans they should affiliate with:

Do your homework to get information on health plans.

Physicians who want to judge the patient satisfaction of specific health plans can use many of the same resources available to employers and consumers. In fact, that task became far easier with the implementation of the Health Plan Employer Data Information Set (HEDIS) 3.0, which creates a standard patient satisfaction tool for all plans accredited by the National Committee for Quality Assurance (NCQA) in Washington, DC. (For more information on HEDIS 3.0, see Patient Satisfaction & Outcomes Management, September 1996, p. 97.)

"In the past, measures between health plans might not be as comparable," notes Jeanine Barlow, MPH, research project manager at the Center for Research in Ambulatory Health Care Administration of the Medical Group Management Association in Englewood, CO.

Physicians also may get information directly from the plan, says Harris. "Look over the reputation and policies and maybe some of the patient satisfaction information you can get from the plans before choosing who to associate with," he advises.

Be aware of changes in the managed care marketplace.

Carefully selecting health plans may be more difficult in markets that are just beginning to experience managed care penetration, Harris acknowledges. "In immature markets, it’s a wild free-for-all," he says. "You don’t know which are the plans that are going to survive and which have a good track record, so you sign everything that comes across your desk.

"As the market begins to mature, some plans drop out. Some plans merge. The number of plans you have competing for the market begins to shrink," he says.

That is the time for physicians to become alert to plan quality and patient satisfaction, he says. In more mature managed care markets, physicians may have high concentrations of patients from several health plans. "They need to look early for signs of which plan they want to put their weight behind," he says.

Ask for ongoing satisfaction and disenrollment information from plans.

Most health plans provide feedback to physicians about their own patient satisfaction, as measured by plan member surveys, Harris notes. The physicians also should periodically review information about how the patients rated the plan itself. Disenrollment rates, as well as reasons for disenrollment, also reveal how well the plan serves patients. "If patients in exit interviews say, ‘We’re not happy with how we’re able to use health resources,’ that tells the physician something," he says.

One caution: "I would avoid reacting simply to anecdotes from patients without checking with the plan," Harris says. While it’s important to listen to patients’ experiences, a problem case or two could be caused by a misunderstanding.

Work with other physicians to influence health plan quality.

Physicians often underestimate their influence in the managed care marketplace, Harris says.

"Since the behavior of the plan can affect your ability to attract and retain patients, the physician should try to influence the way the plan serves the physician’s patients," he says.

For example, Harris suggests working through county or state medical societies to develop certain guidelines for gatekeeping or geographic distribution of physicians, to ensure that managed care plans offer sufficient access to both primary care physicians and specialists.

"If physicians in a particular community are not happy with the way a plan is treating patients, and they as a group don’t contract with that plan, that plan is going to have to change," he says. "If [the health plan doesn’t] have a provider panel, they’re not going to have much of a plan."

The bottom line, says Harris, is that the physician’s reputation will be linked with the plan. "The overall message is that the managed care health plan that a patient is in can color or affect the opinion of the provider that’s associated with that plan," he says.


1. Harris DM et al. Physician and plan effects on satisfaction of Medicaid managed care patients with their health care and providers. Journal of Ambulatory Care Management 1997; 20:46-64.