 As the payers of most health care
bills, employers have considerable leverage when it comes
to assuring high-quality, cost-effective health care.
This is especially true when entering into a contract
with a managed care organization. You should expect
managed care organizations to:
 Assure
quality of care by providing access to a range of
services, credentialed physicians, and a choice of
physicians and plan provisions;
Provide
emergency care in situations deemed emergencies by
employees;
Maintain
a network of physicians whose offices are close to where
employees work and reside;
Specify
clear procedures for accessing care, such as referral
requirements and procedures for obtaining specialized
care outside the plan's physician network;
Provide
adequate information about the plan's administrative
procedures, benefits, terms and limitations, along with
prompt, easy-to-understand notifications about any plan
changes;
Designate
at least one staff member as a liaison to your company.
The liaison should be knowledgeable and authoritative
enough to quickly solve any problems that arise;
Provide
fair, timely internal and external appeals procedures;
Disclose
how the plan pays doctors and the percentage of plan
expenses that is devoted to actual care;
Take all
reasonable measures to minimize administrative costs;
Provide
specific performance data that demonstrates quality and
efficiency of care;
Disclose
all financial incentives paid to brokers, consultants and
physicians, along with any potential
conflicts-of-interest.
Employers should also
adhere to certain obligations. Among them is considering
how company decisions on health benefits can adversely
impact the employee health. Offer a choice of plans, if
possible, and give workers reasonable flexibility in
choosing their doctors. Employees should be educated
about the plan's benefits, including out-of-pocket costs
they will incur. A periodic review of the plan's
performance is recommended, along with a mechanism for
employees to offer input regarding their level of
satisfaction.
COPYRIGHTED MATERIAL. This article first appeared in the
November 2000 issue of North Carolina magazine
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