Network ratings

When it comes to health care for their workers, most employers seek that elusive happy medium between coverage and cost. Companies want to give workers thorough coverage without draining corporate coffers. For many, managed care is the way to do that.

Managed care exists in many forms, but at its core it places doctors, hospitals and insurers as gatekeepers who control the kind of treatment options available to patients. It also asks patients to bear some of the burden by requiring them to pay extra if they wish to seek treatment that isn't covered under their plan.

To address their shared concern over medical cost containment and quality health care delivery, AT&T and the employee unions, the International Brotherhood of Electrical Workers and Communications Workers of America, jointly introduced a managed care program in 1990 called the "health care network," which currently covers approximately 60,000 of its occupational employees. The network is actually 42 local networks across the country, each one administered by one of three different carriers - Prudential, The Travelers and Blue Cross/Blue Shield.

If employees and covered dependents choose to "go in-network," by following specific network utilization procedures, the medical plan pays a higher level of benefits for some services. If they choose to "go out-of-network," they still receive benefits' but the plan will not pay the maximum level for certain services
Not alone

AT&T isn't alone in its movement to managed care, says Steve Wetzell, executive director of the Business Health Care Action Group, a Minneapolis based purchasing coalition of 22 large companies - including 3M, Dayton Hudson, Pillsbury and Honeywell - that is building a managed care product for their employees and retirees

"It varies from market to market, but you're seeing a lot of large employers moving toward strategic contracting with national carriers to get all of their employees into one national managed care network. It gives them a lot more leverage when they negotiate administrative fees when they focus all the business on one vendor," Wetzell says.

"Managed care is such a broad term that covers a whole spectrum of products with different attributes, but the more sophisticated buyers are looking toward vertical integration of the care systems, where doctors, nurses, hospitals and the health plans are all part of one accountable entity for both cost and quality."

Mail survey

Since the program was introduced in 1990, AT&T has used a mail survey to measure employee satisfaction with the network providers and service. "We wanted to get a better handle on employee attitudes towards managed care in general and various aspects of the AT&T health care plan," says Jeff Wides, quality and measurements manager, Health and Insurance Benefits Administration, AT&T.

Once the health care network was introduced, the occupational employees' unions were very interested in seeing how their members reacted to the managed care program. In addition, Wides says "We, as health insurance and benefits managers, believe that the AT&T business units and the employees are our customers. In order to provide the best service, we need to know their reactions to the products we offer."

AT&T also obtains feedback about the network from local access committee meetings which are held throughout the year and which involve both union and insurance carrier representatives.

The survey was handled in-house until 1993, when AT&T decided to obtain an outside vendor's perspective on the survey instrument. So Abt Associates, a Cambridge, Mass. research firm was retained last year to consult on questionnaire development and data analysis.

For the 1993 survey, questionnaires were mailed in eight waves from April to November to randomly selected employees who had recently submitted a claim for a physician visit. The questionnaire covered employee satisfaction levels with such items as overall network satisfaction, the most recent doctor visit, the network doctor and health care network communications, and included space for general comments. Satisfaction was measured using a five-point scale, from very satisfied to very dissatisfied.

Respondents' verbatims about a particular insurance company were shared with that insurance company, with the intention of resolving problems, Wides says. "Once AT&T received survey results, we worked together with the insurance companies and the unions to resolve identified problems and follow up on recommendations."

Analysis of returns showed that respondent concerns focused on four factors:

  • network quality, as represented by service aspects such as claims processing and the network referral process;
  • quality of care, including medical treatment received, amount of time the doctor spent with the respondent, and physician courtesy;
  • administrative effectiveness, including doctor's and staff's understanding of network procedures for billing and referrals, and the amount of time it took to have a claim processed; and
  • access to care, including convenience of doctor's office hours, time spent waiting in the office and days waiting for an appointment.

In general, the survey and related research found that some employees didn't understand the referral process and the role of the primary care physician. "We've learned that we need to focus more on educating the employees on how to use the network," Wides says.

While there is always the potential for employees to view employer-sponsored surveys as intrusive - especially those on health matters - Wides says this doesn't appear to be a problem. "We do the surveys anonymously, using only the respondents' opinions. We don't do any comparisons of the information that comes in on the survey to any other information database," he says.

Plans for '94

While the 1993 survey focused on users of the health care network, Wides says this year, AT&T plans to again survey employees who go out of the network for service (which the company had done in '91 and '92). "By doing that, we hope we'll be able to analyze such things as the effect of frequency of use, whether there's any pattern associated with recency of use, and the attitudes of people who use the system versus people who don't."

Proposed plans for the year-end 1994 survey are for each carrier to have access to all survey results, with the exception of verbatims. Each insurance company would only see its own verbatims. This would repeat the process followed in 1993. In 1991 and 1992, each carrier saw only its own results. Letting the carriers see each other's results will give them a fuller understanding of the results and allow them to compare their administrative services with the services of the other carriers, Wides says.

Another plan for '94 is to make the survey more event-focused, asking about specific visits, for example, rather than continuing to ask broad questions about overall satisfaction, says Bill Gammell, senior associate, Abt Associates.

"What we're hoping to do this year is to enhance the questionnaire so that the data we collect will be able to sustain some satisfaction modeling we can use to identify key drivers of satisfaction. That way, we can assist AT&T better in identifying those things that are the best candidates for quality improvements.

"An effective satisfaction survey has to ask questions that can identify key drivers of satisfaction. A lot of satisfaction surveys ask how satisfied a respondent is with a certain service dimension. I think the purchasers of those kinds of studies go away unfulfilled because those surveys can't attach the relative importance of those dimensions to the things that contribute to satisfaction.

"That's why I think satisfaction modeling is important. We do regression modeling that identifies the key contributors to overall satisfaction and then we have some proprietary methods that derive the importance of each of those drivers and determine how much they contribute to overall satisfaction, so that the client has an idea of where their resources should be dedicated."

Gammell sees health care satisfaction research turning towards outcomes measurement. "I think employers and insurance companies and HMOs have been using employee or customer satisfaction alone as a proxy for quality. In the future, I think they'll be using customer satisfaction programs that are used in concert with other kinds of outcome measures to evaluate the effectiveness and quality of health plans."

Involve carriers

AT&T plans to involve the insurance carriers in the development of the midyear survey, with an eye toward shifting the administration of the annual yearend survey to them.

"Our plan is to have the carriers administer an end-of-year survey using a common instrument that they've participated in developing," Wides says. "They'll contribute to the interim questionnaire and that questionnaire will probably serve as the basis for a year end survey that will be administered by the carriers."

The national trend is a move toward managed care programs, and as the quality of health care delivery and customer satisfaction become increasingly important to the insurance companies, there will also be a move toward developing a more systematic approach to collecting and analyzing data. In the future, the carriers may be able to compare the information about network satisfaction and utilization collected for AT&T with the same type of data collected from their other clients.

More aggressive

Companies aren't waiting to see what happens in the health care debate, the Business Health Care Action Group's Steve Wetzell says. "The larger employers in particular are being even more aggressive because they want to demonstrate that the private sector is solving the problem rather than waiting for regulation to take over. It's a movement towards things like managed care, vertical integration and outcomes measures.

"The primary problem with past cost containment efforts has been the financial incentives and lack of accountability we've had with the consumers and the providers of care. They've had very little economic stake in the health care system."

Not anymore. In the age of managed care, everyone is sharing the load.