Health Insurers in the Spotlight

Consumer Reports Publishes Quality Rankings; HHS Makes Rate Increases Public; They Can Run, But . . .

Are health insurance plans with big brand names better than smaller insurers that most people have never heard of? “Not usually,” says Nancy Metcalf, senior program editor, at Consumer Reports. Unless of course, the plan’s name is “Kaiser.” As Metcalf points out, Kaiser Permanente, a non-profit that insures some 8.8 million Americans nationwide, stands “head and shoulders” above the other large insurers. In general, smaller plans outranked the well-known names, and surprisingly, when it comes to patient satisfaction, Health Maintenance Organizations (HMOs) received higher marks than Preferred Provider Organizations (PPOs) even though HMOs require that the patient remain “in network.”

Consumer Reports’ (CRs’) national rankings for some 830 insurance plans now are available online, with detailed scores based on research done by the National Committee on Quality Assurance (NCQA), an independent non-profit organization that accredits and measures the quality of health plans. The ratings reveal how well the plans perform when it comes to preventive care and management of chronic conditions (which account for 60 percent of the score); patient satisfaction (25 percent); and whether the plan is accredited by the NCQA (15 percent). On the website, readers can research plans by state and compare up to five plans simultaneously.

National rankings reveal wide variations in quality—and mixed results for many of the nation’s largest insurers. The industry’s giants, Aetna, Cigna, Humana, Kaiser Permanente, and UnitedHealthcare—together with the 60 mostly state-based Blue Cross Blue Shield Plans—account for three-quarters of the 390 HMOs and PPOs that NCQA ranked. Yet only 17 of their offerings made the list’s top 50—and six of those were Kaiser Permanente plans.

CR’s ratings include three types of insurance: Medicare Advantage plans, Medicaid plans, and “Private Plans” which include all of the HMOs and PPOs that consumers obtain through their employers or purchase on their own. Each health plan received an overall score on a 1 to 100 scale based on how it compared with other plans in its category. For the best and worst HMOs, PPOs, Advantage plans, and Medicaid plans, see the charts at the end of this post. (If you don’t find your insurer on any of the lists, CR explains that not all plans submit data; those that do must authorize the release of the information to the public, and some choose not to; finally, some don’t submit enough data for valid statistical analysis.)

Kaiser Permanente Shines

Among the 341 Medicare Advantage plans ranked, Kaiser Permanente took the top four spots, and placed in the top 10 percent nationwide in four other regions:

•    Kaiser Permanente Northern California — 1st
•    Kaiser Permanente Southern California — 2nd
•    Kaiser Permanente Colorado — 3rd
•    Kaiser Permanente Northwest — 4th
•    Kaiser Permanente Hawaii — 7th
•    Kaiser Permanente Mid-Atlantic States — 17th
•    Kaiser Permanente Ohio —19th
•    Kaiser Permanente Georgia — 31st

Only one Kaiser Medicaid plan, Kaiser Permanente Hawaii, was included in the ratings, but it captured 2nd place among 99 Medicaid plans.

Of 390 private HMOs and PPOS purchased by employers or individuals, the five largest Kaiser Permanente plans (based in Colorado, Southern California, Northern California), ranked among the top 21, while other Kaiser plans were rated far above average—including Kaiser Permanente Georgia, where it was the highest ranked plan in the state.

•    Kaiser Permanente Colorado — 6th
•    Kaiser Permanente Southern California — 12th
•    Kaiser Permanente Northern California — 14th
•    Kaiser Permanente Northwest — 21st
•    Kaiser Permanente Mid-Atlantic States — 33rd
•    Kaiser Permanente Hawaii — 37th
•    Kaiser Permanente Georgia — 52nd
•    Kaiser Permanente Ohio — 68th

Geographic Variations in Quality

Why does the Kaiser plan in Georgia rank only 52nd nationwide while securing first place in the state?  In general, Consumer Reports Magazine points out, insurance plans in the South and some parts of the West don’t perform as well in national rankings as insurers in the NorthEast, particularly New England: “Eighteen of the 50 top-ranked private plans are in this compact six-state region,” the magazine observes. “Both Aetna and the ‘Blues’ had New England plans ranked in the top 100, while many of the same insurers’ plans in southern and western states ranked near the bottom of the list.”

This may be because some states have fewer resources, poorer patients, less efficient hospitals, more “safety-net” hospitals that are struggling to stay afloat, fewer physicians, and a medical culture where providers are less likely to collaborate to co-ordinate care. Thus, a Kaiser plan in Georgia that ranks 52nd nationally, but 1st in the state, may well be delivering the best care possible under less than ideal circumstances.

Medicare also has found enormous geographic variations in the quality of care nationwide. Medicare uses a 5-star system to rate Medicare Advantage plans and in 2010 it looked at the plans state by state, reporting that, at the top of the ladder more than half of Medicare Advantage enrollees in California, Massachusetts and Hawaii were in plans with four or more stars. In addition, “California and Pennsylvania accounted for nearly half of enrollees in plans that scored 4 or more stars.”

But as the map below reveals, in some states a senior would be hard-pressed to find a 4-star insurer. In dark blue states at least 45 percent of the state’s Advantage members are enrolled in plans that received at  4 stars or more, but in states painted dark orange, such as Louisiana, “0 percent” are enrolled in a plan that managed to garner 4 stars on a 5-star scale. Texas does only a little better: 2 percent of Advantage seniors are in 4-star plans. (In fairness, it should be said that roughly 40 percent of Advantage plans were not ranked because they didn’t have enough quality data to provide a basis for calculating a score. But if an insurer doesn’t collect quality data—or if the plan is too new to have much data—chances are this is not the plan you want.) Image001

Many of the Best Plans are HMOs 

About 31 percent of insured Americans are enrolled in Health Maintenance Organizations (HMOs) which generally insist that a patient stick with the plan’s network of doctors and hospitals. Before seeing a specialist in the network,  the patient also usually needs a referral from his primary care physician. Not everyone is happy with this system. But co-pays and deductibles are generally significantly lower than in Preferred Provider Organizations (PPOs), which have less restrictive network rules than HMOs. Meanwhile,  there are reasons to believe that the best HMOs can deliver better care.

PPOs enroll about 34 percent of the U.S. population and 60 percent of those covered by large employers. In an article comparing “PPOs vs. HMOs,” Consumer Reports outlines the differences.

Some readers may be startled to learn that 15 percent of private HMOs garnered the top score of “5” for consumer satisfaction versus just 6 percent of PPOs. “We were struck by the strong performance among HMOs,” says CR’s Metcalf. “I wish people would read this report and give HMOs another look. People are so scared of being trapped in a network.” But in fact, she explains,”to win a high rating from AHRQ, an HMO network must be large.”

For what it’s worth, I am in a “closed network,” even though my employer offered me a choice. In Manhattan I have never had a problem finding a physician in my network, and, as regular readers know, I am delighted with the in-network ophthalmologist who figured out that I don’t have glaucoma—after some 15 years of being treated for glaucmoa by a physician who didn’t take insurance.

This is, of couse, merely an anecdote about one patient and two doctors. But the stories I have heard from doctors and patients, combined with the statistics from AHRQ’s research, convince me that HMO’s may offer a promising model for the future.

HMO fans point out that in an HMO your primary care doctor is expected to co-ordinate your treatment. He knows which specialists you are seeing because he referred you to them. In theory, this means that he and they communicate. In reality, if he and they work in separate small practices  they may or may not share information. Too often, primary care doctors and specialists  in private practice  find themselves caught in an endless game of phone tag.

By contrast, in an HMO that is part of an integrated health care system such as Kaiser, all patients have one chart that their doctor can see online;  all doctors are  putting their notes on that chart, and thus everyone knows what everyone else is doing.  And if they want to talk to each other, they can easily consult in person.

Low co-pays also can add to better care: because an HMO patient’s out-of-pocket costs are lower, she is more likely to see a doctor when she needs one. And finally, HMOs are more likely to hold doctors accountable for quality of care.

Nevertheless, as the charts at the end of this post indicate, there are excellent PPOs such as Tufts Health Plan, Harvard Pilgrim Health Care, Blue Cross and Blue Shield of Massachusetts and Geisinger Health Plan in Pennsylvania. Moreover, it is important to realize that not all HMOs are created equal. In its 2009 report to Congress, the Medicare Payment Advisory Commission noted that “Quality is not uniform among Medicare Advantage plans or plan types. High-quality plans tend to be established HMOs.” Here, the emphasis is on “established.” Creating a strong, well-coordinated network, along with a database of medical evidence that helps providers measure and improve quality takes time. Many of the “Top” Medicare HMOs on the chart below have been around for many years.

Small Non-profit Plans vs. the “Top Tier” Plans Larger Insurers May Offer

A surprising number of the top-ranked insurers are smaller, community-based plans. Indeed while only 4 percent of plans owned by the six biggest health insurers captured a “5” for consumer satisfaction, 33 percent of plans not owned by one of the six biggest made the grade. The November 2011 issue of Consumer Reports Magazine points out that “Capital Health Plan, a Blue Cross Blue Shield HMO in Tallahassee, Fla., that has just 113,300 enrollees, ranks third in the nation among private plans.” The magazine cites several other examples including Tufts Associated HMO and Tufts Health Plan (a PPO), which have enrollees in Massachusetts, New Hampshire, and Rhode Island, and Group Health Cooperative of South Central Wisconsin. In the state of Washington, Group Health Cooperative’s Medicare Advantage plan stands out.

Many of these smaller plans are non-profits. Indeed when Medicare awarded stars for Advantage plans, non-profits came out ahead. The average non-profit received close to 4 stars, while the average for-profit won only 3 stars.

Today, a growing number of large insurers are trying to “tier” provider networks in an effort to drive consumers toward more efficient doctors and hospitals. Typically, health insurers group hospitals or physicians in these tiers using cost (per episode, service, or stay) or some combination of cost and quality metrics. Consumers pay lower co-pays and deductibles if they choose to use the less expensive and supposedly more efficient provider network. In theory, less costly, more efficient care means higher quality care for the patient. But some observers have raised concerns about the  accuracy of the information insurers use to assign providers to tiers–particularly the methods used to assess efficiency.

To be fair, I should point out that highly-regarded non-profit insurers such as Harvard Pilgrim are among those setting up tiers, and I would hope that their top-tier network does, indeed, offer superlative  care.But in general, I’m not comfortable when for-profit insurers rank providers by quality and cost. These insurers have a compelling reason to put cost first. After all, like all for-profit corporations in the U.S., they are required, by law, to put their shareholder’s interests ahead of customers’ interests. This is why, if given a choice, I would choose an established non-profit HMO that did well in AHRQ’s ranking over a “top tier” network that Aetna told me was the best.

It is worth remembering that the problem with the “managed care” of the  1990s was that, by then, for-profit insurers had taken over an industry that had once been largely non-profit, and businessmen (or medical consultants who worked for businessmen) were judging what care patients needed.  Sometimes they made good decisions. But, too often, cost rather than medical evidence determined what they covered.

I believe that the most important change we can make in our health care system is to let “comparative effectiveness research” determine what constitutes the best care for a particular patient. This is why I would rather have Medicare’s  experts make the coverage decisions that guide the future of health care reform. Here it is essential to realize that Medicare’s decision-makers are not “bureaucrats,” as some fear-mongers suggest. They are scientists, and trained researchers coming from many fields.

As  a recent Robert Wood Johnson Foundation report explains, when Medicare makes a coverage decision it consults “the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), which consists of 100 experts in medicine, biological and physical sciences, public health administration, patient advocacy, health care data and information management and analysis, health care economics, and medical ethics.” The report notes that “The Centers for Medicare and Medicaid (CMS) also convenes smaller groups of content experts for deliberation on specific topics.” These groups are not making business decisions. They are making medical decisions.

Going forward, I expect that CMS will be making many of these evidence-based coverage decisions, and that private insuers will follow their lead, just as they do today.

Under the Patient Protection and Affordable Care Act, Medicare also will be collecting information on rates of hospital acquired infections at hospitals across the nation, while taking a close look at preventable errors and preventable readmissions. Hospitals will no longer be paid for mistakes which could have been avoided.

Private insurers don’t have the power to demand disclosures about infections and medical errors. This is another reason why I would rather choose a hospital based on revelations from Medicare rather than an insurance company’s assurance that this is a “top tier” provider. The hospital might be efficient in certain ways; for example, it might make good use of health information technology. But if patient safety isn’t a priority, patients die.

In the years ahead, as reform unfolds, Medicare also will be offering bonuses to doctors and hospitals who achieve better outcomes for less. This is another area where private insurers are likely to follow suit, and my guess is that providers will be quick to let us know if they are among the winners. All of this will information will make “quality of care” far more transparent than it is today.

Measuring Quality: “Process” vs. Outcomes” 

That said, we are just beginning to learn how to measure the quality of medical care. Today, there are limits to what Consumer Reports can tell us about care that an insurer provides because when either AHRQ or Medicare measure quality they are usually looking at what researchers call “process.” Did the hospital remember to give the AMI patient the aspirin both when he was admitted and when he was discharged?  Did someone give him the Beta-blocker? Did the diabetic patient receive an eye exam?

But in the end, what we really care about is “outcomes.” Did the diabetic lose his eye-sight? Did the AMI patient have another heart attack?

Consumer Reports’ Nancy Metcalf acknowledges that when AHRQ and Medicare assess the quality of an insurance plan they are looking primarily at process.  Though she points out that “in theory, if providers do the right things” on the checklist, “this will lead to better outcomes,” she points out. But research shows that, too often, this is not the case.  Indeed, while focusing on “process” providers can lose sight of other, more important matters—such as listening to and talking to the patient.  As reform evolves, no doubt AHRQ we will be focusing on “outcomes” as well.

In fact, this is already happening on the ground.  When Blue Cross Blue Shield of Massachusetts launched a new provider payment system in January of 2009, it wisely decided that when determining bonuses, “outcome measures such as whether the provider group was successful in controlling blood pressure, would be given triple weight compared to process measures such as whether the patient was screened for breast cancer.” What patients report about their experience, including  “quality of communication with nurses and doctors” also would trump “process.”

In January 2011, BCBS announced the results of a payment system that asks providers share responsibility for “quality.” At that point, it seemed clear that providers who agreed to sign an “Alternative Quality Contract” were succeeding in achieving better outcomes for less.  For example, when the insurer looked at ” chronic disease care measures such as management of diabetes and cardiovascular disease, among the most costly and prevalent chronic care conditions, the AQC groups’ rate of improvement on screening and monitoring measures far exceeded those of physicians not in an AQC contract. In year one of the contract, AQC organizations made gains on these measures at a rate more than four times what they had been accomplishing before the contract.”  At the end of the first year, providers also came away with surpluses that they would be able to invest in infrastructure and other improvements which could help them offer increasingly efficient care.

It worth noting that BCBS of Massachusetts does not lock patients into networks. Co-pays and deductibles do not vary by network. Rather than trying to lure consumers into a supposedly higher quality, less expensive network, BCBS focused on giving providers incentives to provide better care, achieve better outcomes, and pay attention to what patients say.

I do not mean to suggest that Consumer Reports’ rankings are not extremely useful. They are. For one, as CR explains, the very fact that an insurer agrees to give AHRQ the information, and let CR publish the results is telling.

HHS Publishes Information on Premium Increases

Finally just as Consumer Reports and AHRQ are making more information about the “quality” of care that insurers’ provide available, the Department of Health and Human Services has set up a website that brings premium increases into the sunlight. Consumers across the country can now click their state on this federal Web page to see if a health insurer has raised its rates, as well as the company’s reason for doing so.

“That information was mostly unavailable before”, Steve Larsen, the Department of Health and Human Services deputy director for oversight, recently told USA Today. Only a few states include rate raises on their websites. Now, however, under the Patient Protection and Affordable Care Act, all insurance companies must file that information with HHS.

“We are taking a good, hard look at why insurance companies are seeking to raise your rates, why your premiums might be going up, and making sure these decisions are public and justified,” HHS Secretary Kathleen Sebelius said in a statement. “This is just a start, and over time we will be reporting more of these requests.”

As reform moves forward, insurers are now in the spotlight. As more information becomes available, they may run (and I remain convinced that many for-profit insurers will flee the health insurance business altogether)—but they can’t hide. In the end, only those few that know how to actually add value to health care will survive.

Top Private HMOs

National Rank Plan Name Plan Type State(s)
1 Harvard Pilgrim Health Care HMO/POS MA, ME
2 Tufts Associated Health Maintenance Organization HMO/POS MA, NH, RI
3 Capital Health Plan HMO FL
5 Harvard Pilgrim Health Care of New England HMO/POS NH
6 Kaiser Foundation Health Plan of Colorado HMO CO
7 Group Health Cooperative of South Central Wisconsin HMO WI
8 Geisinger Health Plan HMO/POS PA
10 Health New England HMO/POS MA
11 Grand Valley Health Plan HMO MI
12 Kaiser Foundation Health Plan of Southern California HMO CA
13 Fallon Community Health Plan HMO/POS MA
14 Kaiser Foundation Health Plan of Northern California HMO CA
15 Blue Cross and Blue Shield of Massachusetts HMO/POS MA
18 UPMC Health Plan HMO/POS PA
18 UPMC Benefit Management Services HMO/POS PA
20 Excellus BlueCross BlueShield HMO/POS NY
21 Kaiser Foundation Health Plan of the Northwest HMO OR, WA
22 Capital District Physicians’ Health Plan HMO NY
23 Johns Hopkins US Family Health Plan HMO MD
24 HealthPartners HMO/POS/PPO MN



Private HMOs at the Bottom of the List


National Rank Plan Name Plan Type State(s)
328 Martin’s Point Health Care HMO ME, NH, NY, VT
330 Group Health Cooperative of Eau Claire HMO WI
331 Health Tradition Health Plan HMO WI
334 Florida Health Care Plans HMO/POS FL
337 Welborn Health Plans HMO/POS IN, KY
338 Providence Health Plans – Oregon HMO/POS OR, WA
339 Horizon Blue Cross Blue Shield of New Jersey POS NJ
341 Group Health Plan HMO/POS IL, MO
343 Group Health Options (Alliant) HMO/POS ID, WA
344 Rocky Mountain Health Plans HMO CO
345 Group Health Options (Options) HMO/POS ID, WA
348 Preferred Health Systems HMO/POS KS
354 Coventry Health Care of Kansas HMO/POS KS, MO
356 Humana Health Plan of Tennessee HMO/POS TN
361 Coventry Health Care of Delaware HMO/POS DE, MD
367 Humana Benefit Plan of Illinois HMO/POS IL
374 Coventry Health Care of Louisiana HMO/POS LA
386 Vantage Health Plan HMO LA




Top Private PPOs

National Ranking Plan Type State(s)
4 Tufts Health Plan PPO MA, NH, RI
9 Harvard Pilgrim Health Care PPO MA
16 Blue Cross and Blue Shield of Massachusetts PPO MA
17 Geisinger Health Plan PPO PA
24 HealthPartners HMO/POS/PPO MN
40 CDPHP Universal Benefits PPO NY
45 Capital District Physicians’ Healthcare Network (Self-Funded) PPO NY
49 HealthNow New York HMO/POS/PPO NY
59 UPMC Health Network PPO PA
59 UPMC Benefit Management Services PPO PA
63 Univeral Healthcare HMO/POS/PPO NY
69 QCC Insurance (Personal Choice) PPO PA
72 Medica HMO/POS/PPO MN, ND, WI
76 Excellus BlueCross BlueShield PPO NY
80 Hawaii Medical Service Association (HMSA) PPO HI
81 Aetna Life Insurance Company (Connecticut) PPO CT
90 Blue Cross Blue Shield of Minnesota PPO MN
98 Aetna Life Insurance Company (Massachussetts) PPO MA
99 Oxford Health Insurance – New York PPO NY
100 Blue Cross and Blue Shield of Vermont PPO VT



Private PPOs at the Bottom of the List

National Rank Plan Name Plan Type State(s)
373 Health Net of Oregon PPO OR, WA
375 Health Alliance Plan of Michigan PPO MI
376 Regence BlueShield PPO WA
385 Regence BlueCross BlueShield of Oregon PPO OR, WA

Medicare Advantage HMOS at the Top of the List

National Rank Plan Name Plan Type State(s)
1 Kaiser Foundation Health Plan of Northern California HMO CA
2 Kaiser Foundation Health Plan of Southern California HMO CA
3 Kaiser Foundation Health Plan of Colorado HMO CO
4 Kaiser Foundation Health Plan of the Northwest HMO OR, WA
5 Gundersen Lutheran Health Plan HMO WI
6 Capital Health Plan HMO FL
7 Kaiser Foundation Health Plan of Hawaii HMO HI
8 Tufts Associated Health Maintenance Organization HMO MA
9 Geisinger Gold Classic HMO PA
10 Kaiser Foundation Health Plan of the Northwest (Demonstration Project) HMO OR, WA
11 Group Health (Cost) HMO MN, WI
12 Fallon Community Health Plan HMO MA
13 Security Health Plan of Wisconsin HMO/POS WI
14 Group Health Cooperative HMO WA
15 MVP Health Care (Rochester Area) HMO NY
16 Capital District Physicians’ Health Plan HMO NY
17 Kaiser Foundation Health Plan of the Mid-Atlantic States HMO DC, MD, VA
18 MVP Health Care HMO NY
19 Kaiser Foundation Health Plan of Ohio HMO OH
20 Aetna Health – Maine HMO ME


Medicare Advantage HMOs at the Bottom of the List

National Rank Plan Name Plan Type State(s)
333 Harmony Health Plan of Missouri HMO MO
334 Arcadian Health Plan (Southeast Community Care – H2899) HMO NC
335 WellCare of New Jersey HMO NJ
337 Liberty Health Advantage HMO NY
338 Arcadian Health Plan (H7179) HMO LA
339 Arcadian Health Plan (Southeast Community Care – H5578) HMO GA
340 Molina Healthcare of California Partner Plan HMO CA
341 Easy Choice Health Plan HMO CA
Published with permission from the National Committee for Quality Assurance, based on data collected in 2011 from the 2010 plan year.


Medicaid Plans at the Top of the List

National Rank Plan Name Plan Type State(s)
1 Fallon Community Health Plan HMO MA
2 Kaiser Foundation Health Plan of Hawaii HMO HI
3 Boston Medical Center HealthNet Plan HMO MA
4 Neighborhood Health Plan HMO MA
5 Capital District Physicians’ Health Plan HMO NY
6 Security Health Plan of Wisconsin HMO WI
7 Network Health HMO MA
8 Neighborhood Health Plan of Rhode Island HMO RI
9 Priority Health HMO MI
10 UPMC For You HMO PA
11 Medica HMO MN
12 BlueCaid of Michigan HMO MI
13 Passport Health Plan HMO KY
14 Midwest Health Plan HMO MI
15 Excellus BlueCross BlueShield HMO NY
16 UnitedHealthcare of New England HMO RI
17 UnitedHealthcare Great Lakes HMO MI
18 Total Health Care HMO MI
19 HealthNow New York HMO NY
20 Upper Peninsula Health Plan HMO MI


Medicaid Plans at the Bottom of the List

National Rank Plan Name Plan Type State(s)
81 Universal Health Care (Nonreform Counties) HMO FL
82 Rocky Mountain Health Plans HMO CO
83 Health Plan of Michigan HMO MI
84 Jai Medical Systems HMO MD
85 Delaware Physicians Care HMO DE
86 Superior HealthPlan HMO TX
87 Denver Health Medical Plan HMO CO
88 Horizon NJ Health HMO NJ
89 CareSource HMO OH
90 Molina Healthcare of Missouri HMO MO
91 HealthCare USA of Missouri HMO MO
92 CareSource Michigan HMO MI
93 Carelink Health Plans HMO WV
94 Coventry Health Care of Delaware HMO MD
95 Blue Cross and Blue Shield of New Mexico HMO NM
96 Missouri Care HMO MO
97 UniCare Health Plan of Kansas HMO KS
98 Health Plan of Nevada HMO NV
99 WellCare of Ohio HMO OH

9 thoughts on “Health Insurers in the Spotlight

  1. When I was applying for health insurance after losing my job Aetna was all I could get. Now I’m wondering if I should try to get back with an HMO like Kaiser. This post has given me food for thought.

  2. You may want to google “501(c)(15)” insurers.
    They are small insurers, who must sell insurance at their cost.
    Don Levit

  3. You mean the infallible Invisible Hand of the Market doesn’t lead to the very bestest healthcare system? Heresy![/sarcasm]
    I note that CIGNA does particularly badly in one of your lists. I’m not surprised.

  4. Very informative and important post, Maggie. I had no idea Consumer Reports data were available on line. We subscribe to the magazine and I have refused for years to pay for yet another subscription on line, so that was a welcome discovery. (Did they finally learn the Netflix lesson or is your link the exception? I’ll have to check…)
    Also, it never occurred to me that Medicaid insurance plans existed. I thought Medicaid was an arrangement between state authorities and individual providers who agree to service poor people. Does this mean there is “competition” among providers (and insurance companies, no less) for Medicaid patients? And do beneficiaries pay insurance premiums in addition to other expenses?
    Is Medicaid compensated by capitation like Medicare Advantage?
    After following the healthcare reform debate for several years I’m embarrassed to be asking these questions. It’s like finding a lost bowling ball in the fridge. Who knew?
    In other news, another friendly reminded about getting Facebook and Twitter share links for these posts.
    Aaaand, it looks like a couple of spammers have got their Type Pad or Type Key drivers licensed.

  5. elza,Chris,John,
    Elza– Definitely, look into Kaiser. In terms of value for your dollars, and finding docs and hospitals that practice evidence-based medicine, it’s very good.
    Of course, not all Kaiser hospitals are equally good. But over-all it’s far better than average.
    Yes, Cigna does pretty horribly on all of the lists. That’s one thing I forgot to mention.
    I doubt that they’ll survive health care reform. Assuming the Consumer Reports lists get wide exposure, this is the sort of thing that can hurt (or help) market share. That’s why I went into so much detail here. (The online version of Time Magazine) will be running a short, very-well edited version of this post on Monday which I hope will give the CR report more exposure.
    I’m also writing a separate piece for them on Kaiser.
    Good to hear from you.
    Yes, I have talked to our tech expert about putting the twitter and face-books
    links on HeatlhBeat.
    It seems that this is somewhat difficult to do this via Typepad. If you know how it can be done easily, perhpas you could e-mail him at He’s a very nice guy.
    All of the insurance info in the report is available, at no charge, online.
    I’m not sure how much of Consumer Reports healh info is available for free.
    But as you probably know, you can subscribe for just a month to CR, so if you want to look for something specific it’s easy to do for very little money.
    Yes, most (all?) states offer what is often called “Medicaid Managed Care” through HMOs. States hope to lift quality and reduce cost by taking advantage of what is good about HMOs– care co-ordination via a primary care doctor and no fee-for-service driving volume.
    Medicaid HMOs may also offer benefits that traditional fee-for-service HMO’s do not.
    I don’t know about co-pays– this migiht well vary by HMO and/or by state.
    I found this website for New Jersey’s HMOs — they are moving all of their Medicaid patients into HMOs.
    I didn’t take the time to drill down and look at individual plans, but if you do, you’ll get even more information.
    You’ll notice that a patient can keep the doctor he has now even if that doctor is not in one of the HMO networks. But his doctor has to co-ordinate with the HMO and follow its rules.
    Bowling ball in the refrigerator–who knew? Very good!

  6. Article – “HMO fans point out that in an HMO your primary care doctor is expected to co-ordinate your treatment. He knows which specialists you are seeing because he referred you to them. In theory, this means that he and they communicate”
    Yes, in theory. I would like see HMO’s be more flexible in having some specialists become your acting PCP for the plan. There are some chronic conditions (such as ESRD) where the patient will very rarely see their PCP, only their specialist. So in effect you have these specialists managing the patients care, but the plan doesn’t recognize them as such – it’s a real breakdown in coordination.
    @ John – I wouldn’t say providers are competing for Medicaid patients. Usually these Medicaid replacement plans pay at the State Fee Schedule, which is next to nothing. In our PA market, we lose around 50 to 100$ per Medicaid patient because their reimbursement is so low it doesn’t cover the costs of our supplies. Again, this is regardless if the patient has straight Medicaid coverage or an HMO Replacement plan. So, benefits under these Medicaid Replacement Plans will vary based on the State, because in my experience, these plans emulate the State Medicaid Program.

  7. Scott–
    I agree that in a limited number of cases (such as End-Stage Renal Disease)
    the specialist should be the person co-ordinating care.
    As party of its “community involvement” program, Kaiser actually reaches out to those in need– including Medicaid patients, and low-income patients who are uninsured and don’t qualify for Medicaid.
    It also provides financial counseling to help patients qualify for Medicaid.
    This is how Kaiser is different from the many providers who shun Medicaid patients.

  8. If you’re looking for affordable Kaiser Permanente Oregon plans or affordable Small business health plans, get quality health plans to fit most budgets with Kaiser Permanente org.

    • When you look at the reports on quality that Consumer Reports does (using NCQA data) Kaiser does stand out .