In This Issue

As recently as a decade ago, selecting a primary care doctor was the biggest consideration faced by consumers who were making decisions about health care. With the expansion of managed care, individuals often must choose from a bewildering array of insurance plans that have dramatically different structures and varying ranges of options. The decisions consumers make often determine both the clinicians they will have access to and the type and extent of their benefits. Many individuals may influence the complicated, important process of selecting a health plan.

In this issue of the Milbank Quarterly, that process is examined from three perspectives: the role of employers; the contribution of independent insurance agents; and how consumers use information about quality. .

In the first article, “Employer-Sponsored Health Insurance: Are Employers Good Agents for Their Employees?” Pamela B. Peele and her coauthors evaluate how well large employers (of more than 800 employees) act as agents for their workforce. Based on interviews with human resource mangers, focus groups conducted among selected employees, and reviews of the employer-distributed information on health insurance options, these authors conclude that large employers are providing a valuable service.

Mark A. Hall, in “The Role of Independent Agents in the Success of Health Insurance Market Reforms,” reports on the interviews conducted by his research group regarding independent insurance agents. They spoke with regulators, independent insurance agents, actuaries, underwriters, marketers, product designers, and lawyers in seven states. Hall concludes that independent agents play a critical role. Their independence from insurers allows them to represent the interests of purchasers and to solicit both good and bad risks. His group uncovered little evidence that insurers manipulate agents to undermine the insurance market. For example, they did not find that independent agents’ activities limited the ability of high-risk applicants to obtain insurance.

Roger Feldman, Jon Christianson, and Jennifer Schultz surveyed employees who receive coverage through the Minnesota Buyers Health Care Action Group (BHCAG) and reported the results in their article, “Do Consumers Use Information to Choose a Health Care Provider System?” The study had several goals: to discover whether consumers use employer-supplied information when choosing a health care system; to explore the factors that lead employees to turn to sources other than those offered by their company; and to find out whether employees integrate this outside information into the employer materials or rely entirely on their informal sources. The majority of employees used employer-supplied information when selecting a health care system. Classes or workshops increased the likelihood that employees would turn to friends and physicians for advice, rather than relying solely on the employer. The researchers also determined that certain information sources tend to be used together. For example, employees who talk to friends also listen to physicians and advertisements. The results should be informative and helpful to employers who are trying to match their information strategy to the needs of their workforce.

The recent Surgeon General’s Report on Mental Illness reminded us all of the prevalence of mental disorders and their associated morbidity. Such disorders account for a large proportion of the costs to employers of disability insurance programs. David S. Salkever and his colleagues surveyed employers about disability management practices and employee benefit plans. In preparing their article, “Disability Management, Employee Health and Fringe Benefits, and Long-Term-Disability Claims for Mental Disorders,” they analyzed data from 244 employers on long-term-disability plans in effect, employer characteristics, and the characteristics of covered employees.

Employee fringe-benefit arrangements, including coverage for mental health treatment, were important predictors of incidence rates. For example, greater access to outpatient specialty care was related to fewer disability claims. Award rates for public disability insurance coverage (SSDI) were also strongly related to claims incidence, suggesting that private LTD is an important pathway to SSDI benefits. Certain programs that, for example, provide alternative jobs for employees returning to work from disability leave, are linked to lower claims costs.

In our efforts to provide high-quality acute medical care, we do not pay adequate attention to community-based efforts to promote health and well-being (see Paul K. Halverson et al., MQ 75 [1]: 113-38; William E. Welton et al. MQ 75 [2]: 261-88; Gloria J. Bazzoli et al. MQ 75 [4]: 533-62; Thomas M. Wickizer et al. MQ 76 [1]: 121-48; Susan Watt et al. MQ 77[3]: 363-92). Although hospitals mainly provide acute-care services, they can play an important role in health promotion activities. Peter C. Olden and Dolores G. Clement analyzed data from the American Hospital Association Annual Survey of Hospitals to evaluate how often general hospitals provide health promotion and disease prevention services. The results, which they present in “The Prevalence of Hospital Health Promotion and Disease Prevention Services: Good News, Bad News, and Policy Implications,” are encouraging, in that thousands of general acute-care hospitals have begun to offer health promotion. The discouraging news is that thousands of other hospitals have taken only minimal steps in this direction. The authors recommend that such hospitals change their institutional policies and activities, and they suggest ways that government action could facilitate this endeavor.

Paul D. Cleary

Author(s): Paul D. Cleary

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Volume 78, Issue 1 (pages 1–3)
DOI: 10.1111/1468-0009.00041-i2
Published in 2000