University Times

The University Senate has devoted substantial attention over the years to health benefits issues. The spring 2005 Senate plenary session addressed the topic of consumer satisfaction with UPMC. Subsequent to that plenary session, Dr. Nick Bircher, then Senate president, appointed me head of an ad hoc committee on consumer satisfaction with UPMC.

This April I presented the ad hoc committee’s report to Faculty Assembly. Foremost among the committee’s recommendations was that the University Senate executive committee, which consists of the four Senate officers, recommend to the University’s central administration the establishment of a comprehensive and systematic consumer advocate function, to be carried out by an individual or individuals whose primary duty would be to represent the interests of faculty, staff and their family members. The consumer advocate proposal was discussed at a meeting the Senate executive committee had with University administration. To date, there has been no publicized establishment of such a function by the University or UPMC, beyond what already existed at the time.

There are some mechanisms currently available to deal with consumer concerns. UPMC Health Plan maintains a dedicated phone line for Pitt plan members to seek assistance during specified hours. Faculty, staff and family members also can seek assistance from Pitt’s Office of Human Resources during regular business hours.

UPMC, for both its health services providers and the health plan, uses the media extensively — television, newspapers and press releases — to tell the public how well it performs. For example, it has referred often to its top 50 rating by U.S. News & World Report.

However, an April 2006 Pennsylvania Health Care Cost Containment Council (PHC4) report, titled “Measuring the Quality of Pennsylvania’s Commercial HMOs,” paints a somewhat different picture. One of the areas covered in the report is member satisfaction.

Before considering the results of the PHC4 report, be aware that there has been a considerable change in the operation of HMOs. In the early days, utilization management techniques were used widely to control the cost of the health care for which HMOs had to pay. Over time, HMOs have reduced their use of these techniques, such as pre-admission review and referral requirements. UPMC Health Plan, with the Panther Gold option that eliminates prior review and referral requirements, essentially is an exclusive provider organization, with plan members limited to services from the providers selected by the plan. In the case of Pitt’s arrangement, the exclusive providers consist primarily of those providers that are part of the UPMC Health System. That means the hospitals, other diagnostic and treatment facilities, and physicians are all, one way or another, providers controlled by the UPMC Health System.

The PHC4 study rated HMOs in terms of consumer satisfaction based on nine criteria. For each of these criteria, the data indicate how UPMC ranked during 2004 among the nine commercial HMOs in Pennsylvania, including the four in Allegheny County. No more current data were available.

The data indicate that UPMC ranked first among the four Allegheny County HMOs and second among the nine Pennsylvania HMOs in terms of obtaining approvals from the HMO. Since as of July 1, 2006, the Pitt plan does not require referrals, no plan can surpass UPMC in this respect.

On none of the other criteria did UPMC rank first. Five of the nine Pennsylvania HMOs had a higher percentage of their members giving them a better overall rating than UPMC, which ranked third among the four in Allegheny County.

Of perhaps greatest importance in terms of consumer satisfaction are the survey results with regard to volume of complaints/problems, and complaints settled satisfactorily. Only one of the nine Pennsylvania HMOs ranked worse than UPMC Health Plan based on the percentage of members voicing complaints/problems. The best had half the percentage reported to UPMC. One might assume that the volume of communicated complaints and problems accurately reflected the amount of difficulty encountered by plan members in their encounters with their plans.

With regard to complaints being settled to the satisfaction of members, UPMC ranked sixth out of the nine in Pennsylvania and second of four among the Allegheny County plans.

What conclusions can be drawn from this consumer satisfaction data? First, UPMC Health Plan does not stand out as superior overall in either the state or the county, for the report year. Second, unless UPMC has made significant strides in improving its performance in a number of the areas, it needs to improve its performance as perceived by its plan members. Given its widely heralded financial success and its growth the last few years, it possesses the resources to do so. Third, the results of the PHC4 survey suggest that the Senate’s request for a clearly identified and effective consumer advocacy function is a reasonable one.

The PHC4 report does not deal with issues that may be seen by some as plan problems, but instead are problems of providers — hospitals and physicians’ offices. Some problems brought to the attention of the plan may be problems that should be reported to the administrators of provider entities that serve plan members.

As head of the Senate’s ad hoc committee, I have reviewed patient handbooks from non-UPMC provider institutions, as well as similar materials provided to members by other plans. Many prominent institutions provide much more assistance in their patient handbooks than do those provided by UPMC entities. For example, the patient handbook for the MD Anderson Cancer Center in Houston provides the phone number of the patient advocate during regular hours, as well as a phone number to reach the on-call patient advocate during other times. I question whether UPMC is making sufficient efforts to satisfy its members. A second question is whether the University, on behalf of its employees and their family members, is placing sufficient pressure on UPMC, in its roles as both a provider of services and health plan operator, to meet consumer needs.

In June, I accompanied John Kozar, Pitt’s Benefits director, on a visit to the UPMC Health Plan offices. I learned a good deal about the health plan’s efforts to improve customer services. The plan officials I spoke with clearly are attempting to improve plan performance. I specifically requested during the visit that a Pitt employee be placed on any plan advisory panel, a recommendation that appears in the report approved by Faculty Assembly.

I hope that the Senate leadership will continue to press for an effective consumer advocacy function to improve customer service by both the health plan and the health system.

Nathan Hershey is professor emeritus of health law in the Graduate School of Public Health.