BUFFALO, N.Y. – At an office tucked next to Macy's at the Boulevard Mall, Susan Kleimann pushes two sets of papers across a table to a woman in her 40s wearing a grey sweatshirt. "We aren't testing you," assures Kleimann, who runs a market research firm in Bethesda, Md. "We are testing health plan information."
Kleimann explains that they will be comparing the two documents (one here and the other here) describing two hypothetical insurance plans. "What you tell us today will help us improve the information and be sure that consumers can easily understand what they read about different health plans," she says. While a video camera captures every moment, the woman accepts the task with gusto. She says getting rid of some columns will make the form clearer and changing the blue ink to black will be easier on the eyes. But the last page is trouble. "This is really wordy," she says. "I would have to put it down and go get a bowl of ice cream and go back to it later."
Starting next March, all insurers and employers will have to make it easier for consumers faced with the ordeal of picking a health plan. Under the 2010 health law, they’ll have to provide health policy information that the average enrollee can understand and use to compare with other plans. The forms were developed by a group assembled by the National Association of Insurance Commissioners, and policymakers are getting feedback the same way advertisers learn the best way to sell orange juice: consumer-focus-group testing.
See proposed coverage labels
The new health law requires that health insurers and employers distribute "coverage facts labels" to beneficiaries and prospective applicants starting in March 2012 and a new summary of benefits form to explain covered services and costs.
To see if the information makes picking a health plan easier, in May consumers tested two drafts of the labels (below) that follow the benefits summary on the last two pages.
The woman in the grey sweatshirt is among eight people who received a $75 stipend to sit in a windowless room and spend 90 minutes reviewing the forms and answering questions. The one-on-one sessions, spread over two days last month along with an identical round in St. Louis, are sponsored by Consumers Union. Two representatives from the group, a Kaiser Health News reporter and other observers silently watch from a darkened hideaway room behind a one-way mirror; sound from the session is piped in through an audio system.
According to the law, the information forms must use standardized language to define some common terms, such as premiums and co-insurance and to explain what benefits are covered and what’s not; what deductibles the consumer will be responsible for; how the plan's network works and the rights enrollees have to appeal denials of claims. The law evens bans the dreaded fine print by mandating at least a 12-point type size (larger than typical newsprint).
To make it easier for consumers to compare how much coverage a plan offers, the forms also include two pages of "coverage facts labels" – modeled after nutrition facts labels on food products – that illustrate what a policy might pay and what a consumer would pay for three common medical conditions: maternity care, breast cancer and diabetes.
The testers are asked by Kleimann to read the papers describing the imaginary plans and pick one they like best. One young man dives into the task, but is stopped by the word co-insurance. The form offers a definition he says he doesn't understand. During a break halfway through the session, he tries unsuccessfully to call a friend who is an insurance agent.
See Reports On Coverage Labels
Read what two groups have to say about what the coverage labels could do for consumers.
He also has trouble with another term that tripped up other consumers. "Allowed amount, allowed amount, allowed amount," he says, as if repeating it will make it clearer. (It’s the maximum amount on which payment is based for a covered service, according to the glossary of standard definitions that the law also requires insurers to provide consumers, although the testers didn't get that information in the session.)
In addition to the Consumer Union testing, America’s Health Insurance Plans (AHIP), a trade association of more than 1,300 insurance companies, and the Blue Cross Blue Shield Association also held separate consumer focus group testing sessions in St. Louis and Seattle with 40 people. Consumers Union's preliminary results and AHIP's report found that the labels achieve most of their mission. "There is universal support for a simplified, standardized format," said AHIP spokeswoman Susan Pisano.
"The forms serve a policy goal that is included in the act, to help consumers understand their coverage options and the exceptions to that coverage and allow them to compare plans," said Lynn Quincy, Consumers Union's senior policy analyst who watched the testing. "How would we know if we accomplished that policy goal without consumer testing?"
The health law directed the National Association of Insurance Commissioners to develop the forms, and it turned the task over to a group of state insurance regulators, consumer and patient advocates, insurance companies and health care providers. Over the course of several lengthy conference calls, the group revised the forms based on the suggestions from consumers and others.
After the group revised the labels, the insurance commissioners approved them and sent them to Departments of Health and Human Services and Labor. Officials at those agencies will issue the regulations on the use and distribution of the forms.
Consumers Union used an intensive consumer-focus-group testing called "cognitive interviewing," where researchers encourage participants to express every reaction they have to the product being tested, with prompting from an interviewer. The testers were 26 to 64 years old, and either had no insurance or bought their own policies in the individual market. (Anonymity was guaranteed, which is why participants’ names cannot be published.)
One woman, who appeared to be in her early thirties, said she and her husband have no insurance and go to a free clinic for medical care. The forms puzzled her, until some numbers grabbed her attention: "Showing what the plan is paying and what I'm paying, that's a big eye-catcher for me," she said. "A lot people think they are paying for the majority of the cost."
The testing targeted the "coverage facts labels." The labels say that the information can help consumers compare plans by showing how much they would pay for procedures based the national average costs. A beneficiary's actual costs might be different, based on the doctor's advice, what providers charge, how much the policy pays, among other factors. That didn't go over well with some testers.
"The word 'might' ruins everything," one young man says. "It's kind of sketchy."
The woman who needed an ice cream break tells Kleimann that she understands the purpose of the coverage facts labels: "Even though they may not be real numbers, if the treatment is the same, this tells me which plan will save me money," she says. "I am in the population at risk for breast cancer, so this would help me."
But like some participants, she suggests adding other medical treatment examples for the coverage facts labels, something an average family would experience. "I'm much more likely to fall in my driveway than be diagnosed with diabetes."
Premiums, deductibles and other numbers intimidate another participant, a man in his 20s, wearing shorts and flip-flops. He had to turn his baseball cap around so it wouldn't hide his face from the video camera recording the sessions. "I'd have to have a calculator or ask someone from NASA to do the math," he says.
Finally, at the end of each session, Kleimann asked the crucial question: which plan would you buy? All but two participants are able to make a decision, and one man says that he now feels confident that he knows what questions to ask when it comes time to buy a real health plan.
But for the two others, the new forms are no substitute for the all-purpose expert in their lives, no matter what the health law says.
"I'd have to ask my mom," says the woman who liked seeing what she would have to pay.
The young man who needed a calculator, also needs good advice: "I'd probably call my mom and ask her."
Contact Susan Jaffe at Jaffe.firstname.lastname@example.org