The American health care system is in the midst of revolutionary change. Traditional indemnity health insurance plans are becoming obsolete. Surveys indicate that as many as 85 percent of workers covered by employer-sponsored health plans are now enrolled in some type of managed care plan.
Managed care plans themselves are also changing. HMOs, which were primarily non-profit entities in the past, are rapidly changing to for-profit corporations. Most newly developed Preferred Provider Option (PPO) plans are also for-profit. Many of these plans are more concerned about profits than about quality of care. At the same time, in response to serious public concern about health care quality, state regulation of managed care is proliferating. Some federal restrictions have been enacted and further action is being considered.
In response to these changes, union negotiators must adopt new approaches to bargaining over health care benefits. Past negotiations focused primarily on benefit levels and cost sharing provisions. With the new choice restrictions, access to quality health care also becomes a major negotiating issue.
To further complicate matters, it appears that, after sev-eral years of moderation in health benefit costs, we may again see costs rise at a rapid pace. Cost containment strategies, such as pre-authorization for specific services, mandatory outpatient surgery, and utilization review, are already widespread. Controlling costs at this point will require new and innovative strategies on the part of employers, unions and health care providers.
The goal of this manual is to offer information useful to AFSCME leaders and staff responsible for membership health benefits, whether through contract negotiations or through a benefits trust. The manual provides the reader with questions that can be asked about each managed care plan under consideration. For those not involved in health care negotiations, this manual can help in selecting among plans offered through the employer, if more than one health plan option is available.
With managed care plans, what you don’t know can hurt you. Asking the questions in this manual can help ensure that our members get the health care they need and deserve.