New health-plan forms put through acid test: Focus groups

Kaiser Health NewsJune 21, 2011 

BUFFALO, N.Y. — At an office tucked next to a department store in a shopping mall, Susan Kleimann pushed two sets of papers across a table to a woman in her 40s wearing a gray sweatshirt. "We aren't testing you," assured Kleimann, who runs a market research firm in Bethesda, Md. "We are testing health plan information."

Kleimann explained that they'd be comparing two documents that described 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 said. While a video camera captured every moment, the woman accepted the task with gusto. She said that getting rid of some columns would make the form clearer and changing the blue ink to black would be easier on the eyes. But the last page was trouble. "This is really wordy," she said. "I would have to put it down and go get a bowl of ice cream and go back to it later."

Starting next March, insurers and employers will have to make it easier for consumers faced with the ordeal of picking health plans. Under the 2010 health care law, they'll have to provide health policy information that the average enrollee can understand and use to compare with other plans.

A group assembled by the National Association of Insurance Commissioners developed the forms, and policymakers are getting feedback the same way advertisers learn the best way to sell orange juice: consumer focus-group testing. The woman in the gray sweatshirt was among eight people who received $75 stipends to sit in a windowless room and spend 90 minutes reviewing the forms and answering questions. Consumers Union sponsored the one-on-one sessions, spread over two days last month along with an identical round in St. Louis.

According to the law, the information forms must use standardized language to define some common terms, such as premiums and coinsurance, and to explain which benefits are covered and which aren't, what deductibles the consumer will be responsible for, how the plans' networks work and enrollees' rights to appeal denials of claims.

The law even bans the dreaded fine print by mandating at least a 12-point type size, larger than in a typical newspaper. To make it easier for consumers to compare how much coverage plans offer, the forms 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.

Kleimann asked the testers to read the papers that described the imaginary plans and pick the one they liked best. One young man dived into the task, but was stopped by the word "coinsurance." The form offered a definition he said he didn't understand. During a break halfway through the session, he tried unsuccessfully to call a friend who's an insurance agent.

In addition to the Consumers Union testing, America's Health Insurance Plans, a trade association of more than 1,300 insurance companies, and the Blue Cross Blue Shield Association held separate consumer focus-group testing sessions in St. Louis and Seattle with 40 people.

Consumers Union's preliminary results and America's Health Insurance Plans' report found that the labels achieve most of their mission. "There is universal support for a simplified, standardized format," said Susan Pisano, a spokeswoman for America's Health Insurance.

The National Association of Insurance Commissioners turned over the task of developing the forms 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 suggestions from consumers and others.

The revised forms were endorsed and sent to the insurance commissioners for approval last Friday. The labels then will go to federal officials — perhaps by the end of June — who'll issue the regulations on the use and distribution of the forms.

Consumers Union used an intensive consumer focus-group test called "cognitive interviewing," in which researchers encourage participants to express every reaction they have to the product, 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 can't be published.)

The testing targeted the "coverage facts labels." The labels say the information can help consumers compare plans by showing how much they'd pay for procedures based on the national average costs. A beneficiary's actual costs might be different, based on the doctor's advice, what providers charge and 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 said. "It's kind of sketchy."

The woman who needed an ice cream break told Kleimann that she understood 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 said. "I am in the population at risk for breast cancer, so this would help me."

But like some other participants, she suggested 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 intimidated 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 that was recording the sessions. "I'd have to have a calculator or ask someone from NASA to do the math," he said.

At the end of each session, Kleimann asked the crucial question: Which plan would you buy?

All but two participants were able to make decisions. For those two, the new forms were no substitute for the all-purpose experts in their lives.

"I'd probably call my mom and ask her," said the young man who needed a calculator.

(Kaiser Health News is an editorially independent news service of the Kaiser Family Foundation, a nonpartisan health care policy organization that isn't affiliated with Kaiser Permanente.)

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