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SELECTING A SOUND HMO

Often every 3 years, companies begin to feel the itch for a new HMO for their employees. Such is the average life-span of a company-HMO relationship, confirms Norman Amora, Vice President for Sales and Marketing of leading HMO Intellicare. But it need not be that way. Intellicare's relationships with a lot of its clients prove it.

The need to look for a new one is usually triggered by laxity or the sudden successive failures of HMOs to deliver on their promises. Sometimes, it happens when top management actually experiences the failure of the HMO. This habit of shifting every 3 years or so can put a tremendous stress on companies, their employees, most especially who benefit from the health plans.

This habit of shifting every 3 years or so can put a tremendous stress on companies, their employees, most especially who benefit from the health plans.

If only there were a set of criteria on which companies can immediately appraise a line up of HMOs when they shop for one, the constant shifting may happen a lot less.

But companies do it differently. They have their own set of criteria and may vary depending on what their needs are or financial capabilities are.

So what should a company look for in an HMO?

Intellicare has been in the industry for years and has observed the behavior of companies when it comes to looking for an HMO. Amora says, This practice of looking into the price of an HMO's offer is of course, all sound and logical. Sometimes though, companies tend to prioritize their wants rather than their needs, which is evident in their choice of a lower priced HMO with more benefits, overlooking the fact that this scheme will be more costly in the long run. If companies stick to their “terms of reference” (TOR), they can do away with benefits to lessen the cost of their health care benefit.

But high cost of their incumbent HMOs is just one of the reasons why companies look for other HMOs. Other issues include contract implementation and interpretation when members do not understand what are covered and how to use the card, the bad service of the HMO, and its providers like the absence or quality of doctors among other things which even regular patients, not just HMO cardholders, complain about as well. When clients experience such things, that is the time that they look for another HMO.

It does not have to reach this point. As its outstanding client retention rate of above 90% should prove, Intellicare is now in a very good position to share with many what the ideal set of criteria is.

Benefit package

Companies usually look for wide coverage of the benefit package first. What company would not? They are looking after the welfare of the employees after all.

Any benefit package must include the basics, such as access to clinics and tertiary hospitals for consultation with the common medical specializations and in time of confinement or in-patient.

The basics are after all the most commonly utilized service of the HMO.

The benefit package must be tailor fitted into the company's needs. There are cases when some benefits, though incorporated at the time of bidding or choosing an HMO are never used by the cardholder.

"To be able to tailor fit the health care package, the HR has to be involved with the so called health consultant of the provider," Amora says.

Caution must be set though when appraising the benefit package. The benefit package though should be fair and must be in the most feasible of terms. It must be within the budget set. Any demands that go beyond the realistic terms will without a doubt affect the services of the HMO and its affiliates.

Since most companies have a budget set for this service, companies cannot just rely on data given to them without studying the terms of reference or the benefit package given by the previous HMO.

Network

An HMO’s strength should be measured in terms of its network. This includes the hospitals, clinics, other facilities and affiliates or expert resources such as doctors and specialists.

How far can an HMO go? Do they have affiliates in far flung areas outside of Manila? Or at least in key cities that cardholders need not be compelled to come to Manila when they avail of the services?

A lot of the beneficiaries and extension cardholders reside outside of Manila. They are the families of the principal holders who are based in Manila. To be of proper service to these, the HMO's reach must go as far as at least the key cities of the provinces where they reside.

Also, the affiliate doctors should be complete at least on the level of the basic medical specializations – in each facility.

Intellicare for one has the numbers to show its strength. With over 9,000 affiliate doctors, 350 accredited hospitals, over 200 clinics, some of which are owned by the company and some are accredited independent facilities. Add to these its dominance in the number of Patient Relations Officers (PROs) spread out in the country. All these manpower are distributed in a manner that fits the locale.

Financial capability

Financial capability is a crucial factor in the selection because its capacity to deliver the services depends highly on it. If your prospective HMO impresses you with a benefit package with a below-industry price tag, you might want to think twice. Such a practice spreads them too thinly and the result can be disastrous.

In the last ten years there were a handful of HMOs that closed shop because of wrong pricing. These companies were keen on penetrating the market by offering low prices. In the end, their capacity to deliver because of the financial instability that resulted from the risky pricing scheme, suffered.

The closure put a negative effect on the HMO and people started questioning just how feasible this kind of service is on the long run. The concern was so serious because not only were money being wasted, they affected greatly the cardholders.

To look into the financial capability of an HMO, one can begin with looking into its roster of clients. Do they include big corporations that put a premium on quality service or are not willing to risk their investment on a company that they see is bound to fail?

Pricing/Premiums

This is usually the first on the list of most companies. Again, it is fair because most companies already have a budget set for a health plan for its employees. Some are even carved in stone. But when considering the price, one has to assess carefully before being impressed by low costs and big promises.

Fair pricing are the key words. As long as the package is fairly priced, all stakeholders, including the providers, the hospitals, the general administrative expenses of the HMO and all medical claims will be appeased. Their fees will be paid accordingly and will eventually redound to good service.

As a fairly priced HMO, you will not shortchange the client and all of your stakeholders will not lose.

And most importantly, Service – After sales service

What happens after the promises are made? You then expect them to be delivered.

The product is sensitive because it deals with human life so an HMO can only aim for excellent service, nothing less.

Unfortunately, service is only appreciated only when a crucial case is attended to or criticized when a glitch happens. Hardly is service appreciated when it is fairly delivered outside of an unfortunate medical incident.

Service is a complete package of offerings – even in times when availment isn't even there yet. It starts from the orientation seminar given by the HMO up to the availment of actual services.

Service is after all, hard to define especially if you do not yet have an experience with the HMO. Intellicare, for its part, tries to manage the orientation not only when they gather the employees in a forum for some frequently asked questions (FAQs) and introduction into the services.

Everything should be given in the orientation from the interpretation of the contract, to procedures, to the network of providers and other such matters. If the employee needs further information, they can always refer to the customer representative. For big companies where an HMO needs to manage well the information, they can put out a help desk for a period of time, like what Intellicare does.

They have the manuals, collaterals, a website, newsletter and even medical bulletin emails to complete the orientation process. So they should be there long after the actual seminar is conducted.

Like Intellicare, an HMO must have an entire account management team to attend to a client's needs from as simple as consulting on the services even before the need arises.

Seeking testimonials or existing client feedback is also one way of knowing how an HMO will perform. Intellicare even suggests to its clients to call their existing clients and accredited hospitals for feedback. It's the only way to sell an intangible such as service.

Intellicare's clients witness the kind of service given to them when a Patient Relations Officer (PRO) attends to them in their time of need.

They know that their service is outstanding because of their above 90% client retention rate, a figure that is unheard of in an industry that averages at 3 years per client.

When you carefully review your company's needs, this set of criteria will surely appear a sound way to choose an HMO. It's almost a sure formula to avoid that 3 year itch.

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