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Complexities of health insurance spur growth of independent help agencies

As health insurance systems become ever more complicated and as people with low incomes struggle to get health care, independent help agencies are increasingly filling the gap in resolving consumers’ problems, according to researchers at the Keck School of Medicine.

Patients have had few places to turn for help—aside from their own health plan—if they receive unexpected medical bills or refusals for much-needed medical equipment. They also have had few resources in figuring out how to choose health coverage or how to navigate public insurance programs. But now a network of California legal services groups has become a valuable lifeline for these patients, researchers write in the April issue of the Journal of Community Health.

The Health Consumer Alliance, or HCA, is an independent, coordinated effort of nine non-profit groups that provide free help to low-income consumers in 10 California counties stretching from Placer to San Diego. More than 4 million people in these areas live at least 200 percent below the federal poverty level.

The groups are not affiliated with any insurance company or government insurance program, so they may serve as an independent voice at a time of growing concern over patient rights, employer and health plan liability, and independent review.

“Our study shows that there is a need for assistance in navigating our complicated health care system, and the establishment of independent centers to provide that assistance is key to improving health care access for our vulnerable populations,” said Lori Miller Nascimento, the study’s lead author and associate director of the division of community health in the Keck School’s Department of Family Medicine.

“The centers may also reduce costs, morbidity and litigation that could occur if consumers’ problems were not otherwise resolved.”

Interviewers surveyed 1,291 HCA users from 2000 to 2002. The surveys, done over the phone in English or Spanish, assessed consumer satisfaction, health insurance status, access and use of health care and preventive-care usage.

About three-fourths (76 percent) of consumer problems were related to eligibility; that is, consumers were uninsured, had their coverage terminated or were denied coverage, for example. The other 24 percent of consumers had service problems, such as trouble with billing, denial of care or problems changing providers.

Researchers found that 62 percent of participants reported their problems were resolved after calling one of the health consumer centers, and almost 90 percent of those surveyed reported they got the facts they needed through the center.

“Although the centers were not always able to resolve the consumers’ problems, they almost always provided consumers with necessary information,” said study co-author Michael R. Cousineau, director of the division of community health in the Department of Family Medicine.

“In cases where consumers felt their share of medical expenses was too high, for example, the counselor might review the situation and determine that coverage was correct according to the plan’s rules,” he added.

“The problem may not have been resolved, but the consumer was assured that the share of cost was correct. Counselors also may provide referrals.”

Interestingly, while about half of consumers interviewed (51 percent) were uninsured at the time of their first call to a health consumer center, only 31 percent were uninsured when they were contacted a month later.

“This suggests that the HCA played a role in helping consumers obtain coverage,” Nascimento said.

Counties covered by the organizations include San Francisco, San Diego, Fresno, Los Angeles, San Mateo, Sacramento, El Dorado, Placer, Yolo and Orange. For more information on the HCA, go to

Lori Miller Nascimento, Michael R. Cousineau, “An Evaluation of Independent Consumer Assistance Centers on Problem Resolution and User Satisfaction: The Consumer Perspective,” Journal of Community Health. Vol. 30, No. 2, April 2005, Pp. 89-105.

Complexities of health insurance spur growth of independent help agencies

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