May 21, 2010
Secretary Kathleen Sebelius
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
Mr. Jay Angoff, Director
Office of Consumer Information and Oversight
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
to the U.S. Department of Health and Human Services
on “Health Reform Insurance Web Portal Requirements”
File Code DHHS-9997-IFC
Consumers Union commends HHS for drafting a well-designed set of web portal interim rules under a very challenging timeframe.
The web portal envisioned by the Affordable Care Act serves two important functions: easing consumer shopping by arraying current health insurance options “side-by-side,” and providing a testing platform that will inform the exchanges that will come online in 2014. If successful, the web portal’s design, and later the exchanges, will allow consumers to identify high-quality health plans that meet their financial and medical needs. To that end, HHS should invest in consumer testing, explore a variety of alternate web designs, and make an aggressive commitment to marketplace changes that allow consumers to meaningfully compare their health insurance options. These investments will then arm States with the information they need to design effective exchanges.
In general, we find the interim rules to be complete and consumer-friendly. The comments that we have relate to the following issues:
- Consumer Testing Of Portal And Feedback Mechanisms
- Helping Consumers Identify Affordable Choices
- Giving Consumers Meaningful Insurance Choices
- Consumer Protections
- Proposed Requirements For Website Vendor
- Miscellaneous items
Note that our comments mainly address the use of the web portal by consumers purchasing non-group coverage, although the vast majority of comments could also apply to small businesses trying to find coverage through the web portal.
I. Consumer Testing Of Portal And Feedback Mechanisms
We applaud the intention of HHS to engage in careful consumer testing to identify the best methods of achieving the goals for the web portal. 
However, the rule contains just a single reference to this issue. We strongly recommend that the HHS add language to the proposed rule, detailing their commitment to this important consumer benefit.
Comparing health insurance options can entail considering a large amount of complex information. It will be extremely challenging to make this information manageable for consumers. Consumer preferences vary widely and best practices are still evolving with respect to the display of this type of comparative information. We suggest the following detail be added to the rule:
- HHS will conduct immediate research to determine consumer needs and preferences. Existing, but limited, research in this area indicates the information most desired by consumers is 1) whether or not a given provider participates in the plan; 2) potential out-of-pocket costs under common medical scenarios; and 3) their premium cost.  Consumers also want a summary measure, developed by a trusted source, that quickly tells them whether or not this is a “good” plan. However, given the limited research in this area, we recommend HHS immediately convene focus groups to develop a more nuanced picture of the health plan information and layout styles consumers find most helpful. This testing should be unbiased and account for the preferences of a wide variety of consumers, including those with low literacy or low English language proficiency, as required by the law. This research should be used to inform the October release of the website and ongoing improvements after that.
- HHS will iteratively test web portal prototypes using focus groups, pretesting, and diagnostic usability testing. Again, this testing should be unbiased and account for the preferences of a wide variety of consumers, including those with low literacy or low English language proficiency. This testing will be particularly important for the October revisions.
- HHS will identify a variety of consumer feedback mechanisms so that the usefulness of the web portal can be assessed and improved over time. HHS may want to consider leveraging approaches like those used by Yelp or Amazon, where consumers share their own feedback among themselves, to see how well consumers are being served and which types of information are of greatest interest to consumers. This should not preclude well-designed surveys or other approaches, but may provide a useful complement to more rigorous methods and appreciated by consumers.
- Consumer testing must extend to those who either didn’t use the portal or were unable to complete their transactions. We recommend a random survey of insurance purchasers (small group and non-group separately), including those who might not have used the portal, to test general awareness of the portal and how its use compares with other methods of purchasing insurance. This survey should also include consumers who went to the portal but were unable or chose not to complete their insurance purchase. Information gained by this exercise will be of great benefit to states as they begin to set up their exchanges.
- Creation of explicit standards for a web portal that meets consumers’ needs. After consulting with experts and consumer/patient advocates, HHS should establish explicit goals for the website to ensure it meets the needs of consumers.  HHS should identify the metrics that will be used to measure progress towards those goals and publicly report these measures on a regular basis.
II. Helping Consumers Identify Affordable Choices
As the rule notes, the Affordable Care Act clearly states that the goal of the web portal is to help consumers and small businesses identify affordable health insurance options.
Understandably, the web portal cannot lower the cost of coverage by itself, unless it is through the mechanism of improved competition. However, we believe there are six areas where HHS can improve upon the current rule to better help consumers find affordable choices:
- As part of the July website release, provide focus-group-tested, educational content to help consumers understand and compare the “true total cost” of coverage, as they go offsite to pursue quotes for the listed insurance carriers. This educational outreach will help consumers understand the twin concepts of premium cost and point-of-service cost-sharing, and explain why consumers must add these two costs together to understand the total cost of their coverage. We recognize that point-of-service cost-sharing cannot be predicted with certainty, and we applaud the use of medical scenarios (starting in 2011) to help consumers understand this difficult-to-predict cost. The consumer testing recommended above should be designed to shed light on the best approaches to this important topic.
- As part of the October website revisions, provide consumers with the “true total cost” of coverage. The website design should make this total cost concept explicit. In other words, the display of premium costs should always be partnered with some indication of point-of-service out-of-pocket costs.
- Explore greater benefits standardization. The tremendous variety of health plan designs makes it extremely difficult for consumers to compare their out-of-pocket costs under various options. We recommend two activities for HHS: (1) through demonstrations, study the consumer benefits of greater benefits standardization , over and above that which will take place in the exchanges starting in 2014 and (2) establish uniform plan designs that insurers could voluntarily offer, enabling consumers to really compare health plans “apples to apples.”
- Make a long-term commitment to providing additional price transparency for physician services, hospital services, lab test, etc. Many consumers are likely to purchase high-deductible health plans, leading them to pay the full-cost for some of their medical services. Consumers will need help in identifying the “prices” they are expected to pay.
- Enhance competition. As the Secretary notes, the web portal has the potential to empower consumers and promote market competition, possibly putting downward pressure on prices. For this goal to be realized, not only do the insurer and provider markets need to have sufficient competitors but consumers must be able to meaningfully choose among their options. The criteria that will provide meaningful choice are discussed in the next section.
III. Giving Consumers Meaningful Insurance Choices
A large body of research finds that too many choices often paralyzes consumer decision-making. When choices are overwhelming, decision-making becomes stressful for consumers. To reduce this stress, people take “cognitive short-cuts.” One common short-cut is “sticking with what we know.” In the world of health insurance, this may mean a consumer sticks with the plan or policy he or she already has, or the one that is widely advertised, even if it doesn’t cover needed care or better, more affordable options are available. Consumers are also prone to dismiss information they don’t understand.  As a result, people often don’t use the insurance company information available. Instead they turn to family, colleagues, and friends to find short cuts through the health plan selection process.
We commend HHS for incorporating a wide variety of plan performance measures starting in 2011. However, it will be important that plan information be displayed artfully, with the initial screens having an appealing and uncluttered look. This will require:
Easy-to-understand mechanisms for limiting the plans displayed. We anticipate that most consumers will have a lot of health plan choices in their area. We support the interactive functionality discussed in the rule and propose an enhancement to the provider network dimension below.
Provider network as a limiting dimension. Consumers are very interested in whether or not their provider participates in a given plan and the overall strength of the provider network. We recommend HHS enhance the ability to filter plans by provider network by including two new features: ability to view only plans where their own provider is in the network, and a summary measure that identifies the overall strength of the network in a manner relevant to consumers. The latter measure could be derived from strengthened standards for network adequacy, as called for in other areas of the Affordable Care Act. In light of the fact that providers drop in and out of plan networks, a disclaimer should be issued that recommends the consumer confirm plan participation with their provider. This sort of “churn” could also feed into the summary measure of network adequacy. HHS may want to establish a standard for currency, that is, a timeframe within which each health plan has to provide provider network updates to HHS. (Note: provider network adequacy did not appear on the list of plan performance measures. Consumers Union strongly urges the addition of this measure).
We do not recommend an alphabetic display as discussed in the rule. Other sorting mechanisms such as price and plan quality would help consumers make better decisions, when they become available in October. We recognize that alphabetic sorting might help consumers find a particular plan that they are familiar with, but HHS should avoid making this the default sort method.
Exploring greater benefits standardization, as described above, will also make it easier for consumers to navigate the website and compare their choices.
Links to Other Websites. Many states and private vendors already have websites that either display comparative health insurance information or consumer educational materials. The interim rule makes multiple references to HHS’s intention to link to this content. As good as this content may be, excessive reliance on links to other websites could undermine the usability of the new web portal. If consumers are to make true side-by-side comparisons, their market choices need to be all in one place. As such, we recommend augmenting the information available on the web portal with links to other sites, but ensuring the basic comparative information is also available on the web portal. Links off the portal should be prominently labeled so that they minimize consumer confusion.
Public Reporting of Data Collected Under Data Submission Mandate. The average consumer may not peruse all the insurer information being collected under the proposed Data Submission Mandate. Nonetheless, it will be important for all this information to be publicly available, downloadable and linked to a unique health plan identifier, so that consumer advocates and other third party organizations can perform research and plan comparisons that will help consumers navigate their insurance options.
Facilitate the development of third-party health plan summary measures. Due to the volume of information they need to consider when selecting a health plan, consumers typically have a preference for summary measures, developed by a trusted source, which quickly tells them whether or not this is a “good” health plan. We recognize the complexity and subjectivity inherent in this task. Subject to safeguards, HHS must facilitate third party vendor efforts to provide consumers with this resource. Early efforts in this area will help inform the 2014 exchanges, tasked with rating health plans. Depending on how broadly HHS defines their forthcoming quality measures, these summary measures may fit under that activity. Any summary measure provided to consumers should be directly linked to the underlying plan performance measures and the methodology made readily available.
IV. Consumer Protections
Consumers are bombarded with information and they could easily overlook the opportunity provided by the web portal to compare their insurance choices. We recommend a required disclosure on all consumer-facing marketing materials and face-to-face meetings with brokers, producers and agents. This disclosure would notify consumers of their ability to compare the policy they are considering buying with other choices on the web portal.
Consumers must be able to find health plans they learn about from other sources on the HHS web portal, in order to assess claims made by outside parties. Ideally, a unique health plan id–assigned to all plans and listed on the disclosure–would allow them to quickly and easily find their health plan on the portal and see what other choices are available to them.
Links to offsite materials. HHS should establish a standard for the types of material that are linked to from the HHS website. In particular, we encourage HHS to avoid sites where leading or recommended plan choices are due to plan sponsorship, as opposed to objective standards designed with consumers’ interests in mind.
V. Proposed Requirements For Website Vendor
The selection of a website vendor, tasked with helping HHS with the Oct 2010 health insurance pricing engine, will profoundly impact the ability of consumers to select health plans using the web portal. Consumers Union recommends that the Request for Proposal (RFP) include the following requirements:
- Insurance content must be readily understandable, meaningful and helpful to consumers, as determined by focus group testing and usability studies.
- Web design must be visually appealing
- Ability to increase text size for easier reading.
- Provide definitions via text “roll-overs.”
- Materials will be available in a variety of languages
- Once provided by insurers, insurance plan data must be updated quickly online, and the updated date readily available to website visitors.
Moreover, we recommend the vendor is not-for-profit, or at least has no conflicts of interest vis-à-vis the insurance plans they are profiling.
The vendor’s contract should include specifically incorporate the website metrics discussed in the first section of our comments. In other words, the task for the vendor is not just to build a website but to provide a site that is proven to meet the specific goals established by HHS. Vendor payment should be tied to progress towards those goals, and the supporting metrics should be publicly reported, providing public oversight of this use of tax payer dollars.
Several states and localities have locally-funded non-group and small group coverage options with no connection to the Medicaid or CHIP programs (for example, AdultBasic in Pennsylvania). We recommend that the HHS web portal include these coverage options as they are likely to be more affordable than private coverage. For funding reasons, some programs have currently frozen enrollment and HHS would want to clearly note this on the portal or omit until enrollment reopens.
The interim rule makes no mention of languages that will be used to display the information. We recommend HHS clarify that health insurance information viewed through the web portal will be available in languages other than English.
Even the best web portal design is likely to be overwhelming for some consumers, given the complex nature of health insurance products. We recommend that HHS arrange for live assistance from enrollment counselors. These counselors should also serve as part of HHS’s feedback loop that will be used to improve the portal overtime. In addition, many consumers lack computer access or computer literacy. Enrollment counselors or other mechanisms should be identified to provide these consumers with side-by-side comparisons of their insurance options.
The move towards standard terms and definitions, as called for in the Affordable Care Act, is a great benefit for consumers. As you build out the web portal, we recommend that, to the extent possible under the enabling laws, these terms also be used on materials for Medicaid and CHIP programs. Many consumers have incomes which fluctuate, causing them to move between private and public coverage options.
As the rules notes, consumers will have to leave the web portal to get a quote from health insurers in states that allow medical underwriting. The Affordable Care Act calls for the development of a uniform enrollment form. HHS should explore allowing consumers to save a completed form on the website, subject to strict privacy protections and safeguards, allowing consumers to more easily obtain quotes from multiple insurers.
Promotion and dissemination. The interim rule is silent on the issue of promoting the new web portal to consumers. We recommend a nuanced approach to this task, perhaps performing some test promotions in selected localities before a more general promotion. It will be important to manage consumer expectations, especially regarding their ability to find an “affordable” insurance option. For many consumers, “affordable” may be associated with premiums that are not realistic in the private market. If consumers develop an initial impression that is unfavorable, it may be hard to lure them back, despite planned future improvements.  Similarly, referrals to public programs must be sensitively done, in order to avoid creating stigma that is sometimes associated with public coverage.
Consumers Union is grateful for the opportunity to comment on the proposed Health Reform Insurance Web Portal Requirements.
Director, Health Reform
 Consumers Union, Simplifying Health Insurance Choices, June 2009. This brief can be accessed: http://www.consumersunion.org/pdf/SimplifyingHealthInsuranceChoices-CU-FINAL-June2009.pdf
 These metrics could include statistics that can be gathered by implicitly by observing website visitor behavior (where people click in the site), complemented by more meaningful metrics that gathered explicitly. Examples of the latter include, a one question pop-up survey “Did you find what you were looking for?,” a small link on every page “contact us with suggestions on how to improve/identify non-working links”, as well as smaller scale usability studies.
 The Massachusetts Connector (exchange) Board has found that greater benefits standardization will likely help consumers shop in their exchange. See, for example, the minutes from the April 9, 2009 Board of the Commonwealth Health Insurance Connector Authority monthly meeting: https://www.mahealthconnector.org/portal/site/connector/menuitem.be34eb79b090a7635734db47e6468a0c/?fiShown=default HHS may want to fund a detailed study of this “natural experiment.”
 Lynn Quincy et al. Designing Subsidized Health Coverage Programs to Attract Enrollment: A Review of the Literature and a Synthesis of Stakeholder Views. Mathematical Policy Research, December 2008. May be accessed: http://www.mathematica-mpr.com/publications/PDFs/health/subsidizedcoverage08.pdf