PublicPrivate Partnership for Health Insurance Coverage - by pharmphresh25

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									  Public/Private Partnership for
  Health Insurance Coverage -

An Evaluation of the West Virginia
      Small Business Plan




         Johnna S. Beane, B.A.
         Gail R. Bellamy, Ph.D.




          ROBERT C. BYRD H EALTH SCIENCES CENTER
          INSTITUTE FOR H EALTH POLICY RESEARCH




               January 2008
                      Table of Contents

Summary                                                            3
Introduction                                                       5
Enrollment Information                                             7
Evaluation Components
  Section 1 - Insurance Agent Focus Groups                         11
  Section 2 - Business Owner Mailed Survey                         19
  Section 3 - Member Mailed Survey                                 25
  Section 4 - Business Owner Telephone Panels                      33
  Section 5 - Member Telephone Panels                              37
  Section 6 - Provider Mailed Survey                               41
  Section 7 - Analysis of Claims Data                              45
Other Issues                                                       51
Conclusions/Observations                                           53
Appendices                                                         55

  Appendix A – MSBCBS Benefit Highlights Summary Description
  Appendix B – Insurance Agent Focus Groups Discussion Guide & Summaries
  Appendix C – Business Owner Mailed Survey & Cover Letter
  Appendix D – Comments Business Owner Mailed Survey
  Appendix E – Member Mailed Survey & Cover Letter
  Appendix F – Comments Member Mailed Survey
  Appendix G – Business Owner Telephone Panel Questionnaire
  Appendix H – Comments Business Owner Telephone Panel
  Appendix I – Member Telephone Panel Questionnaire
  Appendix J – Comments Member Telephone Panel
  Appendix K – Provider Mailed Survey & Cover Letter




                                                                        1
2
                                     Summary
West Virginia, like the entire nation, faces growing numbers of medically uninsured. In
2004, West Virginia created the West Virginia Small Business Plan (WVSBP) as a new
employer-sponsored option for uninsured small businesses to help address this issue.
The WVSBP utilizes the commercial insurance market together with the State of West
Virginia’s negotiated provider reimbursement rates to create a public/private health
insurance product.

This report describes the evaluation activities used to assess the WVSBP and the
results of the evaluation effort. The West Virginia University Institute for Health Policy
Research, under contract with the West Virginia Health Care Authority, designed and
implemented the evaluation. Evaluation components included both primary and
secondary data from various sources. Data were collected from business owners who
had purchased the WVSBP, members who had been covered by the plan, insurance
agents who were eligible to sell the WVSBP and providers who had opted out of the
provider network. In addition, enrollment and claims data from the commercial carrier
were analyzed to provide addition information about the impact of the program.

The evaluation revealed the following:
− Communication is a large area of concern. Information gathered from insurance
  agents, providers, members and business owners all indicate a lack of clear
  understanding about the program, particularly the benefit structure. This is causing
  confusion about what services are covered. This may be hindering enrollment and
  negatively impacting utilization.

− The reputation and name of the current carrier of the WVSBP, Mountain State Blue
  Cross Blue Shield, is viewed as positive by purchasers according to both the agents
  and the businesses enrolled and may contribute to initial purchase but also to some
  dissatisfaction based on purchaser expectations.

− Business enrollment has grown steadily – adding approximately 20 businesses each
  month. However, numbers since January 2007 indicate a slowing in rate of growth
  and may indicate that enrollment is leveling off.

− The number of covered lives is modest – approximately 2000 as of October 2007.

− The majority of members are choosing individual coverage. High cost is identified
  by employers, employees and agents as a reason why family members are not
  covered.

− The price of the WVSBP seems to motivate small business owners to offer group
  health insurance to their employees. The plan is covering previously uninsured
  small businesses but not necessarily providing coverage to previously uninsured
  individuals.

                                                                                             3
− In general, business owners involved in the evaluation activities are satisfied with the
  WVSBP. Yet owners say they are concerned about premiums being too high and
  that their employees cannot afford to cover their families/spouses because of the
  premium costs.

− The plan is more affordable than other products in the initial year but premiums
  automatically increase annually which brings the cost back up and mitigates any
  cost savings from the initial year of enrollment. The only way to reduce premiums is
  to increase the deductible or re-apply again both of which are problematic for
  businesses and employees.

− The members involved in the evaluation are generally satisfied with the WVSBP –
  although less so then their employers. Furthermore, they are less satisfied with the
  program’s costs than with the program’s benefits.

− Sources of dissatisfaction or concern mentioned several times by both satisfied and
  dissatisfied members included the $1000 minimum deductible, lack of coverage for
  preventive services without first meeting the annual deductible, and the prescription
  drug benefit e.g., drugs covered and that costs did not apply to the deductible. .

− It was difficult to definitively determine whether pent-up demand was an issue from
  an analysis of claims data. Deductible levels appear to be effecting utilization as
  they are intended to do. However, deductibles may also be effecting member use of
  preventive/wellness and primary care services, a finding suggested by the decrease
  in the percent of claims for primary and preventive services in 2006 compared to
  2005 and supported by survey and telephone interviews with members.

− Agents involved in the evaluation suggested the followed changes be made to make
  the WVSBP better, more desirable:

      Remove the 12 month in-business requirement
      Reduce the 75 percent participation rate
      Review the impact of the 12 month look back,
      Reduce the employer contribution from 50% to 25% that is required on other
      MSBCBS plans
      Make it more affordable – allow greater flexibility in benefits, i.e., more first dollar
      coverage with copays, ability to remove maternity coverage when not needed,
      etc.




                                                                                             4
                                 Introduction
What is the West Virginia Small Business Plan?
The West Virginia Small Business Plan (WVSBP) is a product of a public/private
partnership between the State of West Virginia and commercial insurance carriers. The
WVSBP is intended to cover those uninsured in West Virginia who work for small
employers. Small employers in West Virginia and across the nation are less likely to
provide health insurance coverage for their employees due to the costs involved costs
that continue to escalate. The WVSBP was originally conceived through a Robert Wood
Johnson Foundation State Coverage Initiative Demonstration grant awarded to the
State of West Virginia. Enabling legislation was passed in 2004 (Senate Bill 143)
allowing commercial insurance carriers access to the WV Public Employees Insurance
Agency (PEIA) reimbursement schedule. Premiums are estimated to be between 17-
22% lower as a result of the government negotiated reimbursement rates. In addition,
the WVSBP also requires a higher minimum anticipated loss ratio of 77% compared to
73% for the standard small employer product. Any commercial insurance carrier
licensed in West Virginia is able to participate and assumes all of the risk for the plan
participants. There are no state funds or subsidies provided to operate the plan. To
date, Mountain State Blue Cross Blue Shield (MSBCBS) is the only carrier to ever offer
the WVSBP. The plan carries a minimum $1000 deductible, and is subject to a 15%
annual durational increase at renewal that MSBCBS applies to all groups in the 2 to 9
market. The effective date of coverage for the WVSBP was January 1, 2005. A
summary benefit description for the MSBCBS plan is included as Appendix A.

Businesses are eligible to purchase the WVSBP if they have–
   o between 2 & 50 employees,
   o not provided group health insurance to their employees in the previous 12
      consecutive months,
   o been in business for at least 12 months, and
   o agreed to pay at least 50% of the cost of individual coverage.

In addition, a minimum of 75% of the eligible employees must participate in the plan.


Evaluation Plan
The West Virginia University Institute for Health Policy Research (Institute) was tasked
with designing and implementing an evaluation of the WVSBP. The WVSBP Advisory
Group approved the proposed evaluation plan at a meeting in 2005. The final plan
includes an analysis of enrollment information and claims data provided by Mountain
State Blue Cross Blue Shield, the commercial carrier offering the plan, and the results of
evaluation activities intended to address the bulleted questions:




                                                                                        5
Enrollment Data
   o How many businesses have enrolled in the WVSBP? How many people are
       covered?
   o Is enrollment greater in those areas of the state with high rates of uninsured?

Focus Groups with Insurance Agents Eligible to Sell the WVSBP
   o What do prospective customers like about the plan?
   o What don’t they like about the plan?
   o What would make the plan more attractive to the target population?

Mailed Survey of Businesses and Members that had ever been enrolled in WVSBP
between January 1, 2005 and June 30, 2006
   o Are you still enrolled in the plan? If not, why not?
   o How satisfied are you with the costs of the plan, with the benefits covered?
   o Individuals/Members: Did you have health insurance prior to your employer
      offering the WVSBP?

Telephone Interviews with a Panel of Business Owners and Members who Responded
to mailed survey
   o Are you still enrolled?
   o Has access improved?
   o Has health status improved?
   o Difficulties experienced?

Survey of Providers who have Opted Out of the Network through 2006
   o What is the major reason you dropped out of the program?

Claims Data
   o How soon after enrolling do members begin to use services?
   o What kinds of services do they use?
   o Number, nature, and cost of claims?




                                                                                       6
                       Enrollment Information
Mountain State Blue Cross Blue Shield provided monthly enrollment information on the
number of businesses covered by the WVSBP, the number of businesses who dropped
their coverage and the number of covered lives. This information was provided for the
period starting June 1, 2005 through October 31, 2007. Due to a change in computer
systems at MSBCBS, data for the first five months of the program was no longer
available. Evaluators were able to use another report to estimate the number of new
businesses per month for January through May 2005 however covered lives were not
included in that report and are not reported here.

                                  As depicted in Figure 1, business enrollment has
 As of October 31, 2007, 325      grown almost every month over the program’s first 34
  businesses were covered         months with two exceptions, between June and July
       by the WVSBP               2007 and again between September and October
                                  2007. The largest monthly increase in the number of
businesses purchasing the plan occurred between August 2005 and September 2005
with enrollment increasing by 24 businesses. The WVSBP continued to grow by about
20 businesses each month up through January 2007 when enrollment slowed and
potentially begins to level off.
                                  The WVSBP added over 600 lives between July
    As of October 31, 2007,       2005 and January 2006. The greatest monthly
  1632 lives were covered by      increase occurred between November and
       the WVSBP health           December 2005 when 114 new people enrolled in the
            insurance             plan. Most recently, between September and
                                  October 2007, the number of covered lives dropped
by 17. The monthly number of covered lives is shown in Figure 2.

MSBCBS also provided a list of all active and cancelled groups as of November 2007.
These data indicate that 53 businesses had their WVSBP insurance cancelled at some
point within the last 28 months. The reasons for cancellation were, from highest to
lowest, nonpayment (n=23), request termination without a reason (n=14), switch to
another commercial carrier (n=8), no members left in the group (n=4), per request of
group due primarily to rates (n=2) and a few other reasons.

The data for the active businesses also indicated their West Virginia county location.
Not surprisingly, the counties with the larger populations have more enrolled
businesses. It is interesting, however, that Mercer and Randolph counties, both in rural
areas of the state, have double-digit enrollment as of November 2007. The map of
West Virginia (Figure 3) shows the number of businesses enrolled in the WVSBP by
county and the regional rate of uninsured 19-64 year olds according to the WV
Healthcare Survey, 2007. Counties outlined in red indicate double-digit business
enrollment and the shaded areas depict the uninsured regions. The areas with greatest
penetration of businesses are the regions with the highest and lowest percent of
uninsured adults aged 19-64.


                                                                                       7
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                                                                                                                                                                                                              325 325
                           Figure 2: Number of Covered Lives Per Month
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                                                                                                                         9
10
                       Evaluation Components
Section 1
Insurance Agent Focus Groups

Methodology
In October 2006, invitation letters were mailed to agents who were licensed with
MSBCBS and were thus eligible to sell the WVSBP. The invitation was sent to agents
who had sold at least one contract and to a sample of agents who had not sold any
contracts. MSBCBS provided their mailing list for licensed agents.

Agents were offered a $100 incentive to participate in one of five focus groups
scheduled in different areas of the state. The cover letter provided a toll-free contact
number to sign up for a session. Efforts were made to assure that each group included
agents that had sold at least one WVSBP contract and those that had not sold any.

Results
There were a total of 46 participants. Twenty-eight (60.9%) had sold at least 1 contract
and 18 (39.1%) had never sold the WVSBP. The number of years working as an
insurance agent ranged from 1.5 years to 49 years. The median number of years was
18; the mean was 17.9 years. Participants were predominantly male - 35 male agents
and 11 female agents attended the sessions.

There were no major differences in responses based on geography. Some differences
in perspective emerged based on years as an agent and philosophy regarding
insurance.

Themes
     The plan is not affordable for minimum wage employees.
     Small businesses that have been doing the right thing and are on the verge of
     having to discontinue health insurance coverage due to the increasing costs of
     health insurance aren’t eligible for the WVSBP. We should be trying to prevent
     people from becoming uninsured in addition to covering those currently
     uninsured.
     As long as the WVSBP product is carried, agents will pitch it whether or not there
     is external marketing.
     To make the product more desirable and easier to sell, make it more affordable;
     increase flexibility within the product by providing more benefit choices; make it
     Health Savings Account (HSA) compatible.
     If you want agents to promote the plan raise the commission rates; a 50%
     reduction is asking too much.
     The WVSBP is a loss leader, something that gets people into the door or starts
     conversations.

The majority of participating agents include the WVSBP in their portfolio of plans but few
actively promote the plan, i.e., advertise, make cold calls. The reasons given for not
actively promoting include not having an effective way to market the product to qualified

                                                                                       11
businesses; disagreeing with some of the plan’s restrictions, e.g., needing to be in
business for the preceding 12 months; the sales commission being low; the difficulties
dealing with frustrated employers wanting to change from their current coverage; the
plan not being as beneficial as anticipated; the plan being too expensive despite the 22
percent discount for employers, especially for those that pay minimum wage.

      [actively marketed the WVSBP] “Not in the last six months…in the beginning,
      definitely I fielded a lot of calls. Seemed like it kind of fizzled because the plan
      wasn’t as beneficial as I think the consumer thought it might be, and so, I really
      haven’t fielded that many calls, therefore, I haven’t been promoting it either.”
      (Charleston participant)

      “I’ve always ran into the situation where if the people couldn’t get their regular
      insurance, they try to get this, and their health problems were so bad, the
      premium was so high, they still couldn’t afford it.” (Beckley participant)

      “…They usually have some form of coverage already and I think there’s a
      common misconception among the clients, they just think any business can step
      up to the plate and buy this policy…when we promote, we either sell the product
      or run into that problem.” (Flatwoods participant)

When asked how they ‘promote” the WVSBP, a few agents do make cold calls, many
offer the product to any of their existing clients who are eligible, others respond to
referrals or answer questions about the plan when asked. Some have used billboards,
flyers, and letters to alert people to the WVSBP.

      “I target commercial customers, and most of them either have had them
      [insurance] for a year or more, or they just can’t afford it.” (Beckley participant)

      “I don’t actively seek a whole new business, especially in that market
      [uninsured].” (Charleston participant)

      “We haven’t really promoted it with the advertising or anything, but we definitely
      bring it up and present it to people. When we request quotes, we always ask that
      they quote that. If we think it’s a small group, you know, we have it ready to
      show it to them, and we’ll present it side-by-side with the other quotes and it
      usually gets their interest.” (Flatwoods participant)

      “We’ve developed a letter actually to a lot of our clients that aren’t or do not
      currently have health insurance…so we generated a small business letter to kind
      of grab people’s attention, which has worked great.” (Flatwoods participant)

      “I would think it would be an extremely viable thing to promote to new businesses
      coming into the state, if we had a database where you could actually go to
      research to see what businesses have been started within the past say, 12
      months…” (Morgantown participant)



                                                                                             12
Agents primarily pitch the plan to eligible small businesses employing 10 or fewer
employees, mostly mom-and-pop enterprises.

       “Normally the ones that we find that are successful are the family-owned
      businesses, where the husband and wife own it and maybe one or two or three
      employees, where they’ve looked into getting insurance or there may be new
      business in the past two or three years that just haven’t gotten health insurance
      policy and they’re eligible now and now they can afford to do it.” (Flatwoods
      participant)

      “Small group market, I think that’s just…one reason why is because larger
      groups already provide coverage, but smaller groups are the ones that typically
      haven’t had coverage, so I think it fits the small group market better.” Beckley
      participant)

Agents won’t promote the product when the employer is ineligible (required 12 months
in business, 12 month look-back, 50 percent employer contribution), and when
employees can’t afford it - when employees are minimum wage. The discounted
commission is definitely a factor in whether agents promote the plan.

       “If I wouldn’t promote it, it would have to be just knowing that the group was so
      small that they couldn’t afford it or that they could get better coverage through
      something else or just individually.” (Flatwoods participant)

      “Well, you can’t promote it if they’re not eligible for it.” (Flatwoods participant)

      “…he says he can tell by a person’s car, house, etc., how much money they
      make and see who might not be able to buy insurance.” (Martinsburg participant)

      “…if I’m only getting $14 a month and I have to go out and service these people
      50 miles away, it seems like I’m spending more than what – I’ve got more going
      out than I’ve got coming in, so I’m really not going to promote this product that
      much, unless I’ve got a real big group, maybe right next to us or something like
      that, then it might be beneficial.” (Morgantown participant)

It is not rare for a potential plan customer to walk away without having signed up for the
WVSBP particularly given the unanticipated expense associated with the plan. It is also
not rare for an eligible customer to sign-up for another MSBCBS plan that only requires
them to contribute 25% of the premium for their employees, or to purchase individual
plans when one of their employees has serious and costly health conditions.

      “I’ve had people walk away. One in mind, a doctor’s office, three or four people,
      and they haven’t had as a group, met all the eligibility but the premium was high.
      The Doc said ‘no can do.’” (Flatwoods participant)




                                                                                             13
      “When we quoted the SBP we also presented the Super Blue Plus 2000 and
      2004, and they came as a Tier 1 and so they went with the better coverage, the
      lower deductible.” (Flatwoods participant)

      “If I was selling a Blue Cross plan I would say 90 percent of the time, maybe 95
      percent of time, I sell another Blue Cross plan and then, if it’s neither of those
      plans, then probably 75 percent of the time they’ll walk away or buy an HMO.”
      (Beckley participant)

      “I’d say maybe about 40 percent of the time we’re able to do business under the
      WVSBP maybe another 50 percent were put somewhere else, maybe another 10
      percent just walk away because, you know, they really just can’t afford it.
      They’re small business and I could say the majority of the groups that I have are
      2 to 10, I mean, they’re small business.” (Morgantown participant)

According to the agents, prospective purchasers like the MSBCBS network. The
WVSBP also includes PEIA providers who may or may not have been a member of the
MSBCBS network. What prospective purchasers dislike includes the high deductible,
the high premiums, the lack of a co-pay option, and the limited drug benefit. Agents
having experience with clients at renewal time note that the automatic increase in
premium that occurs is a serious problem for WVSBP customers.

      “They really think it is a much richer plan than what it is and I think that’s where
      they get disappointed and kind of get turned off on it right away.” (Morgantown
      participant)

      “…their renewal comes, and it’s Blue Cross, so you get 30 percent renewal
      increases, have to go through requalification and they’re like, I never used the
      plan, you know, so they’re not feeling very rewarded.” (Morgantown participant)

      “I think a lot of it is the name of Blue Cross that sells a lot of policies, just by the
      name itself.” (Flatwoods participant)

      “As far as dislikes, it’s just what those folks said; it’s the perceived value of what
      they’re actually getting for their money. Some of them don’t think it’s a value
      because there’s no co-pay on there, and that they’ve got that high deductible.”
      (Charleston participant)

Not many customers mention WVSBP marketing efforts when they come to an agent for
insurance. Those that do mention marketing most often have seen the TV
advertisement with Governor Manchin and some have seen a billboard. Agents in rural
areas report that none of the marketing reaches their prospective client base.

The agents themselves have been aware of the majority of marketing efforts, either
directly (they saw or heard radio, TV, billboard, attended a WVU game) or indirectly
(marketing was discussed at the WVSBP training in 2004). Whether or not the
marketing has value gets mixed reviews. Some feel the efforts to market the plan have

                                                                                             14
been very valuable in raising awareness and bringing people to their offices for
insurance. Others feel that it is money wasted. A few had suggestions for how
marketing might be improved.

      “I think the advertising has made people more aware that there‘s options out
      there for them.” (Flatwoods participant)

      “I’d say no, that external marketing really hasn’t helped in our area.” (Flatwoods
      participant)

      “I think it’s been productive, but it could be more targeted…if you could look at
      your demographics on where these people that qualify for that, if you have that
      information, and if you could target those particular areas with those stations.”
      (Beckley participant)

      “You know, are we getting the bang for the buck? I kind of question that.
      Perhaps going to an accessible database, you know, where you could find
      companies that were anywhere from 11 to 13 months in business and you could
      contact them and send a flyer and then do a follow-up call to see if there’s
      interest. Maybe that would be more productive.” (Morgantown participant)

      “Along with the advertising…have them call an 800 number in the state insurance
      department if they want inquire about it and let the state insurance department
      contact an agent in that area…because the true idea behind this is having all our
      citizens insured. Right?” (Morgantown participant)

      “..the most productive has always been mailers, has been a good percentage.
      What’s been done with the money, it’s been used on radio and TV, now the TV
      ad was good.” (Beckley participant)

The end of external marketing efforts, supported by the RWJF grant, is seen either as a
negative or as having no real impact at all on an agent’s business. Those that see the
loss negatively feel that the customer base will think the WVSBP no longer exists; that
MSBCBS will decide the plan does not have value and discontinue it. By-and-large,
however, agents do not see there being any major changes once the marketing ends.
The WVSBP is part of their insurance portfolio.

      “Once the marketing stops, then does the public think that the program has
      stopped, that there’s no longer eligibility and can I not get this because I’m
      carrying a salary?” (Beckley participant)

      “Personally, the value to me of the marketing has been to give me more of an
      opportunity to engage people in a meaningful discussion and possibly cross sell
      them some things that they do need, that they have an interest in.” (Charleston
      participant)




                                                                                          15
       “Now the reality check is 99 percent of all the products that I have don’t do
       marketing anyway, other than just the plan brochures, maybe a website,
       something like that.” (Charleston participant)

       “I think as long as you, the agent, are trying to promote this, I don’t really see the
       outcome marketing. I think you, as the agent, are going to make the big
       difference.” (Beckley participant)

       “I don’t think it will have a large effect because the seed has been planted and
       people know about it, so I would offer it to any client as an alternative or as a
       prospective client first line because of the cost.” (Beckley participant)

Agents were almost unanimous with respect to changes to the WVSBP to make it
better, more desirable:
       Remove the requirement related to being in business 12 months
       Reduce the 75 percent participation rate,
       Review the impact of the 12 month look back,
       Reduce the employer contribution for the plan from 50% to the 25% required on
       other MSBCBS plans,
       Make it more affordable

There was also interest in allowing for greater flexibility in the plan around benefits. In
particular, allowing for options that would be compatible with a Health Savings Account
and providing more first dollar coverage with co-pays for office visits or annual physicals
without having to first meet the deductible.

       “I bought the plan with the 22 percent discount in mind. My first renewal goes up
       30.9 percent….So I think there should be some guarantee that there be limited
       inflation for the premium, to help retention, because you know, I want to keep my
       employees covered.” (Beckley participant)

       “..let the particular product fill a niche, rather than to try to answer a social
       problem about not being totally insured. I would like to let it help prevent folks
       from becoming uninsured, not just helping those after they’ve been uninsured for
       a year….Let it compete with the rest of them.” (Charleston participant)

       “I’d like to see two $25 co-pays per person. So if you have a family, they’re
       allowed two visits per person per year. And also to put their commissions back
       up… if it’s a 22 percent reduction in price, I don’t see why you’d make it 50
       percent reduction in commissions, maybe a 22 percent reduction in
       commissions.” (Morgantown participant)

       “Bring the maximum down from a million, you know, bring it down lower and give
       the employees what they want, but give them the option of buying a higher
       …[catastrophic on top of that]” (Beckley participant)



                                                                                           16
       “Just that they make sure that they pay attention to that preexisting condition.
       That might be what’s important that this WVSBP is not subject to---they don’t
       have to worry about preexisting conditions. They’re not going to cover that
       because there’s no critical coverage. But other plans, that we’re taking over, that
       would price against it, we are given credit for preexisting and that’s got to be a
       huge price differential there…. No, not change it; just take it into consideration in
       the pricing of the product.” (Beckley participant)

Discussion
Benefits
What is covered by the WVSBP was not understood consistently among participating
agents. Specifically, there appeared to be some confusion on the benefit structure of
the plan. It is a reasonable assumption that most business owners and their employees
use the information about products provided by their insurance agent in their decision
making process. The impact of potential misinformation on WVSBP sales could be
either positive or negative.

Insurance agents feel that the benefits covered under the WVSBP should be more
flexible than is currently the case. Flexibility in benefit structure could make the WVSBP
compatible with Health Savings Accounts which they feel would attract more businesses
to the product. They also indicate that customers are telling them they want more value
for their money and more first dollar coverage with co-payments for services without
having to first meet the annual deductible. Suggestions made were to allow carve-outs
of certain benefits or possibly reduce the benefit maximum in order to further lower the
premiums for businesses, especially lower wage employers.

Eligibility
Agents agreed that changes to the eligibility requirements would make the WVSBP
more desirable to businesses. One suggestion that arose in all of the sessions was to
change the requirement for a business being in existence for 12 months. The agents
felt that a shorter time frame would still protect the current market place. They did not
feel that a company would drop insurance coverage and/or change their business name
just to obtain this product. The agents felt that other safeguards less likely to turn away
potential business could be used.

One unique suggestion was to allow this product to work in concert with the AccessWV
program for individuals that have major health problems. The concept would be to allow
an employee with health problems to purchase an individual plan through the high-risk
pool and remove this employee from the 75% eligible employee participation
requirement. Currently, persons who have individual insurance plans are considered
eligible and must be used when calculating the 75%.

Marketing
Agents who have been in the business for a longer period of time are less likely to
actively market the plan outside their current customer base; they won’t be actively
advertising, making cold calls or asking for referrals. Agents earlier in their careers,
particularly those that service a large geographic area, are put-off by the very low

                                                                                           17
commission rate. These agents are less likely to recognize the value of the WVSBP as
a tool to get them in the door for possible future business. In general, they do not see a
negative impact when the marketing grant support ends, however they are concerned
that without any marketing people will think that the WVSBP is no longer an option.
They do not plan to change the way they conduct their business when the marketing
support ends.

A detailing of each session along with the discussion guide used to lead the groups can
be found in Appendix B.




                                                                                        18
Section 2
Business Owner Mailed Survey
Methodology
In January 2007 a self-administered survey was mailed to 257 small business owners
who had enrolled in the WVSBP at any time between January 1, 2005 and June 30,
2006. Each survey was accompanied with a cover letter from the project director and a
self-addressed and stamped return envelope. The survey was approved by the West
Virginia University Office of Research Compliance (a copy of materials is provided in
Appendix C).

The Dillman Method for Survey Research was used to increase response rate [Dillman,
D., Mail and telephone surveys: The total design method. 1978, New York: Wiley]. This
three step process included: (1) mailing a cover letter signed by the evaluation project
director, a self addressed stamped reply envelope and the survey instrument to each
recipient; (2) approximately 14 business days later mailing a reminder post-card to all
recipients encouraging their response; and (3) approximately 14 business days after the
second mailing of the post-card (approximately 4 weeks after the initial mailing), mailing
the entire packet including cover letter, self-addressed stamped envelope and survey
instrument again to all non-respondents.

Mountain State Blue Cross Blue Shield handled the mailings using addresses they had
on file. The self-addressed response envelopes were returned to the West Virginia
Health Care Authority using their business reply mail permit via the United States Postal
Service and subsequently hand-delivered to the Institute for Health Policy Research
offices.

Results
Demographics of Responding Businesses
Completed surveys were received from 116 of the 257 businesses surveyed, a 45%
response rate.

Business owners were asked how many full and part time employees were currently
working for them. The median number of employees was 5 and the average business
size was 7.1 employees. Full-time employees represented 74.6% of their workforce with
part-time employees making up the difference (25.4%).

Owners were asked to indicate the nature of their business. They were given a list of
20 industry categories with an option to specify “other” if the listed categories did not fit
their business. The category with the largest number of businesses was construction
(16.4%; n=19) followed by healthcare (14.7%; n=17) and sales (10.3%; n=12). All other
categories had fewer than 10 respondents.

Twenty-eight respondents (24.1%) marked “other” and provided a comment to describe
their business. A full listing of answers for this question is included in Appendix D.



                                                                                          19
Businesses were asked how they first learned about the WVSBP. Again a list was
provided with space to specify another answer if necessary. The majority remarked
they heard about it from insurance brokers/agents (48.7%; n=55). Television was the
second highest source of knowledge (15.0%; n=17). Radio and newspapers tied for
third with 10 people each (8.9%) stating that each of these was their first source of
information about the WVSBP.

The majority of respondents (92%; n=107) were still enrolled at time of survey.
Seventy–two percent (n=78) of respondents enrolled in the WVSBP during 2005; 27%
(n=30) enrolled during 2006. Cost was a factor in disenrollment. Reasons for
disenrollment are shown in Table 1.

Table 1:
    Number of
                 Reason Given for No longer being enrolled in WVSBP
   Businesses
         1    Business was not as profitable and I couldn’t afford it any longer
         3    Cost of Premiums
         1    Cost of Premiums AND Not happy with benefits
          4        Other

Comments provided by those who marked “other” ranged from “Brickstreet priced us out
of providing insurance” to “wife attained insurance at her job”. A listing of all verbatim
comments from the survey, including this question, can be found in Appendix D.

Businesses were asked what factors influenced their decision to enroll in the WVSBP.
Owners were allowed to mark more than one factor that influenced their decision to
purchase the plan. The responses were:
   − 57.4% Benefits are important to retain workers
   − 51.3% Cost was right
   − 47.8% It is the right thing to do.
   − 25.2% Important to attract workers
   − <10% Workers demand benefits; Competitors offer so I need to; or other reasons

The majority of respondents       Figure 4: Has Business Offered Insurance Before WVSBP? (n=116)
- 78.5% - (n=91) had never
offered health insurance to their
employees (Figure 4). For those who                                   Yes
had previously offered health insurance,                             21.5%
(n=25) the length of time since offering
the benefit was spread pretty evenly
between 1-2 years to more than 5
years.                                                      No
                                                         78.5%
Most of the reasons given for
discontinuing the health insurance


                                                                                        20
benefit were related to cost. 65.2% said they stopped offering health insurance
because of the cost of premiums.

Respondents indicated that the top three reasons their employees declined WVSBP
coverage were:
   1) They had health insurance elsewhere – 70.2%
   2) Premiums too high – 20.9%
   3) Coinsurance too high – 11.9%
                                          Figure 5: Business Owner Satisfaction with WVSBP (n=112)
Business owners were asked how                                     47.3%
satisfied they were with the WVSBP.
Satisfied respondents (those checking
satisfied or very satisfied) outnumbered
the dissatisfied (dissatisfied or very
dissatisfied) by more than two to one
(72.3% satisfied versus 27.7%                       25.0%                     25.0%
dissatisfied) - Figure 5.


The reasons given for dissatisfaction
with the plan were “premiums were too                                                  2.7%
high” (78.1%; n=25); “co-pays or
deductibles too high” 53.1% (n=17).          Very Satisfied Satisfied Dissatisfied    Very
Twelve respondents indicated both                                                  Dissatisfied

premiums and co-pays or deductibles as reasons they are dissatisfied with the WVSBP.
All responses for this question are reflected in Figure 6.

          Figure 6: Reasons for Dissatisfaction with WVSBP - Business Owner (n=32)


                       78.1%



                                  53.1%




                                               15.6%                  15.6%
                                                            6.3%


                    Premiums   Co-pays &    Doesn't    Providers      Other
                    Too High   Deductibles Cover Svcs Don't Accept
                                Too High    Needed




                                                                                            21
Respondents wrote-in the following explanation/reason for their dissatisfaction:
  o “No Cobra benefits; In a couple years I will be on Medicare & office manager will
     have no insurance as there will not be a group.”
  o “Placed in high tier without any reason.”
  o “Premiums have doubled in 2 yrs; being forced into highest deductible due to
     cost increase”
  o “Premiums increased $200 since inception”
  o “Told on 2 claims we would be covered but after seeking medical care they
     declined payment”

Ten respondents who had indicated satisfaction with the plan included hand-written
comments on sources of dissatisfaction that centered on the costs of premiums, co-
pays or deductibles. Three noted that both premiums and co-pays or deductibles were
too high, four stated premium costs alone were too high and another three commented
that co-pays or deductibles were too high.

   o “Premiums too high; wish plan was less expensive so more employees could
     benefit from it”
   o “Premiums raised too high; absolutely criminal hike!”

                   Figure 7: Business Owner Perspective – Employee Satisfaction with Costs (n=111)

Respondents were also                                    46.9%
asked their opinion
regarding employee
satisfaction with the
WVSBP. With respect to
costs, a few respondents                                             28.8%
said they pay more than
the required 50% of the                   18.9%
individual premium and
indicated either that their
employees are “satisfied’
                                                                                     5.4%
or did not answer the
question. Overall, most
respondents felt that their
                                     Very Satisfied   Satisfied   Dissatisfied      Very
employees were either                                                            Dissatisfied
satisfied or very satisfied
with the costs (65.8%; n=
73) - Figure 7.

The main reason given for perceived employee dissatisfaction was premiums, identified
by 53.6% (n=21) of respondents. Co-pays and deductibles and “other” accounted for
23.1% each (n=9 respectively). In 8 of the 9 “other” responses, the hand-written
comments indicated that dissatisfaction was due to both premiums and co-
pays/deductibles being too high.



                                                                                                22
With respect to perceived employee satisfaction with benefits almost all of the
respondents - 91.0% - indicated their employees were either satisfied or very satisfied
(Figure 8).


                 Figure 8: Business Owner Perspective – Employee Satisfaction with Benefits (n=111)


When asked for the major                                 73.0%
reason their employees
were not satisfied with
benefits, the owners
responses were split
between “doesn’t cover
services needed” (45.5%;
n=5) and “other” (45.5%;
                                           18.0%
n=5), however, a review of
remarks written for this                                               8.1%
question suggests that                                                                0.9%
coverage for services was
the main source for                   Very Satisfied   Satisfied   Dissatisfied      Very
dissatisfaction.                                                                  Dissatisfied


   o “Doesn't cover enough besides major medical”
   o “Doesn't cover services AND providers don't accept”
   o “Don't cover what they even verbally approve prior to care”

A few respondents wrote additional thoughts and comments about the WVSBP overall:

   o “Too expensive for most employees; last yr. premium went up 13%; this yr. 20%;
     if continues will price us out of plan; need plan with smaller premiums”
   o “Premiums have doubled in 2 yrs; being forced into highest deductible due to
     cost increase”
   o “Employees do state that cost for female spouse is too high.”
   o “The plan does not cover office visits”
   o “If we did not pay the employee premium the cost would be too high for the
     employee. The costs were affordable when we purchased the plan w/3
     employees; 1 employee has left-- now that there are only 2 insured & cost of
     premiums are far greater than when we had our previous policy.”
   o “As a small business owner we should have a plan that we can afford such as
     PEIA”
   o “Only $1000 Deductible available; lower deductible not available at any price”
   o “Employees state prescription coverage could be better”

Discussion
Although not ideal, a 45% response rate is considered a respectable response for
mailed surveys. Unfortunately, the evaluators do not have data to compare
respondents to non-respondents in order to assess how representative the former are of

                                                                                                 23
all enrolled businesses. Nevertheless, information from almost half of the possible
business owners is valuable. Given that the majority of respondents are satisfied with
the plan’s cost and benefits, it seems reasonable that what they identified as possible
sources of dissatisfaction would be shared by those dissatisfied non-respondents and
could provide valid direction for modifications in the WVSBP to make it a better fit for
small employers and their employees.

The WVSBP does appear to be successfully reaching small business owners who have
not previously provided health insurance coverage for their employees. When asked,
respondents indicated they were satisfied with the WVSBP, however, costs are still a
major problem for both business owners and members even with the reduced rates.

Owners reported that their premium rates automatically increase to the next rating tier at
the annual renewal for the plan and that such increases are causing some businesses
to drop the coverage or raise the deductible amount from the minimum deductible of
$1000 to be able to afford the coverage. Since the costs of co-pays or deductibles were
listed as main reasons for dissatisfaction, increasing deductibles may intensify the
dissatisfaction with the program and increase the potential for cancellations in the
future.

From the owners’ perspective, some members are unhappy with the coverage. Some
specific items mentioned were coverage for office visits and improved prescription drug
coverage. A review of the coverage may be beneficial to determine why people feel it
does not cover services that are needed.




                                                                                       24
Section 3
Member Mailed Survey
Methodology
The methodology for the member survey was the same as that employed in the survey
of business owners. In January 2007 a self-administered survey was mailed to all 898
small business employees who had enrolled in the WVSBP at any time between
January 1, 2005 and June 30, 2006. A copy of the survey instrument and cover letter
is included in Appendix E.

Results
Completed surveys were received from 209 of the 898 members surveyed, a 23%
response rate.

Gender: Male respondents outnumbered female respondents by a small margin (54%;
n=111 versus 46%; n=94).

Employment: 15.7% indicated they worked more than one job at the time of the survey
(n=32).

Marital Status: 70.2% (n=146) of respondents were married, 17.3% (n=36) divorced,
and 11.1% (n=23) had never been married.


Age: A little more than half   Figure 9: Age of Beneficiary Survey Respondents (n=209)
of respondents were middle
aged, that is between 35 and
                                            0.5%            2.4%
54 years old (54.5%; n=114).
The 25-34 and 55-64 age        22.0%                                 20.6%
groups accounted for an
additional 20+ percentages                                                               19-24 yrs
each (n=43; n=46,                                                                        25-34 yrs
respectively).                                                                           35-44 yrs
Individuals younger than 25                                                              45-54 yrs
(age 19-24) and those older                                                              55-64 yrs
                                                                                         65+ yrs
than 64 (65+ yrs) accounted
for the remaining 3% (n=5;       28.7%
n=1, respectively) - See age                                       25.8%
distribution in Figure 9.




                                                                                          25
                           Figure 10: Education Level of Beneficiary Survey Respondents (n=205)
Education: A
                                                              5.4%
quarter of respondents                          14.6%
were high school
graduates (n=55), about                                                  26.8%   Less than High
a third had completed                                                            School
some college or voc-tech                                                         High School Grad
training (n=62), another
                                        22.9%                                    Some College or
third graduated from
                                                                                 Vo-Tech
college (n=47) or had
                                                                                 College Grad
postgraduate training or
degrees (n=30). Only a                                                           Postgrad Training
few reported less than                                                           or Degree
                                                              30.2%
high school education
(n=11) – Figure 10.


When looking at the length of time respondents had been enrolled in the WVSBP,
almost three-quarters (74.1%) reported being enrolled for over one year. The largest
group was represented by those enrolled between 13-18 months (39.8%; n=80). Only a
small percentage (1.5%; n = 3) had been enrolled for less than 6 months at the time of
the survey (Figure 11). Over half (59.5 %) chose individual coverage, the remainder
purchased coverage for themselves plus other family members. The coverage
breakdown is shown in the list below.

     Figure 11: Length of Time Enrolled in WVSBP (n=201)
                                    39.8%
40.00%                                                          Type of Coverage Represented
                                                                (n=205)
30.00%
                                            21.4%
                                                                − Individual Coverage - 59.5%;
                            19.4%                                 n=122
20.00%                                                          − Family Coverage -18.1%;
                                                     11.9%        n=37
10.00%            6.0%
           1.5%                                                 − Individual plus Spouse -
                                                                  13.2%; n=27
0.00%
         4-6 mos 7-9 mos   10-12    13-18   19-24   24+ mos     − Individual plus Children -
                           mos      mos     mos                   9.3%; n=19




                                                                                               26
                                                      Figure 12: Health Insurance Prior to WVSBP (n=206)
     Over half of the respondents (56.8%,
     n=117) had been covered by a health insurance
     product prior to enrolling in the WVSBP (Figure 12).
     They indicated they were either covered by another                No
     employer (49.0%, n=47) or were covered by their                 43.2%;         Yes
     spouse’s insurance (44.8%, n=43).                                n=89         56.8%;
                                                                                   n=117




Figure 13: Length of Time Without Insurance (n=87)
                                                     Among those who did not have insurance
                                                      coverage (n=89), over one-third
                    First time                        (36.8%;n=32) had been without coverage
                       ever      Less than            for between 1 and 4 years. Almost 20%
                     having         1 yr
                                                      (17.2%; n=15) reported never having had
                   insurance      14.9%
                                                      health insurance. For 14 individuals
                     17.2%
                                                      (16.1%) it had been 10 or more years
                                                      since they were last covered by health
          10+yrs                                      insurance. (Figure 13.)
          16.1%                     1-4 yrs
                                    36.8%

                   5-9 yrs
                   14.9%




     Significantly more respondents were satisfied with the benefits of the WVSBP than with
     the costs of the plan. Almost 80% (78.2%) of respondents reported being satisfied with
     the benefits of the plan (n=25 very satisfied; n=133 satisfied) compared to 57.5% - who
     reported they were satisfied with the costs (n=22 very satisfied; n=93 satisfied). Figures
     14 and 15 depict the responses for these questions.

     Interestingly, while the business owners seemed to accurately perceive employee
     satisfaction with costs (see previous Figure 7), their perception of employee satisfaction
     with benefits was more positive that the actual responses from the employees
     themselves. 46.9% of business owners believed their employees were satisfied with
     the costs compared to 46.5% of members who said they were in fact satisfied. With
     respect to benefits, 73.0% of business owners believed their employees were content
     with the benefits while in fact only 66.2% indicated satisfaction with benefits.




                                                                                               27
                    Figure 14: Member Satisfaction COSTS of WVSBP (n=200)


            50.0%                        46.5%


            40.0%                                     36.0%


            30.0%


            20.0%
                          11.0%
            10.0%                                                      6.5%


             0.0%
                    Very Satisfied   Satisfied   Dissatisfied        Very
                                                                  Dissatisfied



                    Figure 15: Member Satisfaction BENEFITS of WVSBP (n=201)


                                         66.2%
         70.0%
         60.0%

         50.0%
         40.0%

         30.0%
                                                        18.9%
         20.0%         12.4%

         10.0%                                                              2.5%
          0.0%
                 Very Satisfied      Satisfied     Dissatisfied    Very Dissatisfied




Among members who indicated dissatisfaction with the costs associated with the
WVSBP almost three-fourths (74.2%;
n=66) identified “premiums were too high”       Member Reasons for Dissatisfaction with Costs-
as a reason for their dissatisfaction; 50.6%  74.2% Premiums Too High
(n=45) identified “co-pays or deductibles     50.6% Co-pays or Deductibles Too High
                                              5.6% Other
too high.” Twenty-six people, (~ 25%)
identified both the premiums and the co-pays and deductibles as reasons for their
dissatisfaction. Five respondents wrote in comments/reasons for their dissatisfaction
with the costs.

   o   “Raise for no reason”
   o   “No drug coverage”
   o   “For what it costs I could use the money”
   o   “Cost that raised after 1st year”


                                                                                       28
   o “Raised 29% from 1st yr to 2nd canceled b/c B/S; Our company saved $2200 a
     year on 9 employees by taking another ins co with better coverage”
   o “We haven't used it but we still have these big premiums each month”
   o “When we initially were enrolled the premium was 28% less. After the first 6
     months premium went up & then 3 months later [xxx] called & told us they could
     handle our group. Since our names have been given out to various brokers-how
     nice someone should have told us. I think this was deal to begin with; Gov. used
     this politically & then we were thrown out to other brokers. Of course can get
     premiums down if we raised deductibles from $3000 to $5000. What a scam.”

Even though the follow up question was asked only of those who reported being
dissatisfied with costs, other respondents took the opportunity to write-in their concerns.
Six individuals remarked “premiums were too high” and 11 indicated that deductibles
and copays were too high. The following comments were also noted.

   o “Was somewhat satisfied until our premiums increased 27% after 1st year; we
     had to drop it”
   o “Each year get higher”
   o “It's better than any I have had in the past but all health insurance is too high.”


The 20% of respondents who were dissatisfied with WVSBP benefits expressed
concerns about the plan not covering services that were wanted/needed as the main
                                                   reason (57.9%) for their
 Member Reasons for Dissatisfaction with Benefits- dissatisfaction. Many individuals
 57.9% Doesn’t Cover Services I Want or Need       “satisfied” with the plan’s benefits
 34.2% Other Reasons                               also listed reasons for
 5.3% Too much Trouble/Too Complicated             dissatisfaction. A review of the
 2.6% Providers Don’t Accept Product               comments revealed a cost factor in
                                                   people’s dissatisfaction with the
benefits. Many remarked about preventive services not being covered until after the
deductible was met or that the high deductible was too expensive. The complete list of
comments is included below.

   o “Benefits good”
   o “To be able to have eye & dental coverage”
   o “Did not cover preventive as stated”
   o “Doesn't cover services & too much trouble”
   o “Price”
   o “Doesn't cover services I wanted; Poor prescription coverage”
   o “Office visits & prescriptions initial out of pocket are too costly”
   o “Insurance changing its mind on what it will cover after I've paid my bills about a
     year later & resulting in more fees that I had to pay unexpectedly”
   o “Deductible too high; would like more options with prescription drug option”
   o “Doesn't cover services want/need; deductibles per person on family plan too
     high”



                                                                                           29
   o “I have not used this much. I am about the only person that used insurance & I
     had to pay out over $2000.00 for about $3000.00 total bill.”
   o “Deductible too high; Prescription coverage at 50% too low”
   o “Prescription co-pays too high”
   o :I will never use it”
   o “Office Calls and prescriptions should pay more”
   o “Bills & statements are confusing; paying 1 bill & starting another; Because of the
     continuing illness I had to pay 2 deductibles. If I had been ill January August or
     September only 1 deductible would have been necessary”
   o “Co-pays and deductibles too high”
   o “Would rather have small co-pay not have to pay total cost until reaching
     deductible”
   o “Family Doctor is not a network provider; Penalties too harsh”
   o “Didn't pay preventive medicine; Office call Premium too high”
   o “Mainly the deductible is just too high; It would be better if deductibles were
     cheaper so the 80% would kick in; paying $47/week for my wife; should pay
     better than it does now”
   o “High Deductible”
   o “Didn't offer family benefits”
   o “Prescription coverage not too good”
   o “Only for protection; Deductibles too high; Prescription no real discount”
   o “Too much trouble/complicated; please print claims 1 per page; CSRs aren't very
     knowledgeable about what is covered & which doctors are in the network.”
   o “There needs to be lower deductibles”
   o “Medications”
   o “Doesn't cover services; Providers don't accept; Too much trouble/complicated”
   o “What it all boils down to is COST! At first we could afford it almost too good to
     be true & then after you begin to enjoy at least getting your health on track &
     feeling comfortable it is taken away. Now worry is how long can we continue to
     afford $615.00 per month premium. We are back in same situation. A 28%
     increase is unacceptable & we hear it's going up again. So much for being self-
     employed. Thanks Governor now what? We know Governor is aware of this. It's
     not nice being used.”

The last series of questions pertained to health status and health access. 24.7% of
respondents (n=47) reported that their health had improved and almost half (44.3%;
n=77) said that their access to health care had also improved since getting health
insurance. Over three-fourths (79.3%) rated their health as either very good or good
(n=84 very good; n=80 good). None of the respondents indicated poor health. When
asked about difficulties experienced trying to access needed care when they did not
have health insurance, more than 30% reporting having had problems. However since
obtaining health insurance, less than 10% reported difficulties – see Table 2.




                                                                                     30
Table 2
                         Difficulties Accessing        Difficulties Accessing
                         Care Prior to Having           Care Since Getting
                                Insurance                     Insurance
          Often              20/164 = 12.2%                  1/195 = 0.5%
          Infrequent         31/164 = 18.9%                14/195 = 7.2%
          Never             113/164 = 68.9%               180/195 = 92.3%


Discussion
Although the response rate was poor, information gained from the members provides
some insight into issues that need to be reviewed, particularly since the issues they
identified were very similar to the ones identified by the business owners. The majority
of respondents have been enrolled in the WVSBP for at least 12 months increasing the
probability that they have sought health care and had a basis for their opinions about
the WVSBP.

When asked, respondents were satisfied with both the costs and benefits, however,
costs are still major problems even with the reduced premiums. Respondents
mentioned that the annual rate increases were difficult and that the premiums were too
high. The premiums can be lowered by raising the deductible, however members also
complained about coverage not being provided until after the deductible was met,
specifically coverage for preventive care services. Raising the deductible would only
serve to exacerbate the cost issue and possibly delay receipt of more services that are
preventive in nature. The other common complaint was about the prescription drug
coverage.

The WVSBP does address the issue of access to needed health care. Results
overwhelmingly indicate that people who had health insurance coverage had fewer
difficulties accessing the health care they needed than they did before they were
covered.

According to the respondents of this mailed survey, the rate of uninsured West
Virginians working for small businesses may be less than believed. While the
businesses were previously uninsured over half of the employee respondents had been
covered by another insurance product.




                                                                                      31
32
Section 4
Business Owner Telephone Panels

Methodology
In order to assess possible changes in enrollment and access to health services, a
panel of 20 business owners was drawn from 47 business owners who
    1) had responded to the mailed survey conducted earlier in the year,
    2) were still enrolled in the WVSBP at the time of the mailed survey,
    3) indicated a willingness to participate in two more waves of data collection, and
    4) provided a telephone number for follow up.

Names were drawn at random. Four attempts at different times of the day, including
evenings and weekends, were made to reach individuals after which a replacement
name was pulled from the remaining names. Similarly, if a business owner who had
previously indicated a willingness to participate changed his/her mind, a replacement
was pulled. Interviews were conducted with 20 employers at Time 1 in late July 2007
and again at Time 2 approximately 90 days later. Panelists were paid $25 for each
interview they completed.

In the first and second series of phone interviews, if a business had dropped WVSBP
coverage since the mailed survey the respondent was asked a few questions about
current health insurance status, their own, that of the business and of the employees,
and the interview was concluded. Only one person who had previously indicated a
willingness to participate refused during the Time 1 phone calls. No one refused during
Time 2 calls; however interviewers were unable to reach one business owner after four
attempts.

The questionnaire used for the interviews was approved by the West Virginia University
Office of Research Compliance (see Appendix G).

Results
At Time 1 all of the respondents were still enrolled in the WVSBP. Responding
businesses employed 109 employees all of whom were eligible for their employer’s
health benefit, e.g., worked full-time. Of those 109 eligible employees, 81 (74.3%) had
enrolled in the WVSBP at the time of the interview.

Business owners reported on coverage choices made by employees as follows:
   − 69% individual coverage;
   − 15% family coverage;
   − 5% employee and spouse; and
   − 11% employee and a child or children.

The reasons given by employers for why employees declined coverage were related to
cost and to already having another source of health coverage.




                                                                                          33
   Eighty-five percent of businesses expressed satisfaction with the plan. Those who
   expressed dissatisfaction identified the plan’s cost and that it did not cover the services
   needed.

        o “Too expensive - for small businesses, there's almost no discount from the
          regular Blue Cross plan.”
        o “Way too expensive - if one of my employees insured her whole family, it would
          be more than her entire pay check once a month.”

   One business reported that their insurance agent had spoken to them about how to
   lower their premium costs.

        o “Yes, he said we could take a higher deductible.”

   At Time 2, calls were completed with 19 of the 20 businesses from Time 1. The number
   of eligible employees dropped from 109 to 107, but the number of employees enrolled
   increased by 1, from 81 to 82. Fifty-eight employees (70.7%) had individual coverage;
   11 (13.4%) had family coverage; 3 (3.7%) had employee-spouse coverage; and 10
   (12.2%) had employee-child coverage (Table 3).

   Table 3: Insurance Coverage Business Owner Panelists Time 1 and Time 2
         Type of Coverage             Time 1                  Time 2
        Individual Coverage                      56/81=69.1%                   58/82=70.7%
        Family Coverage                          12/81=14.8%                   11/82=13.4%
        Employee+Spouse                             4/81=4.9%                   3/82=3.7%
        Employee+Children                           9/81=11.1%                 10/82=12.2%

   Reasons for declining employer-sponsored coverage did not change from Time 1 to
   Time 2.
    Figure 16: Business Owner Panel Overall Satisfaction
         with WVSBP Time 1 (n=20) & Time 2 (n=19)

                         50.0%                                       Business owner satisfaction with
                                                              Time 1
50.0%                            47.4%                               the plan declined from 85.0% to
                                                              Time 2 78.9%, (figure 16) with cost
45.0%
                                                                     being the major reason cited for
40.0%
           35.0%                                                     dissatisfaction. The perceived
35.0%           31.6%                                                employee satisfaction with cost
30.0%                                                                and with benefits mirrored the
25.0%                                                                business owner overall
20.0%                                                                satisfaction with the plan.
                                         15.0% 15.8%
15.0%
10.0%                                                         5.3%
5.0%                                                     0
0.0%
        Very Satisfied   Satisfied   Dissatisfied         Very
                                                       Dissatisfied
                                                                                                   34
   o “Premiums for coverage other then Individual are too expensive - employees
     can't afford to cover spouse and family.”
   o “Items not covered, providers don't accept and inconsistency with what is told.”
   o “Would prefer to pay a copay for doctors visits and things instead of having to
     meet deductible.”

Of those who explicitly mentioned high costs of premiums as a reason for
dissatisfaction, two indicated their insurance agent had spoken to them about how to
lower costs; however, the options were either not feasible, and/or uncertain:

   o “Everyone reapplying again or increasing the deductible but we already have
     $1000 deductible - we didn't do either”
   o “Filled out paperwork; increased 19% will know soon if it goes back down once
     we've reapplied.”

Panelists were the most forthcoming with the open-ended question at the end:
“Anything you’d like to add about your experience with the WVSBP.” Reoccurring
themes at Times 1 and 2 included the concern over high deductibles, the issue of
preventive services not covered, and the annual automatic increases. However, there
were also panelists that had not heard any complaints and who are grateful that there is
a product out there they can afford.

   o “Haven’t heard any complaints.”
   o “In order to re-qualify for Tier 1, have to do all paperwork again - increase was
     half amount after reapplying. Bothers me that we have to do that each year.
     Personal note: I'm covered and used the insurance for pregnancy this year. I was
     surprised by coverage for prenatal services, ultrasound, blood work, etc. wasn't
     covered without meeting the deductible so I had to pay for all of that. Seems like
     it should be covered.”
   o “It's a little hard to understand what's covered and what's not covered --
     especially with prescriptions.”
   o “Always had MSBCBS before WV Small Business Plan and services were better
     prior to WVSBP. Example: colonoscopy not covered because not 50 years old;
     seems before covered annual exam and preventive maintenance items better.
     Difficulties with communication with MSBCBS. EOB's are very hard to
     understand and are confusing for me and the providers too when I have to fax
     them to my doctors.”
   o “Lowered deductible recently to try to help the employees - would and have
     recommended it to other businesses. I'm very pleased with it.”
   o “Would like some coverage of the doctors visits and things and pay a copay
     instead of having to pay for it all until the deductible is met”
   o “Regular office visits and not all prescriptions are covered; Coverage doesn't
     include general office visits - preventive care or just a cold or something.; We’ve
     had it for 2 years and the agent guy came in the Fall this year to ask if we wanted
     to change or anything. He'd been to a seminar or something. It's not the cost but
     the services that are a problem.”



                                                                                        35
   o “Have heard no complaints. Glad it's there; been telling other businesses that it is
     available.”

Discussion
All of the business owners participating in the panel interviews remained covered by the
WVSBP. Reported satisfaction did not change from Time 1 to Time 2; owners in the
sample were generally happy with the WVSBP. This result was also consistent with the
satisfaction level of business owners from the mailed survey.

Premiums, co-payments for office visits, and deductibles levels were all sources of
frustration for business owners and and their employees. Business owners believe that
their employees cannot afford to cover their families given the cost of premiums and
deductible levels

The ability to make changes to lower costs is frustrating to some owners. The option of
re-applying to offset annual renewal increases is a major source of frustration to
owners. The only other option available to them to decrease premiums – increasing
deductibles – is also unpalatable to owners who are trying to help their employees
afford the coverage.




                                                                                      36
Section 5
Member Telephone Panels

Methodology
A panel of 30 employees was drawn from among the 87 members who
   1) had responded to a mailed survey conducted earlier in the year,
   2) were still enrolled in the WVSBP at the time of the survey,
   3) indicated a willingness to participate in two more waves of data collection, and
   4) provided a telephone number to be reached for the panel telephone interviews.

Panelists were paid $25 for each interview they completed.

The questionnaire used for the interviews was approved by the West Virginia University
Office of Research Compliance (see Appendix I).

If a person was also listed in the pool of eligible business owner panelists, their name
was removed from consideration for the beneficiary sample. Names were drawn at
random using a random number generator. Four attempts to contact the individual were
made at different times of the day, including evenings and weekends, after which, a
replacement was pulled from the remaining names. A total of 28 replacements were
used at Time 1:
      3 telephone numbers were no longer accurate;
      11 people refused to participate, and
      13 people were unreachable in four attempts.
There were no replacements at Time 2.

Telephone interviews were conducted with 31 employees during July 2007 (Time 1) and
were contacted again approximately 90 days later (Time 2). If an individual had
dropped their employer coverage an attempt was made to ask a few questions to
ascertain their current insurance status and reason for dropping coverage, after which
the interview was concluded. The person was not called again at Time 2.

Results
At Time 1, only one individual had dropped their coverage in the West Virginia Small
Business plan due to a change of employment. They did have insurance coverage with
the new employer.

The median time enrolled in the plan at Time 1 was 19-24 months.
      73% of panelists (n=22) reported having individual coverage;
      10% (n=3) family coverage,
      10% individual plus spouse, and
      7% individual + children.
Twenty percent (n=6) of respondents worked a second job.


                                                                                     37
The majority of participants at Time 1 were satisfied or very satisfied with the cost of the
WVSBP (70.0%) and with the benefits covered (80.0%) (figures 17 & 18).
Dissatisfaction with cost was related to premiums and copays or deductibles that were
“too high.”                              Figure 17: Member Panel Satisfaction with COSTS
                                                             Time 1 (n=30) & Time 2 (n=29)

                                   70.0%                                                               Time 1
o “Both is too high; the                                              62.1%
  premiums cost me                 60.0%                                                               Time 2
  $128/week and the                                           50.0%
  deductible is $2,000 per         50.0%
  person/per year. That's
                                   40.0%
  $6,000 a year for me.
                                                                                 26.7%
  The premiums and                 30.0%
  deductible are way too                      20.0%20.7%                                17.2%
  high.”                           20.0%

                                   10.0%                                                          3.3%    0
                                    0.0%
                                            Very Satisfied      Satisfied      Dissatisfied        Very
                                                                                                Dissatisfied

Dissatisfaction with benefits was related to the plan not covering the services that the
individual wanted or needed (n=3), but for at least one panelist the cost decidedly
impacted the available benefits:

o “With that high deductible, it doesn't cover anything - I can't get any services; still
  difficult getting them to cover screening mammograms because of age. Insurance
  doesn't cover certain providers”
o “Coverage for prescription drugs”

                          Figure 18: Member Panel Satisfaction with BENEFITS
                                     Time 1 (n=30) & Time 2 (n=29)
                                             60.0%
                  60.0%
                                                   51.7%                             Time 1

                  50.0%                                                              Time 2


                  40.0%

                  30.0%
                            20.0%
                                    17.2%                          17.2%
                  20.0%
                                                         13.3%                       13.8%
                                                                              6.7%
                  10.0%


                   0.0%
                          Very Satisfied    Satisfied        Dissatisfied      Very
                                                                            Dissatisfied



                                                                                                               38
Just about half (48.4%) of respondents had not been to a health care provider for
routine or preventive care. Twenty-three percent (n=7) had one visit and 10% had three
or more visits.

Seven percent of panel members (n=2) visited the emergency room once. There were
an additional three visits to the emergency room made by family members of the three
panelists with family coverage. The reasons given for going to the ER were that their
illness made it necessary or they were unsure about the illness.

Twenty percent (n=6) of          Figure 19: Member Panel Health Status Time 1 (n=30) & Time 2 (n=29)
panelists reported that
their health had improved since                             37.9%      37.9%
                                      40.0%                       36.7%
enrolling in the WVSBP; the                                                                  Time 1
remaining panelists said their        35.0%
                                               30.0%                                         Time 2
health had pretty much remained 30.0%
                                                       26.7%
the same. As far as their health
status was concerned, fifty-seven 25.0%            20.7%
percent (n=17) reported their         20.0%
health status as very good or
excellent, another 36.7% good,        15.0%
and the remaining 7% as fair.         10.0%                                  6.7%
All but three (10%) of panelists                                                  3.4%
reported that they have never          5.0%
                                                                                        0 0    0 0
experienced difficulties getting the 0.0%
health care they need. The                   Excellent Very        Good       Fair     Poor Very Poor
remaining 10% have experienced                           Good
difficulties infrequently. Access to health care has remained the same for 97% of
panelists; only one panelist reported that access had worsened for them.

At Time 2, one of the panelists had discontinued WVSBP coverage and was covered by
his wife’s health insurance. The number of panelists carrying individual coverage
increased by one, from 22 to 23. Satisfaction with the costs of the WVSBP increased
from Time 1 to Time 2, with 82% of panelists saying they were satisfied or very satisfied
at Time 2 compared to 70% at Time 1. The reasons given for dissatisfaction did not
change. Although satisfaction with costs improved, satisfaction with benefits decreased
from 80% satisfied or very satisfied in Time 1 to 69% in Time 2. A possible anomaly is
that in Time 1 two respondents reported not having used the services and therefore not
having an opinion; that number increased to four at Time 2.

The number of visits made by members for routine and preventive care was the same
for Time 1 and Time 2. Family members made 18 visits for routine or preventive care in
Time 1 and 16 visits in Time 2, with two panelists reporting four or more visits by family
over that three month period of time.




                                                                                           39
Reported health status did not change significantly but fewer panelists reported their
health status as excellent at Time 2 (n=6) as did at Time 1 (n=9). Access to care and
difficulties experienced getting care did not change.
When asked for any final comments with respect to the WVSBP, one quarter of the
panelists felt the plan is good, they are pleased, or they haven’t had any trouble or
hadn’t used it. About a third of panelists spoke to their concerns about costs,
particularly the high deductible that can effectively keep them out of care unless they
have a major illness or injury. A few specifically mentioned the plan not covering
prevention.

   o “It's paid for by my employer. I would like to see coverage for well visits-
     preventive care. For the type of insurance that it is, the premiums are pretty
     excessive because we at the office -- I'm the office manager -- carry ~ $3,000
     deductible for carrying it. That and the well visit coverage are the only things.”
   o “Too expensive to add wife-premiums are too high if I added her; Cost of
     premiums especially for adding a 30-something woman. It is the first time in 12
     yrs. I haven't been able to cover her on my insurance so she is uninsured. I used
     to have a plan where I worked & it was expensive but not as much as this to
     cover her.”
   o “Dissatisfied with benefits because a couple of things weren't covered. Also
     dissatisfied with prescription benefits because amount you pay doesn't get
     applied to deductible. Poison Ivy reaction needed prescription drugs to treat it.”
   o “They just need to offer a doctor visit co-payment to the plan. I'm a broker and I
     support the plan, by the way.”
   o “Too expensive also frustrated that we have to re-apply each year to get a lower
     rate”
   o “Very happy, no complaints.”
   o “Would prefer a co-pay for doctors visits.”
   o “Don't understand why chiropractor visits twice a month not covered - they pay
     for prescription drugs monthly and would pay for me to take a pill or have surgery
     but I don't want those. I need these visits to be able to function. Other than this
     issue, I've been pleased with it.”
   o “Very good for small businesses - a good opportunity”
   o “Deductibles too high - would have to have major illness before it would cover
     anything; Because deductibles are so high, don't go to the doctor unless it is
     absolutely necessary. I don't think that's an improvement in health care.”

Discussion
At Time 1 all the employees in the panel were still enrolled; that number decreased by
one at Time 2. While the majority of the panel members were satisfied with the plan’s
cost and its benefits, there were real concerns voiced by a number of other panelists
related to the size of the deductible and how that affected utilization of services. This
information is consistent with that gathered from the mailed survey. Members are
concerned about the amount of out of pocket expenses they incur before any coverage
is provided, especially for preventive or well visits. This again echoes the information
provided by the insurance agents that people are requesting plans with co-payments for
each visit versus meeting deductibles before coverage begins.

                                                                                          40
Section 6
Provider Mailed Survey

Methodology
Each year the State of West Virginia sends a letter to providers in the WVSBP network
giving them the choice of opting out of the program. In March 2007 a self-administered
survey was mailed to 205 providers who had opted out of the WVSBP network up to
that point. The survey was accompanied by a cover letter from the project director and
a self-addressed and stamped return envelope. The West Virginia University Office of
Research Compliance approved all materials before mailing (Appendix K).

As with the previous mailed surveys, the Dillman Method for Survey Research was used
to increase response rate. Using the addresses provided by the WV Health Care
Authority from the opt out list, the Institute for Health Policy Research mailed surveys to
all providers listed, with the exception of the nursing homes, a service not covered by
the WVSBP.

Results
Ninety-seven surveys were returned resulting in a 47.3% response rate. The evaluation
team discovered after-the-fact, that dentists and/or oral surgeons were included in the
mailing. The WVSBP does not cover dental care. Nevertheless, an interesting finding
was discovered.

Figure 16: Major Reason Not Participating in Network (n=94)
                                                                 Respondents were asked
                                                   45.7%   why they were not participating in
       41.5%                                               the provider network. 41.3%
                                                           listed low reimbursement rates as
                                                           a reason for their non-
                                                           participation. Another 43
                                                           individuals (45.7%) responded
                                      17.0%                with “other” as a reason. (see full
                                                           results in Figure 16)
                        6.4%



  Reimbursement   Practic e is   Adminis trative   Other
  Rates Too Low    Clos ed         Burden



Upon review of the hand-written comments for the “other” option, it was apparent that
there was confusion among respondents about the program. Almost half, 20 of 43
responded with comments dealing with why they personally did not purchase the plan
for themselves and their employees. Another 7 indicated that they had little to no
knowledge about the program. There were very few comments that related to why they



                                                                                            41
were choosing to not be part of the provider network. The provider comments are
recorded verbatim below:

   o   “As I recall, orthodontics wasn’t an option”
   o   “Reimbursement rates too low.”
   o   “Have health insurance”
   o   “Administrative burden”
   o   “Opt out.”
   o   “I am an employee of a participating dentist whose practice is closed.”
   o   “My practice is limited to endodontics only.”
   o   “We feel it is unfair to ask regular patients to subsidize care for others.”
   o   “Retiring”
   o   “Cannot afford – have no insurance for ourselves, or family, or employees”
   o   “No interest”
   o   “I was advised that since my staff and I were previously covered by a private
       policy, we did not meet the requirements”
   o   “At high cost to myself, I already provide healthcare to my employees. I feel I
       should have been able to participate in the program; I was penalized for doing
       the right thing – providing insurance. But not eligible for a low cost plan. Thanks a
       lot WV – not really open for business.”
   o   “Employees already have health insurance coverage.”
   o   “I have no employees.”
   o   “Have health insurance.”
   o   “Self-employed with no employees.”
   o   “We have over 50 employees.”
   o   “My practice is closed to new patients.”
   o   “Cost to administer acupuncture is much lower than western medicine.
       Participating in insurance programs will raise costs with no improvement to
       services rendered.”
   o   “On Medicare; less than 2 employees.”
   o   “Patients have high deductibles ($2,000 typically – and don’t pay bills because
       they think insurance does!!)”
   o   “Didn’t know about.”
   o   “Do not participate in plan as a preferred provider.”
   o   “Don’t know anything about the plan.”
   o   “Don’t offer health benefits – fear of future increases.”
   o   “We are pediatric dentistry only.”
   o   “Never heard anything about it.”
   o   “Retired.”
   o   “We have no knowledge of this program.”
   o   “I am a dental provider – is this in the ‘Plan’?”
   o   “Only had one employee.”
   o   “Had insurance with my professional association but my cost is increasing with
       them. I will need to check the WV Plan again.”
   o   “Cost – cannot afford to provide this service.”
   o   “Don’t know enough about the plan. Presently provide coverage but awfully
       expensive and would consider a switch.”

                                                                                         42
   o “Not enough info on the plan.”
   o “Not interested in third party providers at this time unless reimbursement is better
     than average.”
   o “No employees/never offered before.”
   o “No information about this program”
   o “Not need at this time.”
   o “Not very familiar with plan and not had any urgent need to research it.”
   o “Satisfied with present coverage and don’t completely trust a State run plan.”
   o “Present coverage satisfactory.”
   o “I do not provide services at a reduced rate based on insurance.”
   o “I am self-employed and my practice is full.”
   o “Already providing, but would surely like the option of participation.”
   o “Never heard of it.”
   o “All staff want to pick own provider. 99% are in Winchester, VA or Hagerstown,
     MD.”
   o “Administrative burden at my age”
   o “Will be closing business.”


Discussion
Many health care providers are themselves small businesses, employing fewer than 50
employees and, therefore, potentially eligible for the WVSBP. These providers are also
part of the MSBCBS provider network which reimburses them for services they provide
to enrollees at an accepted rate. The WVSBP was built on the reimbursement schedule
negotiated with providers by the State of West Virginia and reimburses them at a lower
rate than MSBCBS. The WVSBP Advisory Committee anticipated that some providers
in the network would drop-out rather than accept a lower rate of reimbursement. There
is some support for the Committee’s concern in that close to half of the respondents
specifically mentioned reimbursement levels as their reason for opting out of the
program.

Either as a result of a poorly worded cover letter and/or questionnaire (Appendix K), the
provider survey was not well understood by a significant number of respondents. As a
result, the evaluators are unable to conclusively address the issue of why eligible
providers (i.e., those whose services are covered in the WVSBP) have dropped out of
the network, although reimbursement levels certainly is a factor. However, the data
gathered does provide some input from a specific small business category as to
reasons for not enrolling in the plan, e.g., cannot afford, ineligible. It also potentially hi-
lights the need for additional information to be communicated to providers about the
program.




                                                                                             43
44
Section 7
Analysis of Claims Data
Claims data and membership information for WV Small Business Plan enrollees was
provided by MSBCBS for the two year period beginning January 1, 2005 (the first
effective date of the plan) through December 2006. Data is reported separately for
2005 and 2006.

Figures 21 and 22 graph the breakdown of the enrolled population by their relation to
the member (Figure 21) and their age at time of enrollment (Figure 22). Over the 24
months, 1859 individuals enrolled in the WVSBP, of which 61.7% (n=1143) were
employees, 15.2% (n=283) were employee spouses, and 23.2% (n-433) were employee
children. 1026 individuals enrolled in year 1 and 833 in year 2.

                                                                               Figure 21: Relation by Member

                                                      70.0%           63.7%                                                2005
                                                                              58.7%
                              Percent of Enrollment




                                                      60.0%                                                                2006
                                                      50.0%
                                                      40.0%                                          25.6%
                                                      30.0%                                21.4%
                                                                                                                 14.8% 15.7%
                                                      20.0%
                                                      10.0%
                                                      0.0%
                                                                  subscriber                 child               spouse



                                                                      Figure 22: Age at Time of Enrollment by Member

                                     25.0%                    23.4%                         22.1%                                    2005
                                                                                                 20.2%     20.9%                     2006
                                                        20.0%
                                                                                                     19.3%
                                     20.0%
      Percent of Enrollment




                                                                                   18.2%
                                                                                        15.6%
                                     15.0%
                                                                           11.3%
                                                                      10.3%                                        10.0%
                                     10.0%                                                                              8.5%


                                                5.0%
                                                                                                                                    1.2%
                                                                                                                               0%
                                                0.0%
                                                         <=18          19-25       26-34     35-44       45-54     55-64       65+




                                                                                                                                            45
449 members of the 1026 enrolled in 2005 (44%) submitted 2716 claims, an average of
6 per individual in 2005. 1057 members of the total 1859 enrolled (57%) submitted
8341 claims, an average of 7.9 claims per member in 2006. In the first program year 51
members discontinued their WVSBP coverage. In year 2, an additional 83 members
discontinued coverage (Table 4).

Table 4: Number of Members by Claims filed in 2005 and 2006

            Variable               Year         Count       Description
Members                             ALL          1859       Members enrolled in 2005 and 2006
Members                            2005          1026       Distinct members enrolled in 2005
Members                            2006          833        Distinct members enrolled in 2006
Distinct Members Filing Claims     2005          449        Distinct members filing claims in 2005
Distinct Members Filing Claims     2006          1057       Distinct members filing claims in 2006
Claims                             2005          2716       Count of 2005 claims
Claims                             2006          8341       Count of 2006 claims
Claims Per Member                  2005          6.04       Average claims per member in 2005
Claims Per Member                  2006          7.89       Average claims per member in 2006
Cancelled                          2005           51        Members with cancel dates in 2005
Cancelled                          2006           83        Members with cancel dates in 2006


Table 5 lists the number and percent of claims by the nature of the member. The
percent of claims submitted for children and for the employee subscriber rose from 2005
to 2006.

Table 5: Number & Percent of Claims by Relationship to Subscriber 2005 and
2006
                                        2005                              2006
                           Number of           Percent of     Number of      Percent of
            Relationship
                            Claims              Claims         Claims         Claims
         Spouse              572                 21.1%          1337           16.0%
         Subscriber              1640            60.4%           5321            63.8%
         Child                   504             18.6%           1683            20.2%


Over 89% of the claims in both 2005 and 2006 were submitted by employees working
for firms with 2-9 employees (Figure 23), not surprising since MSBCBS has said that the
majority of businesses purchasing the WVSBP are in the 2-9 group.




                                                                                                46
                                                 Figure 23: Business Size by Claims

                                             89.1%      89.5%
                                   90.0%                                                  2005
                                   80.0%
                                                                                          2006
            Percent of Claims
                                   70.0%
                                   60.0%
                                   50.0%
                                   40.0%
                                   30.0%
                                   20.0%                               10.9%          10.5%
                                   10.0%
                                    0.0%
                                              2 to 9                       10 to 50
                                                       Number of Employees
Source of Care
In 2005, 25% (n=683) of the claims were submitted by a primary care provider (Ob-Gyn,
Internal Medicine, Pediatrics, General Practice, Family Practice); this percent dropped
to 19.1% (n=1610) in 2006. Just above 4% of claims came from out-of-state providers.
Thirty-one claims in 2005 were for inpatient stays increasing to 73 claims in 2006.

152 claims were submitted by out-of-network providers in 2005, increasing to 210
claims in 2006. In 2005, there were 22 claims for emergency room care increasing to
132 claims in 2006, although these visits accounted for less than 1% of the claims in
either year.

Tables 6 and 7 look at the dollars paid, the provider allowed amount, and the deductible
paid per claim on average, at the 50th, 75th, and 90th percentiles, and the maximum
amount in 2005 (Table 6) and 2006 (Table 7). In 2005 the amount paid on average was
$208 but $0 was paid on fifty percent of those claims, $50 at the 75th percentile, and
$204 at the 90th. One extended stay in the hospital by a child in both years explains the
high average dollar per claim. The average member filing a claim paid about $90
toward their deductible, with 50% paying over $40 in 2005 and $71 on average in 2006,
with 50% paying over $16 dollars.

      Table 6: Average, Median, and Maximum Amount Paid per Claim in 2005
                                Variable     mean           p50      p75         p90             Max
                   Amount Paid               $208.90         $0     $50.13     $204.52 $141,371.58 1
          Provider Allowed
                                             $311.10       $77.16 $155.11 $393.01             $139,371.58
              Charges
                                Deductible   $89.60        $40.00   $90.56     $185.92         $3385.10

1
 In 2005, the cost outlier was a newborn male with a 26 day inpatient stay: DRG 010,
principal diagnosis 74569, principal procedure 3582. In 2006, the cost outlier was the same child with a
16 day inpatient stay: DRG 047, principal diagnosis 4178, principal procedure 3956


                                                                                                            47
                 Table 7: Average, Median, and Maximum Amount Paid per Claim in 2006
                                Variable           mean           p50       p75          p90          Max

                           Amount Paid             $166.90       $0.55     $70.80    $206.67 $163,034.02

                        Provider Allowed
                                                   $253.70      $72.91 $148.18 $404.47 $161,034.02
                            Charges
                            Deductible             $71.00       $16.60     $70.82    $156.36       $3003.11

Whether or not there is “pent-up” demand for medical services in this population is
difficult to assess. One potential partial measure of demand is the elapsed time from
enrollment in the WVSBP to when they first seek services, i.e., the submission of a first
claim. Figure 24 shows the time elapsed from enrollment in WVSBP to receipt of care
in 2005 and 2006.
The majority of 2005 claims submitted were for care received within the first 120 days
after enrollment; fifty percent (the median) received care within the first 60 days. In
2006, the median was between 121 and 180 days.

                                Figure 24: Elapsed Times from Enrollment to Submission of First Claim


                        30.0%              28.5%                                                            2005
                                 27.0%                27.4%
                                                                                                            2006
                        25.0%
    Percent of Claims




                        20.0%
                                                        15.8%
                                                                  15.3%                                 15.1%
                        15.0%        12.9%                                  13.2%
                                              10.3%                                  9.0%
                        10.0%                                  8.5%                            8.3%
                                                                         4.7%
                        5.0%                                                      3.3%
                                                                                            0.7%      0%
                        0.0%
                                  0-30     31-60    61-120     121-180 181-240 241-300 301-360         361+

                                                              Number of Days


Discussion
Pent-up demand usually refers to out-of-control medical spending. The minimum
deductible for the WVSBP is $1000; the median amount paid per claim toward the
deductible in 2005 was $16, rising to $40 in 2006. Only ten percent of those submitting
claims paid over $200 per claim in both years. The size of the minimum deductible itself
has a chilling effect on demand for all but the most urgent, and expensive medical
services.



                                                                                                                   48
Of potential concern is that the percent of claims submitted by primary care providers
dropped from 25% in 2005 to 19% in 2006. This may reflect the impact of the
deductible on utilization. For example, enrollees in their first year on the WVSBP may
not have realized that preventive care services were subject to the deductible before the
plan begins to cover these costs. After accessing care in 2005 and discovering that it
was not covered, they may have chosen not to seek primary care in 2006 unless
necessary. Information from the beneficiary panel interviews provides some support for
this possibility. More than one person indicated that the coverage was only for major
illnesses – “Because deductibles are so high, don't go to the doctor unless it is
absolutely necessary” – “That deductible is just too high. I'm a single party and unless
I'm really ill in the hospital, I'm never gonna make $1000 deductible so that doesn't help
me.”




                                                                                       49
50
                                 Other Issues
Evaluators were unable to collect or access existing data to answer a question that
arose after the second insurance agent workshops - Is there an indirect benefit of the
WVSBP? Did WVSBP marketing supported by the RWJF grant funds and/or broker
efforts serve to get employers in the door that subsequently purchased another
product?

The first attempt to collect information to address this question involved asking agents
to distribute an enrollment survey to all businesses to whom they provided a quote for
the WVSBP. The survey was accompanied by a self-addressed/stamped envelope.
This effort was discontinued due to a very low response rate – approximately 25 forms
were ever returned. The evaluators had no way of determining whether the lack of
response was due to the agent not distributing the survey or the business
representative not returning the survey.

A second attempt involved a question and request to MSBCBS regarding their ability to
generate and release to the evaluators a report listing all of the businesses that
received a quote on the WVSBP whether or not they subsequently purchased that
product. Using this list, the evaluators planned to 1) compare it to the WVSBP
enrollment report and match the business name, thereby providing a count of
businesses that received a quote but did NOT purchase the WVSBP, and 2) determine
the number of businesses quoted who did not purchase the WVSBP but did purchase
another MSBCBS product. MSBCBS indicated that there was no practical way to
facilitate this analysis. They said it would involve a significant amount of manual
intervention beyond a level that they could reasonably commit their resources.

The evaluation question was dropped from consideration.

Business owners during the phone interviews and agents during the focus groups often
mentioned the annual premium increase. Evaluators spoke with the WV Insurance
Commission, Rates and Forms Division to fully understand the rating circumstances of
this plan.

Chapter 33 Article 16D Section 5(a)(3)(B) of the WV State Code applies to all
commercial insurance carriers offering group health insurance to small employers
(employers with 2 to 50 eligible employees). This section of the code allows these
carriers to apply an adjustment not to exceed fifteen percent annually due to claims
experience, health status, or duration of coverage. This adjustment is allowed in
addition to any increase to the overall block of business within a class.

MSBCBS applies a 15% annual durational increase at renewal to all groups in the 2 to 9
market only. For groups having 10 to 50 eligible employees, MSBCBS applies an
adjustment up to 15% to each group based on the individual group’s claims experience
and health status. These adjustments are in addition to any increase to the overall
block of business or age-related increases that may apply.


                                                                                         51
It is important to note that the WVSBP is included in the pool with all other MSBCBS
small group product lines so any base rate filing increase would therefore affect all of
MSBCBS small group businesses and not just the businesses in the WVSBP.
Furthermore, the WVSBP not only receives the benefit of PEIA reimbursement levels for
claims but also requires a higher minimum anticipated loss ratio, which is 77% compare
to 73% for the standard small employer product. MSBCBS uses a minimum loss ratio
of 79% for their WVSBP product. With the PEIA reimbursement levels and the higher
minimum loss ratio, the rates for the WVSBP are approximately 22% lower than the
rates for the MSBCBS small employer products that are non-WVSBP.




                                                                                     52
             Overall Conclusions/Observations
The West Virginia Small Business Plan was developed in recognition that the majority of
employers in West Virginia are small employers with 50 or fewer employees; that small
business owners are least likely to provide health insurance coverage due to the high
costs of insurance premiums; and that the per capita income of West Virginia precludes
the great majority of employees from purchasing coverage through the individual
insurance market. The original concept for small business coverage included in the
Robert Wood Johnson State Coverage Initiative Demonstration grant was a public
solution, specifically to allow a PEIA buy-in to the non-state agency pool for small
businesses. The final product, however, represents a public-private partnership
between the State of WV and commercial insurers to provide the benefits needed by the
state’s uninsured working for small businesses.

Only one commercial provider has elected to carry the WVSBP product. That provider,
MSBCBS, is the largest commercial carrier in West Virginia. Marketing for the plan has
been underwritten with RWJF State Coverage Initiative funds and implemented under a
state contract. In spite of factors that should support enrollment (a statewide network of
MSBCBS brokers, active marketing), fewer than 2000 West Virginians are covered by
the WVSBP. Furthermore, based on the findings from the member survey, it is possible
that over half of the employees covered (making up approximately 60% of the covered
lives) already had some sort of health insurance coverage before their employer signed-
up with the WVSBP.

One issue that became apparent after review of several evaluation activities is that
communication about the program, the benefit structure, what it is and how it operates
is an issue for businesses, employees, the agents who are selling the product and
providers who are opting out of the network. Knowledge about the plan specifics is
insufficient and sometimes inaccurate.

Agents play an important role in the WVSBP through their contact with prospective
businesses and their employees. The insurance agent is usually the first contact when
a business is seeking to add or change health insurance coverage and often times is
the person to educate and provide opinions on programs that are available. The
support of a product, or lack thereof, by insurance agents can influence the take up and
success rates of these products. One factor raised during the focus groups with agents
that has some impact on their support of the WVSBP is that the commission they
receive for selling the plan is half what they would receive for any other MSBCBS
product.

The MSBCBS insurance agents responsible for selling the product felt that the publicity
campaign supported with RWJF funds did drive people to inquire about the product, but
only in those areas the campaign reached, i.e., larger more urban parts of the state.
The marketing campaign served to get business owners in the door to start
conversation about health insurance.



                                                                                       53
Once in the door, some of the eligibility and benefit restrictions and costs keep owners
wanting to do something for the employees from being able to do so. Agents feel that
the requirements of 12-month look-back and having to be in business for 12 months are
too restrictive. There is concern that the state, by focusing on businesses that have not
covered their employees, is overlooking the real threat posed by escalating premiums
for small businesses that have been providing health insurance. This assessment
received some anecdotal support from some of the providers, responding to the opt-out
survey, who commented on their ineligibility to purchase the plan. Agents also say the
WVSBP needs more flexibility in its coverage, i.e., more 1st dollar coverage for office
visits without having to first meet the high deductible, ability to remove maternity care
coverage, among other changes that would potentially lower the costs.

With respect to costs, agents say the costs associated with the WVSBP are not
affordable to many low wage employers. Although it is more affordable than other
products in the initial year, premiums increase yearly, which brings the cost back up,
making it difficult especially for small employers. They also indicate businesses
sometimes do not like the benefit structure and choose some other product.

Problems identified by the agents with the WVSBP’s costs and benefits were validated
by both the business owners that purchased the plan for their employees and by
employees enrolled in the plan. Business owners, although indicating satisfaction by
and large with the WVSBP, expressed concern about the automatic rise in premium
rates at the point of renewal, complaining that premiums are too high and the only way
to reduce them is to increase an already very high deductible or re-apply again.
Owners say their employees cannot afford to cover their families/spouses because of
the premium costs.

Employees say the $1000 deductible is too high (this is lowest level available). Some
have said this would only cover major illness/injury. They also echo the agents in
saying that they would prefer to pay a small co-pay for each office visit instead of having
to first meet the deductible. Coverage for annual physicals without having to meet the
deductible was also mentioned a few times. There appears to be a lot of confusion
relating to whether preventive services are covered only after the deductible has been
met or not. This is definitely an area that needs to be studied.

The decrease noted in the percent of claims from primary care providers from 2005 to
2006 may be related to the large deductible and provide some evidence that clients are,
indeed, not seeking care. Individuals in their first year of coverage possibly sought care
without fully understanding that preventive services, office visits, etc., were not covered
until after they first paid their annual deductible. The deductible levels appear to be
constraining access and possibly are having a dampening effect on utilization of
services from primary care providers. The lack of coverage for preventive care is
especially alarming. Anecdotal evidence from the panel telephone calls supports the
case. At least one person indicated that he did not seek a physical exam this year
because last year it was not covered so he had to pay 100% of the costs out of pocket
while others have said they will never use it unless they have something major or are
seriously ill or injured and in the hospital.

                                                                                         54
                             Appendices

Appendix A – MSBCBS Summary Benefit Highlights Description
Appendix B – Insurance Agent Focus Groups Discussion Guide & Summaries
Appendix C – Business Owner Mailed Survey & Cover Letter
Appendix D – Comments Business Owner Mailed Survey
Appendix E – Member Mailed Survey & Cover Letter
Appendix F – Comments Member Mailed Survey
Appendix G – Business Owner Telephone Panel Questionnaire
Appendix H – Comments Business Owner Telephone Panel
Appendix I – Member Telephone Panel Questionnaire
Appendix J – Comments Member Telephone Panel
Appendix K – Provider Mailed Survey & Cover Letter




                                                                         55
 Appendix A: West Virginia Small Business Plan
MSBCBS Benefit Highlights Summary Description




                                                 56
57
58
59
             Appendix B: WV Small Business Plan Agent Focus Groups
                   Discussion Guide & Summary of Transcripts

Discussion Guide
Introduction & Description of the project
Welcome, My name is _____________________ and I’d like to thank you for taking the time to
share your opinions with me today. We will be talking about the WV Small Business Plan with
insurance agents.
I am from the West Virginia University Institute for Health Policy Research and we are
conducting the evaluation of the WV Small Business Plan as part of a Robert Wood Johnson
Foundation grant that helped initiate the Plan. This discussion is part of the evaluation
activities. The purpose of today is to discuss the WV Small Business Plan from your
perspective as insurance agents.
Focus group intro, taping, confidentiality
Your responses will be kept anonymous and your full-name will not be reported in any
document. Any time we cite something from the discussion it will be labeled as either male or
female or your first name only.

My colleague(s) _______________ is/are in the room as timekeeper to make sure we get done
on time. We are also recording this to make sure that we have everyone’s comments. This way
we will have an accurate transcript of our discussion.
Hand out payment form – WVFIMS Supplier Registration Form

In order to pay you the $100 for participating today, we need some information from you. We
are required to collect this information for tax purposes. First, I need to confirm that none of you
are employees of WVU. Are any of you a WVU employee?
IF yes, they still complete the form but make a note on the form that line #4 will be employee
instead of individual

On Line #1, we need the name of the person or business exactly as it should appear on the
check.

If you are requesting payment to an individual, we will need your social security number on line
#2 then complete the address the check should be mailed to and provide a telephone number in
case of questions.

If you are requesting payment to a business, we need the Federal Employee Identification
Number (FEIN) on line #2 then complete the address the check should be mailed to and provide
a telephone number in case of questions.

*** If payment is going to be made to a business, please raise your hand so that we can come
around for the business information needed on lines 4 & 5.

The WVU Research Corporation will mail the check directly to the address listed on this form in
approximately (2) weeks.

Ground rules
Focus group discussions are open discussions, so please feel free to say whatever you think.
We want to hear from every one of you. There are no right or wrong answers; it is your opinion
that matters to us.


                                                                                                 60
Please speak up; if your voice is too soft we will not be able to hear what you say.

Also, please speak one at a time so everyone’s comments can be recorded and try to not have
any side conversations.

We want to hear from everyone so I may call on quiet people or ask for your views specifically.
Since we only have a limited amount of time to finish, I may interrupt so we can move on.

So that we stay on time, we will not have a scheduled break. We have water and soft drinks in
the room. Please feel free to get up and get a drink or take a bathroom break if you need it. I
just ask that we not have more than one person away from the table at a time, as much as
possible. Also, if you have a pager or cell phone, please turn it off for the next 2 hours so that
no one is distracted.

Are there any questions before we begin?

Participant introductions - INTRO QUESTION: (5 minutes)
First, I’d like to go around the room and have each of you tell me (3) things:
Your first name ONLY; The area in West Virginia where you sell health insurance
And, the number of years that you have been an insurance agent
Note to moderator: if necessary reiterate confidentiality

QUESTIONS
1. Do you actively promote the small business plan product? (10 minutes)
    If you don’t promote this product, why not?
2. How do you promote the product? (5 minutes)
    Prompt – do you try to find customers or let them come to you?
3. To whom do you promote the product?(5 minutes)
4. When would you NOT promote the product? Why not? If because of eligibility, what part of
    the eligibility criterion is it? (10 minutes)
5. Have you sold any contracts? If yes, about how many? (5 minutes)
6. Have you sold another plan to clients who initially came to you asking about the Small
    Business Plan? (15 minutes) If so, why? How often does this happen?
7. How have prospective purchasers responded to the plan?(20 minutes)
    What have they specifically liked and disliked ?
    Prompt – what are some reasons for purchase and for decline?
8. Are people coming to you as a result of learning about the product through a marketing
    effort? Which ones? What do they mention? (5 minutes)
9. Fall 2005 marketing vehicles for the Small Business Plan included print, Internet, broadcast,
    and college sports events. Were you aware of marketing efforts? What types of marketing
    are you aware of? (5 minutes)
10. What do you believe has been the value of external marketing?(5 minutes)
11. When grant support for the Plan ends there will probably be no more marketing of the plan.
    What do you see as the impact of there being no extra marketing? (5 minutes)
    Prompt - what do you anticipate as the impact of no marketing on your business?
    Prompt - will you do anything different?
12. What changes would you suggest be made to the WV Small Business Plan to make it a
    better, more desirable, easier to sell insurance product? (20 minutes)




                                                                                                61
Summary of Charleston Session
Participant introductions: The area in West Virginia where you sell health insurance.
And, the number of years that you have been an insurance agent
Cabell County               20 years            Point Pleasant               30 years
Southwestern WV             20+ years           Ashland, KY                  6 years
Kanawha County              18 years            Entire state                 13 years
Cabell County               4 years             Kenova                       14 years
Barboursville               36 years            Putnam & Kanawha Counties 3 years

1. Do you actively promote the small business plan product? Yes No
   If you don’t promote this product, why not?
o “I don’t actively seek a whole new business, especially in that market [the uninsured].”
o “Not in the last six months….in the beginning, definitely I fielded a lot of calls. Seemed like it
   kind of fizzled because the plan wasn’t as beneficial as I think the consumer thought it might
   be, and so, I really haven’t fielded that many calls, therefore, I haven’t been promoting it
   either.”
o “If eligible”
o “If they qualify”
o “I think a good part of the reason that I don’t actively solicit it is the requirements. I do not
   believe that the one year requirement [one year in business} should be there.”
o “12 months in business rules out start-ups and that should be the market.”
o “Well, I don’t promote it. As we discussed….the commission is very low, that’s No. 1.
   Number two, the product design itself is designed not for the benefit of the people but really
   for the benefit of BC. It’s to get people in BC and let them adjust the way they want. And,
   also, the plan itself, to me, it does not have the benefits that people want. People might be
   better off, better served, with a very, very high catastrophic deductible and have some of the
   lower-end benefits in there.”

2. How do you promote the product? Do you try to find customers or let them come to
   you?
o “Part of the “toolbox” of products. No special pitch.”
o “Through cold calls.”
o “If asked.”
o “If referred.
o “We really don’t actively prospect for anything that much, and I just try to stay up on it so that
   I can intelligently discuss it with them.”

3. To whom do you promote the product?
o “Groups under 10”
o “I have spoken to groups over ten, but there are some issues with the plan design that some
   of the employers that have larger groups don’t really like it.”

4. When would you NOT promote the product? Why not?
   If because of eligibility, what part of the eligibility criterion is it?
o “After receiving a few rates, and looking at how those particular clients responded to the
   plan and the workers, I’ve pretty much rules it out for a minimum wage-type employer
   because, you know, the people that are making minimum wage have a very small
   disposable income, …and they want to buy a prescription card or whatever; and so, I found
   that a higher deductible plan that has a co-pay is more advantageous or an easier sell to
   them.”
o “Other products available, better level of benefits.”


                                                                                                 62
o    “Don’t promote to minimum wage, they can’t afford it.”
o    “Higher wage earners lean toward HSAs.”
o    “A lot of people will come in and inquire about—they had a real strong interest in HSAs and
     it’s not compatible with that. What I would like to see BC do is include more of their plan
     designs and then also come up with something that’s HAS compatible.”
o    “…the longer I’ve done it, the most frustrated I’ve become with the tier group, as every year
     this thing comes along that you have to rewrite it or you have a 25 or 30 percent rate
     increase, and if a person becomes to where they have a health problem, then there’s no
     choice for them.”
o    “The goal is to get people insured not necessarily insured through the WVSBP. It gets
     people in the door.”
o    “Cafeteria plan. Flexibility. Take out maternity or substitute with something else the group
     wants.”
o    “Employer doesn’t like the 50 percent contribution required by WVSBP versus the 25%
     required of other blue products. Employees can’t afford to cover 75% of the premium.”
o    “Look back.”

5.   Have you sold any contracts? If yes, about how many?
o    Zero                       o Six or eight                         o   Zero
o    Four or five               o Zero                                 o   Ten
o    One                        o Three                                o   Five or six
o    Zero                       o Zero
o    Zero                       o One

6. Have you sold another plan to clients who initially came to you asking about the
   Small Business Plan? Do people ever walk away without purchasing anything? If
   so, why? How often does this happen?
o “I’ve mentioned it to some potential prospects, but they looked at the plan design, the
   benefits versus the premium and then the Super Blue Plus and they chose the Super Blue
   Plus.”
o “And it’s usually something as easy as an office visit co-pay or a better drug benefit, it wasn’t
   any big thing about it…”
o “Long-term uninsured are blown-away by the cost of insurance.”
o “Individual plans for healthy folks will cost less than SBP.”

7. How have prospective purchasers responded to the plan? What have they specifically
   liked and disliked? What are some reasons for purchase and for decline?
o “Likes BCBS Network”
o “Dislikes, the prescription drug card is pretty light.”
o “Look back.”
o “No co-pay.”
o “As far as dislikes, it’s just what those folks said, it’s the perceived value of what they’re
   actually getting for their money. Some of them don’t think it’s a value because there’s no
   co-pay on there, and that they’ve got that high deductible.”
o “Well, it’s not so much cost, just value, you know, what am I getting for this money versus I
   could spent a little bit more and get this plan…”

8. Are people coming to you as a result of learning about the product through a
   marketing effort? Which ones? What do they mention?
o “Joe on TV.”



                                                                                                63
9. Fall 2005 marketing vehicles for the Small Business Plan included print, Internet,
   broadcast, and college sports events. Were you aware of marketing efforts? What
   types of marketing are you aware of?
o “TV and I go to football games and I was aware that it was being promoted.
o “College sports, the billboard and the TV.”

10. What do you believe has been the value of external marketing?
o “I think its had a huge impact on reaching out to, especially, rural areas of WV and I’m a little
    concerned that when the RWJF grant ends that we’re going to have issues with that. I think
    we need to continue with it.”
o “..it made the public aware, made them aware that there was a plan out there. But I think it
    also made the public aware that there are some 400,000 West Virginians that do not have
    health insurance.
o “…they mentioned in the meeting today that they only had 235 groups, so in that regard, the
    value of the program hasn’t really been that good…..I don’t think that the public awareness
    is where the problem is. I think it’s the perception of the customer as to what the value is
    going to be to them.”
o “So I think to base the success of the program on the number of groups that actually
    enrolled in this particular plan might …I mean, we might be missing something.”
o “Personally, the value to me of the marketing has been to give me more of an opportunity to
    engage people in a meaningful discussion and possibly cross sell them some things that
    they do need, that they have an interest in.”
o “Promote plans generically versus SBP specifically”
o “Value for price.”

11. When grant support for the Plan ends there will probably be no more marketing of the
    plan. What do you see as the impact of there being no extra marketing? What do you
    anticipate as the impact of no marketing on your business? Will you do anything
    different?
o “Now, the reality check is 99 percent of all the products that I have don’t do marketing
    anyway, other than just the plan brochures, maybe a website, something like that.”
o “If they changed a significant thing about, you know, being eligible for the plan, that would
    be something that would need a big marketing blitz, but now it’s out there, it’s just up to the
    agent to sell it.”

12. What changes would you suggest be made to the WV Small Business Plan to make it
    a better, more desirable, easier to sell insurance product?
o “One of the things I would like to see happen and this would be for the WVSBP to be
    marketed alongside the ACCESS WV, the CHIP Plan and even the new facilities plan they
    were talking about today……Again, going back to the same thing, that I think WV insurance
    agents should be compensated for at least putting people in these plans.”
o “Flexibility”
o “Co-pay”
o “HSA compatible”
o “Relook 12 months in business requirement”
o “…maybe just put a cap on it and say, two visits per covered person per year.”
o “…let the particular product fill a niche, rather than to try to answer a social problem about
    not being totally insured. I would like to let it help prevent folks from becoming uninsured,
    not just helping those after they’ve been uninsured for a year…… Let it compete with the
    rest of them.”
o “Increased affordability and increased flexibility with more choices.”


                                                                                                64
Summary of Beckley Session
Participant introductions: The area in West Virginia where you sell health insurance.
And, the number of years that you have been an insurance agent
Charleston                  20 years            Southern WV                  27 years
Beckley                     2 years             Greenbrier & surrounding     33 years
McDowell County             18 years            Southern WV, Mercer County 20 years
Mercer County               2 years             Southern WV                  12 years
Charleston                  6 years             Greenbrier County             7 years
Greenbrier, Pocahontas,                         Greenbrier County            46 years
Monroe                      20 years

1. Do you actively promote the small business plan product? Yes                     No
   If you don’t promote this product, why not?
o Most have promoted
o “Don’t promote, “I’ve always ran into the situation where if the people couldn’t get their
   regular insurance, they try to get this, and their health problems were so bad, the premium
   was so high, they still couldn’t afford it.”
o “…underwriting was too tough, or run up the premium with the employee.”
o “..I’ve run across the problems that they have had insurance within the past 12 months, so I
   usually end up going with the 2004 plan…”
o “I cover my own staff with this plan, because I had to let it (health insurance) go for over a
   year, because I couldn’t afford it. So I’m glad it came along.”
o “I haven’t promoted the plan because I don’t think there’s an effective way to target market it
   to the qualified businesses, but I have sold it to several businesses by chance.”

2. How do you promote the product? Do you try to find customers or let them come to
   you?
o “Let them come to me. Referrals”
o “Cold calls.”
o “I target commercial customers, and most of them either have had them for a year or more,
   or they just can’t afford it.”
o “Advertisements”
o “Word-of-mouth, referrals”
o “Repeat business with present clients.”
o “I’ve found it very effective calling folks that I’ve had insured before. And the biggest
   problem I see with this product, it’s not the product itself, it’s the restrictions.”
o “I think for me this particular product just fits in the portfolio of all our products. If I have a
   prospect that hasn’t had insurance for 12 months, it’s great…I’m not out actively soliciting
   specifically for this product when we’re out there.”
o “In a small area, and people say, what about this new plan, you know, that the Governor
   Manchin has had, you know, and as far as the one year, I mean, I don’t know of a way that
   could ever change.”

3. To whom do you promote the product?
o “Mom-and-pop shops, just small employers.”
o “Small group market, I think that’s just…one reason why is because larger groups already
   provide coverage, but smaller groups are the ones that typically haven’t had coverage, so I
   think it fits the small group market better.”

4. When would you NOT promote the product? Why not? If because of eligibility, what
   part of the eligibility criterion is it?


                                                                                                   65
o    “12 month look-back.”
o    “50% employer contribution.”
o    “So when they evaluate the cost between the difference in the two plans and what they’re
     required to pay, then the 2000 product outweighs the benefits of the ’04 product and they’ll
     generally choose that, even if they are qualified, because they can pay less.”
o    “….if I knew that the client has expressed to me that they have money for the insurance,
     they want their $10 doctor’s visit, they want their drug card, you had to pay to really get the
     30 percent factor..” [customer wants different benefits than offered in SBP]
o    “I think what she’s saying is there’s not enough price difference between the regular product
     and the level of benefits in the SBP sometimes to lure a prospect to buy that.”
o    “And one other thing too, talking about your regular plan and this one, well there’s a
     difference in commission between the two. If you’re going to sell the same plan, then you’re
     going to have to deal with ethics on your part, can they really afford the difference between
     the two plans, the 22 percent difference. Most of the time we go down, give them 22
     percent, they qualify.”
o    “I don’t know what they’re expecting, but they’re surprised still of what the premium is. You
     talk to people who don’t have any insurance, so I think, you know, they haven’t been in the
     ball game, they haven’t seen these rates go up year after year after year, so they look at
     them, you know, and it’s still very high for them……And then they’re going to end up paying
     at least 50 percent of it, the owner, so you know….”
o    “We should always sell the tax advantage to the owners, but you run into a lot of businesses
     who don’t make enough money to even worry about tax incentive.”
o    “12 months being in business.”

5.   Have you sold any contracts? If yes, about how many?
o    One                        o Ten or eleven                         o   One
o    Zero                       o None                                  o   Three-four
o    Four-five                  o None                                  o   Three-four
o    Four-five                  o About 10
o    None                       o None

6. Have you sold another plan to clients who initially came to you asking about the
   Small Business Plan? Do people ever walk away without purchasing anything? If so,
   why? How often does this happen?
o “Don’t qualify.”
o “Second reason being if I sell an HMO product instead of the New Business Plan they’re not
   subject to the—they’re automatically making people subject to the preexisting condition
   clause. Their HMO doesn’t have that, so I can sell that and that sometimes outweighs the
   benefit of the SBP, because you’re going to rate up for preexisting conditions, but you’re not
   covering them. An HMO is going to rate it for them and cover them. So it seems that we
   could be able to get better discounts, since you’re forcing them to be subject to the
   preexisting conditions clause.”
o “If I was selling a Blue Cross plan, I would say 90 percent of the time, maybe 95 percent of
   the time, I see another Blue Cross plan and then, if it’s neither one of those plans, then
   probably 75 percent of the time, they’ll walk away or buy an HMO.”
o “50-50”
o “What they do is compare it to the other Blue Cross plans and they’ll say, do, for this much
   more I can get this, this, this yes”
o “It’s always the affordability. I mean, health insurance is just so expensive….It’s still a lot of
   money [even with the 22 percent discount]. I just got my renewal. I know.”



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o   “I’ve tried to sell it before but it was the employee participation. There wasn’t enough---the
    employer was willing to do it but---not enough employees, so then we just had to go with
    individual accounts.“
o   “I’ve had probably at least half a dozen or so new physician offices that started up and
    they’re particularly upset when they find out that, yes, they participate in the PPO, they
    accept the SBP, but they haven’t been in business a year, even though they’ve been in
    practice someplace else with another physician office..”
o   “The health insurance is okay. You don’t have the benefits they’re looking for. You may
    save money, but you won’t have what they want. You may save money, but it’s not what
    they wanted.”
o   “High deductible.”
o   “The commission”
o   “I can comment on that. It does matter right now. It’s hard starting and not getting paid
    much for all the time you put into it.”
o   “Flexibility”
o   “So we need to have more price difference and maybe even some lesser options on the
    product, if they don’t want some of the benefits in there, then maybe some flexibility on
    designing it down, but I don’t think that you should mess with increasing the benefits
    because then you’re defeating your purpose on getting a price difference.”
o   “I think the biggest thing that I have is they don’t understand they they’re not getting the top-
    of-the-line. They just think, or assume, that because they’re a new business, they’re going
    to get this same plan as the other group’s plan for less money because they own a new
    business.”
o   “I have sold other products….Maybe 80 percent of the time.”

7. How have prospective purchasers responded to the plan? What have they specifically
   liked and disliked? What are some reasons for purchase and for decline?
o Blue Cross Blue Shield
o Drug card
o “Well, the BC Network is important in our area. We have a lot of people that go into Virginia
   and North Caroline for their healthcare, especially for big items, so the BC Network’s a big
   plus and I think the out-of-pocket on it’s reasonable. I mean, in the $1,000 deductible plan,
   we’re looking at $2,000 out-of-pocket in a network..”
o Better benefits
o Co-pays.
o Bottom-line premium.
o “Have they thought about making the deductible higher and maybe throwing in an office visit
   and maybe a better drug card? I wonder if they considered that?”
o “The lower premium gets their interest because that’s your bottom line on all of this.”
o “I haven’t really, to be honest with you, pushed the product because they may not have
   coverage, and the reason they don’t have coverage, I’ve ran into, is because they’ve got
   some very sick people on their payroll….They let the premium to sky high, on the standard
   plan, but couldn’t get one, because the rate was so high, that they couldn’t afford, at least, to
   pay half.”
o “What burns everybody on this, so what if I go out here and pay $500 in co-pay. Well, you
   haven’t paid a dime toward your deductible. They like to include their co-pay in their
   deductible co-pay. Same way with all your contracts is your co-pay should be included in
   your deductible.”
o “The groups that I have dealt with, they dislike the premium.”
o 75% participation



                                                                                                   67
o   “But a lot of times when you get to your participation rate, you know, you’ve got an employer
    who’s got ten employees and out of those ten employees, five them says, okay, I want
    health insurance, and I’m willing to pay my half. Well, then the other five says, no, I can’t,
    you know.”
o   “You know, I want the highest deductible I can get, and I want the lowest premium, you
    know. I’ve looked at all those factors and things, but when I write insurance in blue collar
    groups, that’s not what they’re looking for. Those employees are not looking at...they’re
    looking at the drug card and they’re looking at the co-pays for your doctor’s office. You
    know, we went to the $500 deductible on a group, and I actually have employees say, well,
    what good is that?”
o   “….if they’re making $10 an hour, and they’ve got to pay $500 and then $1000 again, they
    won’t think they have any insurance.”

8. Are people coming to you as a result of learning about the product through a
   marketing effort? Which ones? What do they mention?
o “…the most productive has always been mailers, has been a good percentage. What’s
   been done with the money, it’s been used on radio and TV, now the TV ad was good.”
o “TV”
o “Word-of-mouth”
o “Employer”
o “Community meeting.”
o “Newspaper and ballgame”

9. Fall 2005 marketing vehicles for the Small Business Plan included print, Internet,
   broadcast, and college sports events. Were you aware of marketing efforts? What
   types of marketing are you aware of?
o “TV and newspaper”
o “I knew about all of them”
o “None”
o “Radio”
o “The Governor on TV”
o Most listed TV and newspaper.
o Some knew about them but hadn’t directly seen any.

10. What do you believe has been the value of external marketing?
o “These little ole Sunday supplements and they put this in the Charleston Gazette and you
    can tear it out and send it back in, and they got thousands of these a week, the state, which
    it cost $1,500 a week, but still that’s a lot cheaper than radio and TV.”
o “I think its been productive, but it could be more targeted…..if you could look at your
    demographics on where these people that qualify for that, if you have that information, and if
    you could target those particular areas with those stations…”
o “…I think the advertisement, if there could be some way, you know, call immediately, call
    your agent if you qualify, and the big qualification is when you’ve been in business with no
    insurance.”

11. When grant support for the Plan ends there will probably be no more marketing of the
    plan. What do you see as the impact of there being no extra marketing? What do you
    anticipate as the impact of no marketing on your business? Will you do anything
    different?
o “I think as long as you, the agent, are, you know, trying to promote this, I don’t really see the
    outcome marketing. I think you, as the agent, is going to make the big difference.”


                                                                                                68
o   “Once the marketing stops, then does the public think that the program has stopped, that
    there’s no longer eligibility and can I not get this because I’m carrying a salary.”
o   “I don’t think it’ll have a large effect because the seed has been planted and people know
    about it, so I would offer it to any client as an alternative or as a prospective client first line
    because of the cost.”

12. What changes would you suggest be made to the WV Small Business Plan to make it
    a better, more desirable, easier to sell insurance product?
o “Commission.”
o “You’ve got to have initiative to sell. You don’t pay enough on your contracts. The next
    thing, the product needs to …..be explainable to the people. Again, you’re going to have to
    look at affordability. A small business that has minimum wage or slightly above, they cannot
    afford this premium. They don’t have the benefits they need. One of the biggest selling
    points on group contract was the personal disability, either short or long term, and then the
    life insurance, and you don’t have either on these.”
o “There’s three things you ask yourself when you sell a product. Do I like it, do I need it, and
    can I afford it?….this is not practical for the people on minimum wage or slightly
    above…They can’t qualify for Welfare, and they can’t pay a high premium, so they’re left
    without insurance. We can pretend from now on we’ve got a great product, which we do
    have a product, but it’s not affordable. Anything that’s not affordable is not really
    marketable.”
o “Cap coverage”
o “What can they afford? Give it to them.”
o “The WVSBP has to offer a plan that’s similar or closer to exactly what the Blue Cross
    markets to its other customers….if some of their 2002 products were offered in addition to
    their 2004, in the SBP, …for example, their $1000 deductible2002 product does have an
    office visit co-pay and a lower prescription drug percentage …”
o “…if the Blues come out with an HAS product, I’d like to see them put that in their WV SBP
    product too.”
o “…take a look at it and see if there is any way that they can create a bigger variance in the
    price between that product and their 2000 product….”
o “Remove the 12 months in business.”
o “Review the 12 month look-back “
o “Reduce 75 percent participation rate.”
o “Reduce employer contribution.”
o “Flexibility”
o “…it’s called the dual choice option and you can have two Blue Cross plans within one
    employer group. ….this group could take the base plan, and then the employer can offer
    the other and then they buy up to the other plan, so you don’t need to add a bunch of
    different options, you just need to make sure that it’s compatible on the dual choice. With
    the SBP can we combine that with the 2000 product on a dual choice option…..”
o “I bought the plan with the 22% discount in mind. My first renewal goes up 30.9 percent.”
    “There went that 22%.”
o “So I think there should be some guarantee that there be limited inflation for the premium, to
    help retention, because, you know, I want to keep my employees covered. But I got to a
    point earlier where I couldn’t afford and I dropped it for a year, and then this came along and
    I bought it, and now, I’m right back where I started from.”
o “Bring the maximum down from a million, you know, bring it down lower and give the
    employees what they want, but give them the option of buying a higher…”[catastrophic on
    top of that]



                                                                                                          69
o   “Just that they make sure that they pay attention to that preexisting condition. That might be
    what’s important that this WVSBP is not subject to—they don’t have to worry about
    preexisting conditions. They’re not going to cover that because there’s no critical coverage.
    But other plans, that we’re taking over, that would price against it, we are given credit for
    preexisting and that’s got to be a huge price differential there.” “No, not change it, just take
    it into consideration in the pricing of the product.”

Summary of Martinsburg Session
Participant introductions: The area in West Virginia where you sell health insurance
And, the number of years that you have been an insurance agent
Mineral, Grant, and Hampshire counties in WV; mainly sells in Maryland 35 years

1. Do you actively promote the small business plan product? Yes                No
   If you don’t promote this product, why not?
o Yes, frequently promotes the product. “The rural area is a problem need a ‘general
   practitioner’ type of insurance.”

2. How do you promote the product? Do you try to find customers or let them come to
   you?
o Personal observation – agent says is well-known in the community and word of mouth
   referrals are made or people come on their own

3. To whom do you promote the product?
o Only goes after those that need help and seem sincere in addressing the issue…”some are
   not actively looking to buy”

4. When would you NOT promote the product? Why not? If because of eligibility, what
   part of the eligibility criterion is it?
o It’s usually not because of eligibility – says can “tell by a person’s car, house, etc. how much
   money they make and see who might not be able to buy insurance”.

5. Have you sold any contracts? If yes, about how many?
o About 10

6. Have you sold another plan to clients who initially came to you asking about the
   Small Business Plan? Do people ever walk away without purchasing anything? If so,
   why? How often does this happen?
o “Sometimes people don’t qualify because of the provisions stating that a business must be
   without insurance for at least 12 months, that 75% of eligible employees must enroll, and the
   50/50 premium payments between employer and employee.”
o Reports 75% of those that come leave without buying.
o “We need healthcare reform on those sending out the bills, not on those incurring the costs.”

7. How have prospective purchasers responded to the plan? What have they specifically
   liked and disliked? What are some reasons for purchase and for decline?
o “Employers do not like that they have to pay 50% of premiums, especially families.”

8. Are people coming to you as a result of learning about the product through a
   marketing effort? Which ones? What do they mention?
o “Most marketing doesn’t come here…just the games” [marketing doesn’t come to that area
   of the state]


                                                                                                 70
9. Fall 2005 marketing vehicles for the Small Business Plan included print, Internet,
   broadcast, and college sports events. Were you aware of marketing efforts? What
   types of marketing are you aware of?
o Yes aware of all of the marketing efforts because attending the 2004 agent workshops.
   Reports has not seen much of them in Martinsburg though.
o   Mentioned that business owners cannot cover all employees – the 75% participation
    provision is hard.
10. What do you believe has been the value of external marketing?
o “Marketing is very useful, especially in more metro areas.“

11. When grant support for the Plan ends there will probably be no more marketing of the
    plan. What do you see as the impact of there being no extra marketing? What do you
    anticipate as the impact of no marketing on your business? Will you do anything
    different?
“No, won’t be a dramatic impact because of location.”

12. What changes would you suggest be made to the WV Small Business Plan to make it
    a better, more desirable, easier to sell insurance product?
o “Ways to change the 75% participation rule”, although realize that it is important and there
    may be no real way around it
o “Can’t put everything on the small business owners’ backs – they can’t always pay the 50%
    because of other expenses”
o “Look at “net receipts” – sliding scale based on the size or profitability of a business”
o “The plan’s benefits are fine”
o “A limited benefits plan lets people buy something they can afford; they are a way to get
    more companies in as long as there is a way to make sure people know what they are
    buying”
o “Health insurance is not the answer for everything – we have overlooked the issue of
    catastrophic care – we aren’t doing our job with educating consumers”

Summary of Flatwoods Session
Participant introductions: The area in West Virginia where you sell health insurance.
And, the number of years that you have been an insurance agent
Roane County         5.5 years                  Pocahontas County            1.5 years
Princeton, WV        18 yrs                     Elkins, Randolph County      32 years
Pocahontas County 20 years                      Elkins, Randolph County      8.5 years

1. Do you actively promote the small business plan product? Yes                     No
   If you don’t promote this product, why not?
o “for the smaller businesses, this seems to really get their interest. They’ve heard about it,
   most of the people, when we bring it up, you know, they’ve heard of the program, they’re
   interested to learn more and we also use it in combination a lot of times with a program that
   they’re offering through the Chamber, you know, where you can get a one tier classification
   better than what the underwriting department offer, so between the Chamber program and
   this program it significantly reduces cost.”
o “I think that I haven’t had too many people come to me looking for, it’s more that as we are
   working with our existing clients who are looking for new business that it just sort of matches
   up well…so I would be a little more interested in maybe some local advertising, if we could
   use the radio spot, you know, on our pubic radio or whatever..”


                                                                                               71
o    “Promote for those that qualify. “
o    “…they usually have some form of coverage already and I think there’s a common
     misconception among the clients, they just think any business can step up to the plate and
     buy this policy…when we promote, we either sell the product or run into that problem..”

2. How do you promote the product? Do you try to find customers or let them come to
   you?
o All across the board; some go to the clients; most often they’re working with existing clients;
   don’t promote with advertising.
o “We haven’t really promoted it with the advertising or anything, but we do definitely bring it
   up and present it to people. When we request quotes, we always ask that they quote that. If
   we think it’s a small group, you know, we have it ready to show it to them, and we’ll present
   it side-by-side with the other quotes and it usually gets their interest.”
o “We’ve developed a letter actually to a lot of our clients that aren’t or do not currently have
   health insurance..so we generated a small business letter to kind of grab people’s attention,
   which has worked great.”

3. To whom do you promote the product?
o “Primarily the 2 to 10 small business, the larger already have something and aren’t eligible.”
o “Normally, the ones that we find that are successful are the family-owned businesses, where
   the husband and wife own it and maybe one or two or three employees, where they’ve
   looked into getting insurance or there may be a new business in the past two or three years
   that just haven’t gotten the health insurance policy and they’re eligible now and now they
   can afford to do it.”

4. When would you NOT promote the product? Why not? If because of eligibility, what
   part of the eligibility criterion is it?
o “If I wouldn’t promote it, it would have to be just knowing that the group was so small that
   they couldn’t afford it or that they could get better coverage through something else or just
   individually.”
o “Well, you can’t promote it if they’re not eligible for it.”
o “12 months in business.”
o “12 month look-back, but they wouldn’t change that.”
o “50 percent employer contribution”

5.   Have you sold any contracts? If yes, about how many?
o    Eight or nine                               o Three
o    One                                         o Three to four
o    Two                                         o Ten to fifteen

6. Have you sold another plan to clients who initially came to you asking about the
   Small Business Plan? Do people ever walk away without purchasing anything? If so,
   why? How often does this happen?
o “I’ve had people walk away. One in mind, a doctor’s office, three or four people, and they
   haven’t had as a group, met all the eligibility but the premium was high. The Doc said, no
   can do.”
o “Where we quoted the SBP we also presented the Super Blue Plus 2000 and 2004, and
   they came as a Tier 1 and so they went with the better coverage, lower deductible.”
o “Usually, if they’re looking for the SBP, that’s what they’ve been going with, or they’ve
   walked away and said the premium’s still too high for us.”
   “I probably have had a couple instances where people have opted to go with individual


                                                                                               72
    coverage instead of doing a group, because maybe they didn’t want to cover all their
    employees.”
o   “Probably three out of four go with the business plan if we show it to them..”

7. How have prospective purchasers responded to the plan? What have they specifically
   liked and disliked? What are some reasons for purchase and for decline?
o “I think a lot of it is the name of Blue Cross which sells a lot of policies, just by the name
   itself. I think people sometimes have a question about the WV SPB, they think it’s
   something different than Blue Cross. …”
o “Deductible.”
o “Ability to do HSA.”
o “I think one of the problems this plan has, as well as all other plans, is health conditions
   developing in the group, …the premium within one year, can be wiped out by one claim and
   then you’ve got to increase those premiums in order to offset your losses and the whole
   entire book of business.”
o “..we probably need to look at something to either carve out that one sicker person or rate
   that person higher, but try to keep the other people lower, or a high risk pool in this state or
   something of that sort.”
o “ I think one of the problems that people have and maybe it’s more perceived on my end as
   the agent, is the doctor visit co-pay, the office call co-pay…if you had that, there would be
   more preventative care is attractive to the say, the 40 to the 60 year old. They’re more
   prone to go in and do those kinds of things.”

8. Are people coming to you as a result of learning about the product through a
   marketing effort? Which ones? What do they mention?
o “TV”
o “Newspapers”
o “None---rural area aren’t seeing anything”
o “Billboard”

9. Fall 2005 marketing vehicles for the Small Business Plan included print, Internet,
   broadcast, and college sports events. Were you aware of marketing efforts? What
   types of marketing are you aware of?
o “Newspaper, college games, TV                                                  “
o “Valuable”
o “I think the advertising has made people more aware that there’s options out there for them.”
o “I’d say no, that the external marketing really hasn’t helped in out area.”
o Fairness: Prevent people from becoming uninsured not just cover those currently uninsured.
o “..I’ve given my employees coverage for the last ten years and they’re going to give
   someone that hasn’t given their employees for the past ten years better rates than I have,
   that’s not fair.”
10. What do you believe has been the value of external marketing?
o “I think the advertising’s made people more aware that there’s options out there for them.”
o “I’d say no, that the external marketing really hasn’t helped in our area.”

11. When grant support for the Plan ends there will probably be no more marketing of the
    plan. What do you see as the impact of there being no extra marketing? What do you
    anticipate as the impact of no marketing on your business? Will you do anything
    different?
o So long as the plan is carried, agents will pitch it if it’s appropriate.
o Won’t do anything different.

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12. What changes would you suggest be made to the WV Small Business Plan to make it
    a better, more desirable, easier to sell insurance product?
o “Employee contribution.”
o “…you can even possibly lower the premium even more than what it is now by having
    maybe a graded annual limit….You’d be limited to no more than a quarter million a year, but
    you’d have a $2 million lifetime. Right now, the way BC writes it, it’s just a $2 million
    lifetime.”
o “…the $10 office co-pay, a lot of people love that feature, you know, how much would that
    cost. I know it would increase your premium, but people are willing to pay for that, because
    they think that’s a great option, some people, not everybody.”
o “HSA compatible.”
o “Have dual options to have lower premium and a higher premium.”
o “Office co-pay”
o “Reducing employer contribution back to 25 percent.”

Summary of Morgantown Session
Participant introductions: The area in West Virginia where you sell health insurance.
And, the number of years that you have been an insurance agent
Harrison County              49 years             Mon & Marion Counties       16 years
Tri-county area              30 years             Harrison County             20 years
Ohio County                  35 years             Harrison County             6 years
Forsythe, WV                 21 years             Mon, Marion, Harrison Counties 2.5 years
Fairmont                     13 years             Marion, Mon, Harrison Counties 50 years
Bridgeport, Harrison, Marion Counties & Southern 4 years

1. Do you actively promote the small business plan product? Yes                  No
   If you don’t promote this product, why not?
o 3 don’t promote.
o 1 did promote initially.
o So many customers.

2. How do you promote the product? Do you try to find customers or let them come to
   you?
o “Advertisements in the newspaper weekly.”
o “I have some of these brochures and I mail them out to business owners that I run across.”
o “Trade shows, I usually take the marketing material to the booths and stuff.”
o “Just take referrals and take care of those customers. Sell the product with the case arises.”
o “Lead-in product for the other services that I offer to my business clients. Not something I
   go out and advertise specifically.”
o “We don’t push it but we present it if the people seem to be interested in it.”
o “I’ve found it useful to coordinate with an accountant ….and he’ll refer them to me.”
o “Presented it with other quotes from other companies.”
o “…just depends on their particular situation as to which way we go…”
o “…we put flyers in the newsletters in our local chambers and so when those were sent out,
   we had some advertisements in there promoting the SBP.”

3. To whom do you promote the product?
o “Current business owners in our commercial lines”
o “…you kind of have to pick and choose..”



                                                                                              74
o    “I would think it would be an extremely viable thing to promote to new businesses coming
     into the state, if we had a database where you could actually go to research to see what
     businesses have been started within the past say, 12 months..”
o    “market through the Chamber of Commerce in each county because they are very much up
     on new businesses.”
o    “Let’s make it a law that you have to apply for health insurance after you’ve been in
     business for 12 months.”

4. When would you NOT promote the product? Why not? If because of eligibility, what
   part of the eligibility criterion is it?
o “How do you prove that the person has been in business for a year or more…?”
o “….if I’m only getting $14 a month and I have to go out and service these people 50 miles
   away, it seems like I’m spending more than what – I’ve got more going out than I’ve got
   coming in, so I’m really not going to promote this product that much, unless I’ve got a real
   big group, maybe right next to us or something like that, then it might be beneficial.”
o ‘…if you can’t place any ancillary business with that business owner, other than that SBP,
   it’s not going to be profitable for you and if you do it once or twice, and again…if you’re
   driving 40 miles and a lot of our clients are 40, 50, 60 miles away, one way, and you have to
   go out there to service a health plan…”
o [Agents with large panels don’t need to gin up new business. Commission big issue when
   agent isn’t also selling other product lines. Too little money for too many demands on time.]
o “Being in business 12 months an issue.”
o “50% employer contribution.”
o “It’s 22 % less, but you’re asking them to pay 25% more. It they were only looking to get the
   minimum and there have been people that have chosen a bigger plan and they still saved
   money in the long run by only paying 25%instead of 50%.”
o “..when that change comes down from 50 to 25 percent, then you get into eligibility, the 75%
   eligibility issues, because you’ve got 5 or 6 employees who just can’t afford to spend that
   big number…”
o “if you’re dealing with a group that the employees are only making $7, $8 or $9 an hour to
   begin with, it doesn’t make any difference whether it’s 25 percent of the cost that he pays…
   At 50 percent, that employee can’t afford to pay…, so it’s kind of like a moot point.”

5.   Have you sold any contracts? If yes, about how many?
o    Zero                       o Eight                              o   Twenty-three
o    Seven                      o One                                o   One
o    Three                      o Twenty-two                         o   Twenty-five
o    Two                        o One                                o   One

6. Have you sold another plan to clients who initially came to you asking about the
   Small Business Plan? Do people ever walk away without purchasing anything? If so,
   why? How often does this happen?
o “I went to a new business that had been in business about 15 months and presented the
   SBP, but when we got to looking at the high deductible and his age and the age of the
   group, it was more profitable for him to go to the standard plan and a lower deductible,
   because he ended up getting better coverage…”
o “They already had some….I just have to explain to them how they don’t qualify for it and
   they get made. They don’t think it’s fair.”
o “I’d say maybe about 40 percent of the time, we’re able to do business under the WVSBP,
   maybe another 50 percent were put somewhere else, maybe another 10 percent’s just
   walking away because, you know, they really just can’t afford it. They’re small business and


                                                                                             75
    I could say the majority of the groups that I have are 2 to 10, I mean, they’re small
    business.”
o   “...it seems like some of them are seasonal jobs, where they may have eight months out of
    the year, and so then we still have to carry it for that time frame so to be able to wash that
    out, it just hasn’t worked out.”

7. How have prospective purchasers responded to the plan? What have they specifically
   liked and disliked? What are some reasons for purchase and for decline?
o “I know some of them disliked the high deductible – well, it depends on whether they’ve had
   previous insurance….especially if you see a group that has younger, you know, 21 to 30
   year olds, when you put that in their mind that they’ve got to spend $2,500 out-of-pocket or
   whatever…it kind of hits hard to them. And it seems to be the biggest drawback on some of
   the smaller groups with the younger ages.”
o “There’s no co-pay. You’ve got to meet that big deductible first, so somebody that goes to
   the doctor once or twice a year has to pay for that visit, plus their premium every months, so
   if they make a little co-pay there with it, it might be a little bit more, you know incentive for
   them to buy.”
o “here renewal comes, and it’s Blue Cross, so you get 30 percent renewal increases, have to
   go through requalification and they’re like, I never used the plan, you know, so they’re not
   feeling very rewarded.”
o “So you can be a perfectly good employer and promote good health for your employees,
   safety on the job so you don’t have to use the plan, and you’re looking at a 28 to 30 percent
   increase automatic with requalifying. And just because you do the requalification forms and
   send them in, and you’ve had zero claims, that doesn’t guarantee you that BCBS is going to
   lump them back down that tier…”
o “…I had one that was the 30 percent increase and his employees just could no longer pay
   so we dropped and actually went to individual plans, I mean, that was the only
   option…Everyone wasn’t healthy in the group. Those people no longer have health
   insurance….It was half the costs, the individual price was half what they were paying for
   BCBS…”
o “They really think it is a much richer plan than what it is and I think that’s where they get
   disappointed and kind of get turned off on it right away.”

8. Are people coming to you as a result of learning about the product through a
   marketing effort? Which ones? What do they mention?
o “The Governor’s TV shot.”
o Radio and TV

9. Fall 2005 marketing vehicles for the Small Business Plan included print, Internet,
   broadcast, and college sports events. Were you aware of marketing efforts? What
   types of marketing are you aware of?
o TV primarily.
o “You have to increase target marketing, small businesses that have just been in business for
   a few months to prepare them for the future of the agony of health insurance. Get the foot in
   the door with them, I guess.”

10. What do you believe has been the value of external marketing?
o “You know, are we getting the bang for the buck? I kind of question that. Perhaps going
    back to an accessible database, you know where you could find companies that were
    anywhere from 11 to 13 months in business and you, you could contact them and send a



                                                                                                 76
    flyer and then do a follow-up call to see if there’s interest. Maybe that would be more
    productive.”
o   “I certainly think that all new businesses or businesses that have been in business for 12
    months or longer should be sent something from the governor’s office or whatever.”
o   “Most companies of any substance who are starting a new business or bringing a business
    to the state will want to address group insurance from day 1 and not wait 12 months.”
o   “…when a business opens in the state, don’t they have to register with somebody? Why
    don’t they develop a survey for them to send these businesses immediately, do you have
    health insurance for your employees, etc.”
o   “Along with the advertising,…., have them call an 800 number in the state insurance
    department if they want inquire about it and let the state insurance department contact an
    agent in that area, ….because the true idea behind this is having all our citizens insured.
    Right?”

11. When grant support for the Plan ends there will probably be no more marketing of the
    plan. What do you see as the impact of there being no extra marketing? What do you
    anticipate as the impact of no marketing on your business? Will you do anything
    different?
o “It will go away. If there are not free brochures to send out, I won’t put a stamp on them. I
    won’t promote it because it’s paying me 50 percent of the commission. Unless someone
    asks about it, which when you give it 12 months of no marketing and nobody will remember
    the SBP and move on down the road.”
o “I think somewhere down the road, Blue Cross is going to look at this thing and say, it’s not
    working….how much effort did it take for us to put in on the books for half of what it’s
    supposed to be and if the state doesn’t push it, they’re not going to push it.”
o Won’t do anything different
o “Participation of the 230, 235 groups is really said. That means something is not being done
    right or there would be more participation.”

12. What changes would you suggest be made to the WV Small Business Plan to make it
    a better, more desirable, easier to sell insurance product?
o “I would like it to be HSA compatible.”
o “I think there should be a small co-pay in that work, HMO exclusively, low cost, managed
    care.”
o “I feel personally on this plan that would be the best single thing you could do is eliminate
    that 12 months waiting period (new business NOT look back).”
o   “I’d like to see two $25 co-pays per person. So if you have a family, they’re allowed two
    visits per person per year. And also to put their commissions back up at least if it’s a 22
    percent reduction in price, I don’t see why you’d make it 50 percent reduction in
    commissions, maybe a 22 percent reduction in commissions would be more…”




                                                                                                  77
      Appendix C: West Virginia Small Business Plan
Business Owner Mailed Survey Cover Letter & Questionnaire




                                                            78
Business Owner Mailed Survey Questionnaire

Please fill-in the circle/dot next to your answer and return the survey in the
enclosed postage paid envelope.
1. When did your business enroll in the WV Small Business Plan?
   PLEASE INDICATE MONTH AND YEAR
       O     January          O        July                    O     2005

       O     February         O        August                  O     2006
       O     March            O        September

       O     April            O        October

       O     May              O        November

       O     June             O        December

2. Is your business still enrolled in the WV Small Business Plan?

       O    Yes
       O    No

2a. If NO, why are you no longer enrolled?

      O      My business wasn’t as profitable and I couldn’t afford it any longer

      O      Cost of Premiums

      O      Not happy with benefits
      O      Lack of employee interest

      O      Other - please specify:

3a. How many people work for you full-time?

3b. How many people work for you part-time?

4. Prior to enrolling in the WV Small Business Plan, did you ever offer health insurance to your
   employees?

       O    Yes
       O    No - Please Skip to Question #6

5. If YES to Question #4, how long ago did you offer health insurance to your employees?

      O      1-2 years ago

      O      3-4 years ago
      O      5 or more years ago



                                                                                              79
5a. Why did you discontinue the health insurance? PLEASE CHOOSE ONLY ONE

         O      My business wasn’t as profitable and I couldn’t afford it any longer

         O      Cost of Premiums
         O      Not happy with benefits
         O      Lack of employee interest

         O
                Other - please specify:

6. What factor(s) influenced your decision to enroll in the WV Small Business Plan?

     O     Cost was right                                       O     Workers demand these benefits

           Offering benefits is the right thing to do                 Offering benefits is important in terms of
     O                                                          O
           for workers                                                keeping your good workers long term

           Offering benefits is important in order to                 Competitors are offering these benefits
     O     attract new employees                                O     so I need to offer them too

     O     Other - please specify:

7. How many of your employees are eligible for health insurance?

8. How many of your eligible employees have signed-up?

Of the enrolled employees, what percentage has signed-up for:

9a. Individual Coverage                __________%
9b. Family                             __________%
9c. Employee + Spouse                  __________%
9d. Employee + Children                __________%

10. What are the major reasons given by your employees for declining coverage?
         Having insurance is not important to them          O       They have insurance through somewhere
 O
                                                                    else

 O       Too much trouble, too complicated                  O       Premiums are too high

 O       Can get all the medical care I need                O       Doesn’t cover the services
         without insurance                                          needed/wanted

 O       Coinsurance (co-pays and deductibles)
         are too high

 O       Other - please specify:



                                                                                                    80
11. Overall, how satisfied are you as a business owner with the WV Small Business Plan?

       O     Very Satisfied                     O       Dissatisfied

       O     Satisfied                          O       Very Dissatisfied

12. If you answered dissatisfied in Question #11, what are the major reasons for dissatisfaction?

        O    Premiums too high                             O   Too much trouble, too complicated

        O    Co-pays or deductibles too high               O   Providers don’t accept the product
        O    Doesn’t cover the services needed             O   Other - please specify:


13. Overall, how satisfied are your employees with the cost of the WV Small Business Plan?

       O     Very Satisfied                     O       Dissatisfied

       O     Satisfied                          O       Very Dissatisfied

14. If you answered dissatisfied with costs in Question #13, what is the major reason for
    dissatisfaction? PLEASE CHOOSE ONLY ONE

      O      Premiums too high

      O      Co-pays or deductibles too high
             Other - please specify:
      O

15. Overall, how satisfied are your employees with the benefits of the WV Small Business
    Plan?

       O     Very Satisfied                     O       Dissatisfied

       O     Satisfied                          O       Very Dissatisfied
16. If you answered dissatisfied with benefits in Question #15, what is the major reason for
    dissatisfaction? PLEASE CHOOSE ONLY ONE

      O      Doesn’t cover the services needed

      O      Providers don’t accept the product
      O      Too much trouble/too complicated

      O
             Other - please specify:

17. How did you first learn about the WV Small Business Plan?

O    From my broker/agent               O      Poster

O    Radio                              O      Billboard
O    TV                                 O      Other - please specify:


                                                                                               81
    18. What is the nature of your business?

O     Automotive                   O     Farming                    O    Mining

                                         Financial or business
O     Construction                 O                                O    Police or fire protection
                                         services

O     Chemical                     O     Food service               O    Public utilities

                                         Gas station or
O     Communications               O                                O    Sales
                                         convenience store
      Community and social
O                                  O     Healthcare                 O    Timbering / Forestry / Lumber
      services
                                                                         Transportation (railroads,
O     Education                    O     Insurance                  O    airlines, bus drivers, cab drivers)
      Entertainment, Travel,
O                                  O     Legal services             O    Other - please specify:
      Recreation

    Please complete the below information if you are willing to be a part of the business owner
    panel.

    The West Virginia University Institute for Health Policy Research, on behalf of the West Virginia
    Health Care Authority and the West Virginia Insurance Commission, is conducting research to
    assess the impact of the WV Small Business Plan. Your participation is entirely voluntary. The
    telephone survey questions will not include any personal or business identifiers. Your responses
    will be anonymous and you will not have to answer every question. There will be approximately
    (6) questions asked that will take about 10 minutes to complete.

    As indicated by my signature below, I agree to participate in (3) follow-up telephone surveys of
    business owners. I understand that my contact information will be kept completely confidential
    and will not be disclosed to anyone. At the time of the first telephone call, I will be asked to
    provide payment information that will only be used to send my “thank you” check to me after the
    end of the follow-up period. I will also provide a daytime telephone number below where I can
    be reached for the follow-up calls.


    First Name                    Middle Initial                 Last Name

    Street Address

    City                  State                    Zip Code
    _____________________________                         ___________________________________
    Daytime Telephone Number                              Alternative Telephone Number
    Please tell us the best day(s) and time(s) we can reach you for the follow-up
    calls______________________________________________________


    Signature


                                                                                                     82
                   Appendix D: West Virginia Small Business Plan
                     Comments Business Owner Mailed Survey

Question 2a: If NO, why are you no longer enrolled?
o “Wife attained insurance at her job”
o “Brickstreet priced us out of providing insurance”
o “Owner became eligible for PEIA; I provided money for other employee to get private
  insurance”
o “Left business to work with another firm”

Question 5a: Why did you discontinue the health insurance?
o “Cost to the employee”                      o “Insurance carrier stopped offering
o “Switched to WVSBP from earlier                 coverage in WV & unable to find
  MSBCBS same plan”                               replacement”
o “Started this business”                     o “Switched to small business plan”
o “Brickstreet increased 100%”                o “Employee at that time had other ins.”

Question 6: What factor(s) influenced your decision to enroll in the WV Small Business
Plan?
o “Only plan available to us as a group”       o “Product & cost was double”
o “We are getting older & needed               o “Everyone needs benefits”
   coverage.”                                  o “New business-just implemented an
o “Family business-need major care”                insurance plan”
o “Coverage & price comparison”                o “I could obtain coverage for myself at a
o “Advice from my agent”                           more reasonable cost.”
o “Cobra expired for both of us”               o “Insurance plan that must accept you
o “Availability to small company”                  cannot drop you.”

Question 10: What are the major reasons given by your employees for declining
coverage?
o “Too expensive for most employees;last       o “Only employees not covered have
   yr. premium went up 13%; this yr.20%; if      through spouse”
   cont'd will price us out of plan; need plan o “None declined”
   with smaller premiums”                      o “Everyone eligible enrolled”
o “None declined”                              o “We had some state they did not have
o “Can't or won't pay anything toward any        funds”
   benefits”                                   o “All others part-time”
o “None declined”                              o “Was None”
                                               o “They didn't decline”

Question 12: If you answered dissatisfied in Question #11, what are the major reasons
for dissatisfaction?
o “premiums have doubled in 2 yrs; being forced into highest deductible due to cost increase”
o “wish plan was less expensive so more employees could benefit from it”
o “Told on 2 claims we would be covered but after seeking medical care they declined
    payment”
o “Premiums increased $200 since inception”
o “Premiums raised too high; absolutely criminal hike!”
o “Placed in high tier without any reason”
o “No Cobra benefits; In a couple years I will be on Medicare & office mgr. will have no
    insurance as there will not be a group.”


                                                                                           83
Question 14: If you answered [employees were] dissatisfied with costs in Question #13,
what is the major reason for dissatisfaction? PLEASE CHOOSE ONLY ONE
o “They raise concerns about cost frequently & ask me to investigate cheaper options”
o “Premiums & Copay/deductibles both too high”
o “Employees do state that cost for female spouse is too high.”
o “Employees do not pay premiums”
o “The plan does not cover office visits”
o “Premiums too high AND Co-pays/deductibles too high”
o “We pay 75% of cost”
o “Premiums too high AND Co-pays/Deductibles too high”
o “Premiums too high AND co-pays/deductibles too high”
o “Premiums too high AND Co-pays/deductibles too high”
o “Premiums too high AND Co-pays/deductibles too high”
o “Company pays 100% of employee premiums”
o “Premiums too high AND Co-pays/deductibles too high”
o “Premiums too high & Co-pays/deductibles too high”
o “Premiums too high & Co-pays/deductibles too high”
o “If we did not pay the employee premium the cost would be too high for the employee. The
  costs were affordable when we purchased the plan w/3 employees; 1 employee has left--
  now that there are only 2 insured & cost of premiums are far greater than when we had our
  prev. policy.”

Question 16: If you answered [employees were] dissatisfied with benefits in Question
#15, what is the major reason for dissatisfaction? PLEASE CHOOSE ONLY ONE
o “$1000 Deductible available;lower deductible not available at any price”
o “Doesn't cover enough besides major medical”
o “Don't cover what they even verbally approve prior to care”
o “Employees state prescription drug coverage could be better”
o “Deductibles too high”
o “Deductible costs”
o “As a small business owner we should have a plan that we can afford such as PEIA”

Question 17: How did you first learn about the WV Small Business Plan?
o “WV SOS home page”                           o “Newspaper Correspondence”
o “Newspaper”                                  o “Consultant”
o “Another business owner”                     o “Newspaper articles”
o “Newspaper”                                  o “Newspaper”
o “I am an agent.”                             o “Newspaper article”
o “Heard about & then asked agents who         o “Newspaper”
  had not told us earlier”                     o “Written correspondence”
o “Financial Advisor”                          o “Our bookkeeper-Word of mouth”
o “Reading & talking to people”                o “Business Associate”
o “Newspaper”                                  o “Telephone Book”
o “State Capitol”                              o “Coal Show-Booth”
o “Newspaper”                                  o “Recommended by independent agent”
o “WVSCPA”                                     o “Mailing”
o “Newspaper”                                  o “Newspaper”
o “Newspaper”




                                                                                          84
Question 18: What is the nature of your business?
o “wholesale distribution”     o “Oil & Gas Production”   o “Dental Laboratory”
o “Service”                    o “Plumbing”               o “Sign Design- build
o “Retail”                     o “Coffee Service”           install service”
o “Veterinary Medicine”        o “Service”                o “Therapy services”
o “Advertising Design/         o “Non-profit              o “Retail Hardware &
  Photography”                     environmental            Building Materials”
o “Natural Gas & Oil”              education”             o “General Trucking”
o “Pet Boarding Facility”      o “Barber & computer       o “Metal Fabrication
o “Machine Fabrication”            programmer”              O.E.M.”
o “Ad Agency”                  o “Consulting”             o “Florist”
o “Coal Hauling”               o “Wrecker Service &       o “Real Estate”
o “Electrical Sales”               garage”                o “Outdoor Advertising”
o “Non-profit                  o “Consultant to mining    o “Computer Services/IT”
  Environmental”                   industry”              o “Oil & Gas”
o “Coal Truck Driver”          o “Truck repair”           o “Sales to mining supply
o “Real Estate”                o “Garbage company”          companies”




                                                                                85
      Appendix E : West Virginia Small Business Plan
Employee (Member) Mailed Survey Cover Letter & Questionnaire




                                                               86
Employee (Member) Mailed Survey Questionnaire

Please fill-in the circle/dot next to your answer and return the survey in the enclosed
postage paid envelope.

 1. What is your gender?
                              O    Female             O    Male
 2. What is your age?
                          O   19-24         O      35-44          O     55-64

                          O   25-34         O      45-54          O     65+
 3. What is your marital status?
                                   O    Married               O       Widowed

                                   O    Separated             O       Never married

                                   O    Divorced
 4. What is the highest level of education you have completed?

      O    Less than high school                  O   College graduate
                                                      Postgraduate training or
      O    High school graduate                   O   degree
      O    Some college or vocational
           school

 5. How long has your employer been enrolled in the WV Small Business Plan?
       O   0-3 months                             O   13 -18 months

       O   4-6 months                             O   19 -24 months

       O   7-9 months                             O   More than 2 years

       O   10-12 months

 6. How long have you been enrolled in the WV Small Business Plan?
       O   0-3 months                             O   13 -18 months

       O   4-6 months                             O   19 -24 months

       O   7-9 months                             O   More than 2 years

       O   10-12 months




                                                                                          87
7. What type of coverage do you currently have?

      O      Individual                               O     Individual plus spouse

      O      Individual plus children                 O    Family

8. Do you work more than one job?

                              O    Yes              O     No

9. Prior to enrolling in the WV Small Business Plan with your employer, did you have health
   insurance?
                             O Yes               O No

     9a. If YES, how were you covered?

         O      Covered by spouse’s insurance              O     Covered by school health insurance

         O      Covered by parent’s insurance              O     Covered by other employer

     9b. If NO, how long have you been without health insurance?

         O      Less than one year              O    10+ years

         O      1-4 years                       O    This is the first time I’ve ever had insurance

         O      5-9 years

10. How satisfied are you with the cost of the WV Small Business Plan?

     O       Very Satisfied                     O     Dissatisfied

     O       Satisfied                          O     Very Dissatisfied

11. If dissatisfied with the costs, what are the major reasons for your dissatisfaction?

     O       Premiums too high

     O       Co-pays or deductibles too high

     O       Other - please specify:


12. How satisfied are you with the benefits of the WV Small Business Plan?

     O       Very Satisfied                     O     Dissatisfied

     O       Satisfied                          O     Very Dissatisfied


13. If dissatisfied with the benefits, what are the major reasons for your dissatisfaction?


                                                                                               88
      O      Doesn’t cover the services I want/need

      O      Providers don’t accept the product
      O      Too much trouble/too complicated

      O
             Other - please specify:

14. Since getting health insurance how many times have you seen a physician/provider for
    routine, preventive care (e.g., annual physical)?


15. Since getting health insurance how many times have you seen a physician/provider for
    care other than routine or preventive, such as a problem, illness, injury, etc.?



15a. If applicable, on the below lines please briefly describe the problem(s), illnesses or
injuries for which you sought care.




16. Since getting health insurance how many times have you been to the emergency room?


17. Why did you go to emergency room rather than go to your doctor’s office?

  O       My illness or injury made it absolutely necessary to go to the ER.

  O       I was unsure about the nature of my injury or illness so I went to the ER.
  O       I do not have a regular doctor/provider.

  O       The wait time to get a doctor appointment.

          My work schedule or transportation needs make it difficult for an appointment during my
  O       doctor's regular office hours.

  O       Other - please specify:

18. Has your overall health improved since getting health insurance?

               O    Yes                O   No

19. How would you rate your health?

      O      Excellent                          O      Fair

      O      Very good                          O      Poor


                                                                                              89
       O      Good                                O     Very poor

 20. Did you ever experience difficulties accessing health care you needed when you did not
     have health insurance?

       O     Often                O    Infrequently                    O    Never

 21. Have you experienced difficulties getting the health care you need since getting health
     insurance?

       O     Often                O    Infrequently                    O    Never

 22. Has your access to health care improved since getting health insurance?

               O     Yes               O    No

Please complete the below information if you are willing to be a part of the employee panel.

The West Virginia University Institute for Health Policy Research, on behalf of the West Virginia
Health Care Authority and the West Virginia Insurance Commission, is conducting research to
assess the impact of the WV Small Business Plan. Your participation is entirely voluntary. The
telephone survey questions will not include any personal or business identifiers. Your responses
will be anonymous and you will not have to answer every question. There will be approximately
(10) questions that will take about 15 minutes to complete.

As indicated by my signature below, I agree to participate in (3) follow-up telephone surveys of
employees. I understand that my contact information will be kept completely confidential and
will not be disclosed to anyone. At the time of the first telephone call, I will be asked to provide
payment information that will only be used to send my “thank you” check to me after the end of
the follow-up period. I will also provide a daytime telephone number below where I can be
reached for the follow-up calls.

First Name                     Middle Initial                         Last Name


Street Address


City                   State                    Zip Code
_______________________                         _________________________________
Daytime Telephone Number                        Alternative Telephone Number
Please tell us the best day(s) and time(s) we can reach you for the follow-up
calls______________________________________________________


Signature




                                                                                                  90
                    Appendix F : West Virginia Small Business Plan
                     Comments Employee (Member) Mailed Survey

Question 11: If dissatisfied with the costs, what are the major reasons for your
dissatisfaction?
o “Was somewhat satisfied until our premiums increased 27% after 1st year; we had to drop it”
o “We haven't used it but we still have these big premiums each month”
o “Raise for no reason”
o “Answered I don't know to both #10 & #12”
o “For what it costs I could use the money”
o “Raised 29% from 1st yr to 2nd canceled b/c B/S; Our company saved $2200 a year on 9
   employees by taking another ins co with better coverage”
o “Cost that raised after 1st year”
o “Each year get higher”
o “No drug coverage”
o “No longer have this insurance; Changed ins. co.”
o “needed to be affordable; TERMINATED11/30/06-no longer employed by Co.& no longer
   have medical insurance.”
o “It's better than any I have had in the past but all health ins. is too high.”
o “When we initially were enrolled the premium was 28% less. After the first 6 month premium
   went up & then 3 months later XXXX called & told us they could handle our group. Since our
   names have been given out to various brokers-how nice someone should have told us. I
   think this was deal to begin with; Gov. used this politically & then we were thrown out to
   other brokers. Of course can get premiums down if we raised deductibles from $3000 to
   $5000. What a scam.”

Question 13: If dissatisfied with the benefits, what are the major reasons for your
dissatisfaction?
o “Benefits good”
o “To be able to have eye & dental coverage”
o “Did not cover preventive as stated”
o “Doesn't cover services & too much trouble”
o “Price”
o “Doesn't cover services I wanted; Poor prescription coverage”
o “Office visits & prescriptions initial out of pocket are too costly”
o “Insurance changing its mind on what it will cover after I've paid my bills about a yr. later &
   resulting in more fees that I had to pay unexpectedly”
o “Deductible too high; would like more options with prescription drug portion”
o “Doesn't cover services want/need; deductibles per person on family plan too high”
o “I have not used this much. I am about the only person that used ins & I had to pay out over
   $2000.00 for about $3000.00 total bill.”
o “Deductible too high; Rx coverage at 50% too low”
o “Prescription copays too high”
o “I will never use it”
o “Office Calls-prescriptions should pay more”
o “Bills & statements are confusing; paying 1 bill & starting another; Because of the continuing
   illness I had to pay 2 deductibles. If I had been ill Jan. Aug. Spet only 1 deductible would
   have been necessary”
o “Co-pays-deductibles too high”
o “Would rather have small co-pay not have to pay total cost until reaching deductible”
o “Family Dr. is not a network provider; Penalties too harsh”


                                                                                              91
o   “Didn't pay preventive med; Office call Premium too high”
o   “Mainly the deductible is just too high; It would be better if deductibles were cheaper so the
    80% would kick in; paying $47/week for my wife; should pay better than it does now”
o   “High Deductible”
o   “Didn't offer family benefits”
o   “Prescription coverage not too good”
o   “Only for protection; Deductibles too high; Prescription drug no real discount”
o   “Too much trouble/complicated; Please print claims 1 per page; CSRs aren't very
    knowledgeable about what is covered & which doctors are in the network.”
o   “There needs to be lower deductibles”
o   “Medications”
o   “Doesn't cover services; Providers don't accept; Too much trouble/complicated”
o   “What it all boils down to is COST! At first we could afford it almost too good to be true &
    then after you begin to enjoy at least getting your health on track & feeling comfortable it is
    taken away. No worry is how long can we continue to afford $615.00 per month premium.
    We are back in same situation. A 28% increase is unacceptable & we hear it's going up
    again. So much for being self-employed. Thanks Gov. now what? We know Gov. is aware of
    this. It's not nice being used.”

Question 17: Why did you go to emergency room rather than go to your doctor’s office?
o “Illness made it necessary; unsure about nature...”
o “Dr's office recommended me too due to symptoms”
o “injury made it necessary; work schedule/transportation makes it difficult”
o “Happened after hours flu”
o “Late at night-Dr's office not open”
o “Child had croup”
o “Illness/injury made it necessary & do not have regular Dr./provider”
o “Unsure about nature of injury/illness; do not have regular Dr./provider”
o “Son Broke Ankle”
o “My regular Dr. for bowel troubles didn't have time to see me for 2 weeks. Had a
  colonoscopy 1 year before trouble with him”
o “illness/injury made necessary; unsure of nature or illness/injury”
o “My Dr. wasn't open that late.”
o “Had already been to physician”
o “Dr. office not open”
o “Car accident”
o “Practicing in WV as Psychologist w/small private practice; no insurance coverage 2003-
  2005; sons on WV Medicaid with MAJOR access problems; major reason for leaving state &
  moving family to NC”




                                                                                                92
                     Appendix G: West Virginia Small Business Plan
                     Business Owner Telephone Panel Questionnaire

_____ Business Owner Study ID Number                       _______ Today’s Date

   [INTERVIEWER INSTRUCTIONS – PLEASE RECORD VERBATIM RESPONSE FOR ALL
   RESPONSES AND CODE ANSWER LATER]
1. Is your business still enrolled in the WV Small Business Plan?
       O Yes [SKIP to Q7]
       O No
1A. In what month and year did you drop the WVSBP?
        O     QUESTION NOT APPLICABLE

       O     January         O        July                    O     2005

       O     February        O        August                  O     2006

       O     March           O        September               O     2007

       O     April           O        October

       O     May             O        November

      O      June            O     December
2. What is the major reason you are no longer enrolled in the WVSBP?
   [Do not read options, prompt if necessary – RECORD ALL RESPONSES and CODE
   LATER]

      O     QUESTION NOT APPLICABLE

      O     My business wasn’t as profitable and I couldn’t afford it any longer

      O     Cost of Premiums

      O     Not happy with benefits

      O     Lack of employee interest

      O     Other - specify: [Record verbatim response]

[COMPLETE Q3 IF Q2 RELATES TO COSTS, OTHERS SKIP to Q4]
3. Did your insurance agent talk to you about any way to lower the costs for the WVSBP?

       O      QUESTION NOT APPLICABLE
       O      Yes
       O      No
[Record comments, if provided, do not prompt for explanation]
4. Do you now have insurance coverage for your employees through another insurance plan?


                                                                                          93
       O      QUESTION NOT APPLICABLE
       O      Yes
       O      No

5. Do you have insurance coverage for yourself?
      O      QUESTION NOT APPLICABLE
       O      Yes
       O      No

6. Is there anything you want to add about your experience with the Small Business plan?
   [Record verbatim response]

       O      QUESTION NOT APPLICABLE
____________________________________________________________________________
____________________________________________________________________________
We are only interviewing businesses covered by the WVSBP. Since you are no longer
covered, we will not be doing another interview in the fall. We will now start processing
your participation Thank You check. Since you are only completing (1) interview, the
check will be for $25. Thank you for your participation. [END CALL]


7. How many of your employees are eligible for health insurance?


8. How many of your eligible employees have signed-up?


How many of the ________[insert # from Q8] employees have signed up for……
[Read the options – record number and calculate the percentage]

9a. Individual Coverage          _______________# & %
9b. Family                       _______________# & %
9c. Employee + Spouse            _______________# & %
9d. Employee + Children          _______________# & %

[SKIP Q10 if no employees declined coverage]


10. What is the major reason given by your employees for declining coverage?
    [Do not read options, prompt if necessary]




                                                                                           94
 O    QUESTION NOT APPLICABLE No employees have declined coverage.
                                                                They have insurance through somewhere
 O    Having insurance is not important to them           O     else

 O    Too much trouble, too complicated                   O     Premiums are too high
      Can get all the medical care I need without
 O    insurance                                           O     Doesn’t cover the services needed/wanted
      Coinsurance (co-pays and deductibles) are
 O    too high

 O    Other - specify: [Record verbatim response]


11. Overall how satisfied are you as a business owner with the WV Small Business Plan, are
    you …      [Read the options]

       O     Very Satisfied                    O         Dissatisfied

       O     Satisfied                         O         Very Dissatisfied

[If Q11 = dissatisfied, then Q12, others SKIP to Q13]

12. What is the major reason for your dissatisfaction?
    [Do not read options, prompt if necessary]

O    QUESTION NOT APPLICABLE

O    Premiums too high                              O       Too much trouble, too complicated

O    Co-pays or deductibles too high                O       Providers don’t accept the product
O    Doesn’t cover the services needed              O       Other - specify:[Record verbatim response]


[COMPLETE Q13 IF Q12 RELATES TO COSTS, OTHERS SKIP to Q14]

13. Did your insurance agent talk to you about any way to lower the costs for the WVSBP?

       O       QUESTION NOT APPLICABLE
       O       Yes
       O       No
[Record comments, if provided, do not prompt for explanation]



14. Overall, how satisfied are your enrolled employees with the cost of the WV Small Business
    Plan, are they….. [Read the options]


                                                                                                 95
       O     Very Satisfied                     O         Dissatisfied

       O     Satisfied                          O         Very Dissatisfied

[If Q14=dissatisfied with costs, then Q15, others SKIP to Q16]

15. What is the major reason for their dissatisfaction?
    [Do not read options, prompt if necessary]

       O     QUESTION NOT APPLICABLE

       O     Premiums too high

       O     Co-pays or deductibles too high

       O     Other - specify: [Record verbatim response]



16. Overall, how satisfied are your enrolled employees with the benefits of the WV Small
    Business Plan, are they….. [Read the options]

       O     Very Satisfied                     O         Dissatisfied

       O     Satisfied                          O         Very Dissatisfied
[If Q16=dissatisfied with benefits, then Q17, others SKIP to Q18]

17. What is the major reason for their dissatisfaction?
   [Do not read options, prompt if necessary]

       O     QUESTION NOT APPLICABLE

       O     Doesn’t cover the services needed
       O     Providers don’t accept the product
       O     Too much trouble/too complicated
       O
             Other - specify: [Record verbatim response]


18. Is there anything you want to add about your experience with the Small Business plan since
    January [OR since the last time we talked in __ INSERT MONTH of FIRST CALL]
    [Record verbatim response]
____________________________________________________________________________
____________________________________________________________________________
Thank you for your time and comments today. The next telephone interview will take
place in about 3 months (mid to late October if necessary). Can we set a day & time for that
call now? _______________________________




                                                                                           96
                    Appendix H: West Virginia Small Business Plan
                     Comments Business Owner Telephone Panels

Time 1 call Question 10 - Other major reason employees give for declining coverage
o “It's just too expensive - the premiums and the deductibles.”
o “I'm not really sure - maybe the premiums.”
o “The expenses in general.”
o “Too expensive premiums and copays; because of sick children has to pay a lot for their
   care”
o “Not really one reason - there are a couple.”

Time 1 call Question 12 - Other major reason for dissatisfaction
o “Too expensive - for small businesses, there's almost no discount from the regular Blue
   Cross plan.”

Time 1 call Question 13 - Did agent talk abt ways to lower costs
o “Yes, he said we could take a higher deductible.”

Time 1 call Question 15 - Other major reason for employees' dissatisfaction w/ costs
o “Way too expensive - if one of my employees insured her whole family, it would be more
   than her entire pay check once a month.”

Time 1 call Question 18 - Misc Comments
o “We've really benefitted from the plan. Before, we had a couple of people with no insurance
   and that's embarrassing but now places take our insurance even if you have to pay the first
   bit out of pocket.”
o “No, I haven't had a single complaint.”
o “The premiums automatically go to Tier 2 when you renew--that's a 24-27% increase. But
   we were able to requalify for Tier 1 which is only a 12% increase because we had done our
   homework when we were first putting together a program for our employees.”
o “Very satisfied with the Blue Cross part but not as satisfied with the Small Business Plan.; In
   WV, Blue Cross benefits are the best.; If the goal is to make it more affordable for small
   businesses, maybe you could offer an intermediate level of benefits-not the Blue Cross
   Platinum level but just something in between that's cheaper. I mean, we pay 55% of the
   premiums but it's still too expensive for people making $10-$11 an hour.”
o “It's a little hard to understand what's covered and what's not covered -- especially with
   prescriptions.”
o “Always had MSBCBS before WV Small Business Plan and services were better prior to
   WVSBP. Example: colonoscopy not covered because not 50 years old; seems before
   covered annual exam and preventive maintenance items better. Difficulties with
   communication with MSBCBS. EOB's are very hard to understand and are confusing for me
   and the providers to when I have to fax them to my doctors.”
o “We pay the whole cost.; We've been very pleased.”
o “I cover the costs - so they're very satisfied. Never heard from them so I guess they're
   satisfied. The deductibles are high but I'm pleased overall--sometimes just wish we could
   afford a lower deductible.”
o “The WV Small Business Plan is good - it's Blue Cross Blue Shield that's a problem - they
   don't take the claims. We still have claims from 17 months ago - they (BCBS) say they're not
   our primary insurance but they are.; Overall the WVSBP is pretty affordable but BCBS has
   some major issues. They say they've sent me letters for the last 2 years but I haven't gotten



                                                                                              97
    any of them and so they say they're not the primary insurance and haven't paid the claims
    yet. I have another claim from last month and it's starting all over again.”
o   “Satisfied except they say it covers only 50 percent of the prescriptions. But really, we're
    pretty happy. My wife and I actually aren't eligible because my wife has insurance with her
    business, but we're happy.”
o   “I was incredibly shocked by the increase from year 1 to year 2 with no warning or reason. A
    30% increase is ridiculously criminal--with a capital "C". And now it's just too difficult to
    change--to re-apply or something.”
o   “They haven't said - I can't say. To be honest, I haven't heard them say very much except
    that the deductibles are high. They'd rather have a co-pay plan. Right now the deductibles
    are so high that they just don't go to the doctor because the cost is so hard to meet.”
o   “Never used it so I'd say they are very satisfied; We haven't had to use it yet--I guess we'll
    know then.”
o   “Regular office visits and not all prescriptions are covered; Coverage doesn't include general
    office visits - preventive care or just a cold or something.;We've had it for 2 years and the
    agent guy came in the Fall this year to ask if we wanted to change or anything. He'd been to
    a seminar or something. It's not the cost but the services that are a problem.”
o   “Don't remember being enrolled but I have MSBCBS insurance”
o   “The deductible is fairly high so you have to pay a lot out-of-pocket to get reasonable rates. I
    actually get insurance through my husband, so I myself don't use the WVSBP and don't
    really have the inside scoop.”
o   “We're pretty much satisfied. The only thing is that I think the old insurance covered 100% of
    emergencies and this one covers only 80% of emergencies, I think.”
o   “I've never actually asked of course, they raised the premiums this year but it's very
    reasonable compared to the rest of the market.; It was a little difficult to find people in
    charge -- to find information quickly and concisely. We dealt with private agents who didn't
    really get it and they were not knowledgeable. So we cut out the middlemen and worked
    with agents at BCBS--they are much better. Overall, it's a little pricey but I understand that.
    By and large, I had been waiting for an opportunity like this for a small business and hope it
    stays in place.”

Time 2 Question 10 Major reason employees give for declining coverage
o “Because of age, he is young and doesn't want insurance.”

Time 2 call Question 13 - Did agent talk abt ways to lower costs
o “Everyone reapplying again or increasing the deductible but we already have $1000
   deductible - we didn't do either”
o “Filled out paperwork; increased 19% will know soon if it goes back down once we've
   reapplied.”

Time 2 call Question 15 - Other major reason employees' dissatisfied w/costs
o “Premiums for coverage other then Individual are too expensive - employees can't afford to
   cover spouse and family.”

Time 2 call Question 17 - Other major reason employees' dissatisfied with benefits
o “Items not covered, providers don't accept and inconsistency with what it told.”
o “Would prefer to pay a copay for doctors visits and things instead of having to meet
   deductible.”




                                                                                                 98
Time 2 call Question 18 - Misc Comments
o “Have heard no complaints; Overall helped but need to do something about costs of
   healthcare and insurance.”
o “Could do better with deductibles, offer lower ones.”
o “In order to re-qualify for Tier 1, have to do all paperwork again - increase was half amount
   after reapplying. Bothers me that we have to do that each year. Personal note: I'm covered
   and used the insurance for pregnancy this year. I was surprised by coverage for prenatal
   services, ultrasound, bloodwork, etc. wasn't covered without meeting the deductible so I had
   to pay for all of that. Seems like it should be covered.”
o “Increasing premiums; Biggest problem is difficult to make changes with coverage and plan.
   Difficulties with MSBCBS when making changes.”
o “Inconsistency with what is covered.; Premium increased 17% this year - also increased last
   year so it is almost to the price of the individual policies we had before this.”
o “Major increase in premiums - 19.8% increase at renewal.; Only problem with large rate
   increase - one employee not happy with Rx coverage; premium increase is way too much.”
o “Lowered deductible recently to try to help the employees - would and have recommended it
   to other businesses. I'm very pleased with it.”
o “Denied a claim for delivery of baby - plan to shop around for another insurance because of
   denied services.”
o “Bills are confusing. He pays part of the deductible for his employees to help them out.”
o “Echo comments from first call, the premium increases are criminal. You put a carrot in front
   of businesses and everything looks good until the yearly increase happens. It is a great
   initiative but after year 1 with the rate increase, no - I have nothing against Blue Cross but
   the State allows a 30% increase - makes the State look bad. I've shopped around and now
   the costs are the same as any others.”
o “Would like some coverage of the doctors visits and things and pay a copay instead of
   having to pay for it all until the deductible is met”
o “They (employees) wish it could be lower but I wouldn't say dissatisfied. Older people would
   like to have more affordable family policy and the option of not having the maternity
   coverage so that it is cheaper.”
o “Guess so still expensive but all health insurance is expensive; Have had hard time getting a
   hold of MSBCBS to make changes to the plan. Overall helps and employees are glad they
   have health insurance.”
o “Not as it was represented supposed to have been extension of PEIA but that changed
   because of insurance industry and it is now with private insurance. I think it would have
   been cheaper especially for the employees if it was with PEIA. I guess it is supposed to be
   25% cheaper than if it wasn't around, but from the employees perspective it is not affordable
   to cover families; does not protect the whole family because they can't afford to cover
   spouse and children.”
o “Always increases each year and it's tough.”
o “Have heard no complaints. Glad it's there; been telling other businesses that it is available.”




                                                                                               99
                 Appendix I: West Virginia Small Business Plan
               Employee (Member) Telephone Panel Questionnaire

_____ Employee Study ID Number               _______ Today’s Date

   [INTERVIEWER INSTRUCTIONS – PLEASE RECORD VERBATIM RESPONSE FOR ALL
   RESPONSES AND CODE ANSWER LATER]
1.     Are you currently enrolled in the WV Small Business Plan?

      O      YES     [If YES, skip to #Q6]
      O      NO
 2. What is the approximate month and year you stopped being covered?
    [Do not read options]
      O      QUESTION NOT APPLICABLE

      O    January          O      July                     O       2005

      O    February         O      August                   O       2006

      O    March            O      September                O       2007

      O    April            O      October

      O    May              O      November

      O    June             O      December

 3. Why are you no longer enrolled? [Do not read options]

     O     QUESTION NOT APPLICABLE

     O     The business I work for is no longer enrolled in the WVSBP

     O     I am no longer employed by this employer
     O     I could not afford the premiums
     O     I was not satisfied with the coverage Specify: [Record verbatim response]




     O     Other - specify: [Record verbatim response]



 4. Now that you are not covered by the WVSBP, do you have health insurance?
    [Do not read options]

      O      QUESTION NOT APPLICABLE
      O      YES
      O      NO [SKIP to END CALL]


                                                                                       100
 5. How are you now covered? [Read the options]

  O     QUESTION NOT APPLICABLE

  O     Covered by spouse’s insurance               O       Covered by school health insurance

  O     Covered by parent’s insurance               O       Covered by another employer

  O     Medicare                                    O       Medicaid
        Other: specify                                      [Record verbatim response]
  O
We are only interviewing people who are covered by the WVSBP. Since you are no
longer covered, we will not be doing another interview in the fall. We will now start
processing your participation Thank You check. Since you are only completing (1)
interview, the check will be for $25. Thank you for your participation. [END CALL]

 6. How long have you been enrolled in the WV Small Business Plan?
      [Do not read options] – do not ask 2nd interview

       O    0-3 months                          O    13 -18 months

       O    4-6 months                          O    19 -24 months

       O    7-9 months                          O    More than 2 years

       O    10-12 months                        O    Don’t Know


 7. What type of coverage do you currently have… Do you have …….?
      [Read options]

        O    Individual                                 O     Individual plus spouse

        O    Individual plus children                   O     Family
 8. Do you work more than one job?

       O      YES
       O      NO

 9. How satisfied are you with the cost of the WV Small Business Plan, are you…..?
      [Read the options]

       O     Very Satisfied                   O         Dissatisfied

       O     Satisfied                        O         Very Dissatisfied

[If Q9=dissatisfied, then Q10, others SKIP to Q11]

 10. What is the major reason for your dissatisfaction?
      [Do not read options, prompt if necessary]


                                                                                             101
       O     QUESTION NOT APPLICABLE

       O     Premiums too high

       O     Co-pays or deductibles too high

       O     Other - specify: [Record verbatim response]


 11. How satisfied are you with the benefits of the WV Small Business Plan, are you……?
     [Read the options]

       O     Very Satisfied                    O      Dissatisfied

       O     Satisfied                         O      Very Dissatisfied

[If Q11=dissatisfied with benefits, then Q12, others SKIP to Q13]

 12. What is the major reason for your dissatisfaction?
     [Do not read options, prompt if necessary]

       O     QUESTION NOT APPLICABLE – not dissatisfied

       O     Doesn’t cover the services I want/need

       O     Providers don’t accept the product
       O     Too much trouble/too complicated

       O
             Other - specify: [Record verbatim response]


 13. Since January [OR the last time we talked in __ INSERT MONTH of FIRST CALL]
     approximately how many times have you seen a provider for routine or preventive care
     (e.g., annual physical)?

 [If Q7=Individual Coverage Skip to Q15]

 14. How about the others members of your household who are covered by the Small
     Business Plan -
     Since January [OR the last time we talked in __ INSERT MONTH of FIRST CALL]
     approximately how many times have they seen a provider for routine or preventive care
     (e.g., annual physical)?


   O       QUESTION NOT APPLICABLE – no other members covered


 15. Since January [OR the last time we talked in __ INSERT MONTH of FIRST CALL]
     approximately how many times have you seen a provider for care other than routine or
     preventive, such as a problem, illness, injury, etc.?



                                                                                         102
 [If Q7=Individual Coverage Skip to Q17]

 16. How about the others members of your household who are covered by the Small
     Business Plan -
     Since January [OR the last time we talked in __ INSERT MONTH of FIRST CALL]
     approximately how many times have they seen a provider seen a provider for care other
     than routine or preventive, such as a problem, illness, injury, etc.?


     O    QUESTION NOT APPLICABLE – no other members covered
[If Q15 and 16 = Zero, Skip to Q18]

 17. Can you briefly describe the reasons, problem(s), illnesses or injuries for which you sought
     care? [ONLY APPLIES TO QUESTION 14; Record verbatim response]



 18. Since January [OR the last time we talked in __ INSERT MONTH of FIRST CALL] how
     many times have you been to the emergency room?

[If Q7=Individual Coverage Skip to Q20]

 19. How about the others members of your household who are covered by the Small
     Business Plan -
     Since January [OR the last time we talked in __ INSERT MONTH of FIRST CALL] how
     many times have they been to the emergency room?

   O     QUESTION NOT APPLICABLE – no other members covered

 [If Q18 & 19 = zero, SKIP to Q20]

 20. Why did you go to emergency room rather than a doctor’s office? [DO NOT READ -
     RECORD VERBATIM – CODE ANSWER LATER]




   O     QUESTION NOT APPLICABLE – no emergency room visits

   O     My illness or injury made it absolutely necessary to go to the ER.

   O     I was unsure about the nature of my injury or illness so I went to the ER.
   O     I do not have a regular doctor/provider.
   O     The wait time to get a doctor appointment.
         My work schedule or transportation needs make it difficult for an appointment during my
   O     doctor's regular office hours.

   O     Other - specify: [Record verbatim response]




                                                                                            103
 21. Overall, has your health improved, stayed the same, or worsened since January?
     [OR the last time we talked in __ INSERT MONTH of FIRST CALL]

      O     IMPROVED

      O     STAYED THE SAME

      O     WORSENED
 22. How would you rate your health since January [OR the last time we talked in __ INSERT
     MONTH of FIRST CALL] would you say….
     [Read the options]

       O     Excellent                          O     Fair

       O     Very good                          O     Poor
       O     Good                               O     Very poor

 23. Now, I’m going to ask about difficulties getting health care.
     Since January [OR the last time we talked in __ INSERT MONTH of FIRST CALL],
     would you say you have experienced difficulties getting the health care you need
     [Read the options]

      O     Often

      O     Infrequently [SKIP TO Q25]

      O     Never [SKIP TO Q25]


 24. Can you please describe the nature of the difficulties? [Record verbatim response]

 O     QUESTION NOT APPLICABLE – no difficulties
 ___________________________________________________________________________
 ___________________________________________________________________________

 25. Has your access to health care improved, stayed the same, or worsened since
     January?
     [OR the last time we talked in __ INSERT MONTH of FIRST CALL]

      O     Improved

      O     Stayed the same

      O     Worsened
 26. Is there anything you want to add about your experience with the Small Business Plan
     since enrollment [OR the last time we talked in __ INSERT MONTH of FIRST CALL]
     [Record verbatim
     response]______________________________________________________________

The next telephone interview will take place in about 3 months (mid to late October). Can we
schedule a good day and time for that call now?______________________________

                                                                                            104
                    Appendix J: West Virginia Small Business Plan
                   Comments Employee (Member) Telephone Panels

Time 1 call Question 10 - Other major reason dissatisfaction costs
o “Both is too high; The premiums cost me $128/week and the deductible is $2,000 per
   person/per year. That's $6,000 a year for me. The premiums and deductible are way too
   high.”

Time 1 call Question 12 - Other major reason for dissatisfaction benefits
o “With that high deductible, it doesn't cover anything - I can't get any services.”

Time 1 call Question 17 - Describe problems, illness, injury for which you sought care
o “I had surgery again          o “Allergies, bronchitis,         o “I had knee surgery a
   this year.”                      mole removed”                    while back.”
o “Sinus infection”             o “Reconstructive foot            o “Torn tendon in foot”
o “DTS=declined to say”             surgery (spouse)”             o “Remove stitches from
o “Knee surgery. I don't        o “Back issues --                    head-was covered by
   remember exactly -- I            chiropractic visits”             Workers' Comp”
   think it was sinus           o “Son: sick with kid             o “Follow-up to ER visit”
   trouble. She has                 stuff--my wife took him       o “Allergic reaction; hair
   ongoing trouble.”                in. I think it might have        fell out, blood
o “Injured wrist & ear              been ear infections.”            pressure”
   infection”                   o “Laparoscopy -- for             o “Allergies, respiratory
o “DTS; "don't feel                 blocked bile ducts,              problems”
   comfortable giving that          then had to have gall         o “Kidney stone”
   over the phone to a              bladder
   stranger"                        removed/surgery”
o “Poison Ivy reaction          o “Follow-up for kidney
   needed Rx drugs to               stones”
   treat it.”                   o “Stomach virus”

Time 1 call Question 26 Misc Comments
o “Hard to say anything because I've never used it.”
o “It's paid for by my employer. I would like to see coverage for well visits-preventive care.”
o “For the type of insurance that it is, the premiums are pretty excessive because we at the
   office -- I'm the office manager -- carry ~ $3,000 premium for carrying it. That and the well
   visit coverage are the only things.”
o [Confused-didn't know what WV Small Business Plan was]. “No experience with the plan so
   nothing to add.”
o “The deductibles are way too high. It's absolutely crazy to have a $2000 deductible for 2
   people per year. It's a $1000 deductible per person. My employer pays all the cost except
   the deductible and that's the only part I'm dissatisfied about. $178 was reasonable to add my
   son considering the cost of health insurance these days.”
o [Didn't know what WV Small Business Plan was] “No complaints, I am very satisfied.”
o “No, not exactly. Originally we weren't sure how the coverage would be but we've been real
   pleased.”
o “Not really. We've been real satisfied with it. It's a lot cheaper than the regular BCBS
   program, so we're happy. I mean no one wants to pay for health insurance but I'm saving
   $100 a month with it.”
o “Too expensive to add wife-premiums are too high if I added her; Cost of premiums
   especially for adding a 30-something woman. It is the first time in 12 yrs. I haven't been able


                                                                                             105
    to cover her on my insurance so she is uninsured. I used to have a plan where I worked & it
    was expensive but not as much as this to cover her.”
o   “The office manager pays the cost but the deductibles are way too high!; My only issue is
    that the deductibles are way too high.”
o   “Dissatisfied with benefits because a couple of things weren't covered. Also dissatisfied with
    prescription benefits because amount you pay doesn't get applied to deductible. Poison Ivy
    reaction needed prescription drugs to treat it.”
o   “I'm so glad they finally did it; it's a wonderful opportunity for small businesses. I hope they
    will expand it to other insurances. Will someone other than BCBS offer it in the future?”
o   “Been very satisfied with it. Have had no problem; everything has gone pretty smooth”
o   “Even though my boss splits the premium, the deductible so high that by the time I pay out
    all of this it is the end of the plan year and I don't even get to use the 80% coverage of the
    benefits; Also prescription co-pays are too high compared to what I used to have; Difficulty
    getting physician ordered mammograms covered. if they have been denied, I have difficulty
    getting the right person during the appeal process; people I talk too can't help me, denied by
    Blue Cross because I’m under the recommended age; Overall been good, issue with Dr.
    ordered preventive services being denied because of age - seems like it would be better to
    cover preventive services like mammogram than waiting and I end up with cancer and they
    have to pay more for that treatment.”
o   “They just need to offer a doctor visit co-payment to the plan. I'm a broker and I support the
    plan, by the way.”
o   “Can't answer about satisfaction with costs because my boss pays for all of it-out of pocket
    costs are fine.”
o   “Yes, I would like them to cover 1 annual physical a year. I think it's good preventive care
    and they don't pay for it. And I need to talk to my insurance agent about dental coverage. I'd
    like to be able to get that for my family and maybe I can if I just ask.”
o   “Originally had individual and children but the "kids are out of the house now"; I've been
    pleased--haven't had any trouble. Even my health care provider hasn't had problems--
    except with some ID numbers once. I've been with different small business plans for the last
    7 years and this is the best one.”
o   “May not be related -- cost of dental plan great but only pay for services at certain times of
    year.”
o   “Employer pays all of premium.;Never had to use it.”
o   “Just that deductibles are huge for what I pay every month”
o   “Meets my needs for individual.”
o   “My employer says the premiums are very high, I don't really see the costs though.”
o   “Don't know, been with company for 28 years and don't know when it switched to small
    business. I think family coverage should be rated per person; it's not fair that I have to pay
    as much as an employee with 6 kids when I have only 1 kid. And I received a cancellation
    for my son who just turned 19, even though state law says he's covered until he's 25. The
    prescription coverage should be 90-day through MedCo, not 30-day/30-day/30-day; you'd
    save money like that”
o   “I've never had to use it.; I had to get stitches in my head-it was really bloody, pretty much
    an emergency. I couldn't wait for a doctor's appointment. I think it's a good thing; with the
    cost of insurance now, it's the only way businesses can afford to do it for their employees.”
o   [Didn't know what WV Small Business Plan was]; “Premiums are too high-used to be
    satisfied with costs when first signed up but not now”
o   “That deductible is just too high. I'm a single party and unless I'm really ill in the hospital, I'm
    never gonna make $1000 deductible so that doesn't help me. It really only helps these
    women who stay at home popping out babies. They're uneducated and don't work and we
    keep paying for them. I'm wondering when they're gonna give back. The government will


                                                                                                   106
    give women and children anything and there's a trillion dollars overseas; we need to throw
    that guy in the White House out on his ear. Just the regular, single people working real hard
    everyday need something.”
o   “It could always be cheaper though; I've never had to use it.”
o   “Too expensive also frustrated that we have to re-apply each year to get a lower rate”

Time 2 call Question 3 -why no longer enrolled
o “Wife obtained option for health insurance and it was a lot cheaper.”

Time 2 call Question 10 - Other major reason dissatisfaction costs
o “Both premiums and deductibles too high”
o “Premiums and deductibles both too high”

Time 2 call Question 12 - Other major reason for dissatisfaction benefits
o “Still difficulty getting them to cover screening mammograms because of age.”
o “Insurance doesn't cover certain providers”
o “Coverage for prescription drugs”
o “No real benefit outside of something major happening because of deductible.”

Time 2 call Question 17 - Describe problems, illness, injury for which you sought care
o “Sinus infection”                              o “Kidney stone”
o “Wife: injury to leg - covered by another      o “Son: problem with skin on feet; Wife:
   insurance”                                       hospitalization with skin infection had
o “Follow-up to my pap smear because of             numerous follow-up visits”
   results”                                      o “Head injury-Workers' Comp”
o “Suspicious mole removed”                      o “Accidental fall; poison oak rash”
o “Spouse: foot surgery”                         o “Sinus infection and upper respiratory
o “Chiropractic care for back problems.”            illness”
o “Heart related check-ups; a stress test;       o “Family - went to dermatologist for skin
   echo-cardiogram”                                 issues”

Time 2 call Question 24 - Describe nature of difficulties getting care needed
o “MSBCBS doesn't cover care - they used to pay for chiropractor visits but stopped. They
   said it was maintenance and wasn't covered.”

Time 2 call Question 26 Misc Comments
o “Makes it nice to know if something happened I have insurance.”
o “Overall costs of health insurance too high - more unified care overall - not just this plan;
   need more affordable options for average person”
o “Deductibles way too high.”
o “No complaints”
o “Very happy with it.”
o “Deductibles too high - would have to have major illness before it would cover anything;
   Because deductibles are so high, don't go to the doctor unless it is absolutely necessary. I
   don't think that's an improvement in health care.”
o “Very good for small businesses - a good opportunity”
o “Would prefer a co-pay for doctors visits.”
o “Don't understand why chiropractor visits twice a month not covered - they pay for
   prescription drugs monthly and would pay for me to take a pill or have surgery but I don't
   want those. I need these visits to be able to function. Other than this issue, I've been
   pleased with it.”


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o   “Had no problems with it.”
o   “Have not used it yet.”
o   “Bothered by issues with not paying certain providers - like the health center or for
    equipment rented after hospital stay”
o   “Haven't used it; Glad it was started-businesses can't afford it any more it is especially good
    for small businesses.”
o   “The fact that the costs go up each year bothers me.”
o   “Should cover new smoking cessation products because it is a preventive type service that
    will improve your health.”




                                                                                               108
  Appendix K: West Virginia Small Business Plan
Provider Mailed Survey Cover Letter & Questionnaire




                                                      109
Provider Mailed Survey Cover Letter & Questionnaire

Please fill-in the circle/dot next to your answer and return the survey in the enclosed
postage paid envelope.

1. Have you ever participated in the provider network for the West Virginia Small Business
   Plan for employees with 2-50 employees?

               O     Yes – Please skip to Question #2

               O     No

       1a. If NO, what is the major reason you chose not to participate?


           O       Reimbursement rates are too low

           O       My practice is closed

           O       Administrative burden

           O       Other - please specify:


2. You indicated in Question #1 that you have participated in the provider network for the West
   Virginia Small Business Plan in the past. What is the major reason you are no longer
   participating?


           O       Reimbursement rates are too low

           O       My practice is closed

           O       Administrative burden

           O       Other - please specify:




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                      Acknowledgements

Support for the evaluation activities for the West Virginia Small Business
Plan was provided through a Robert Wood Johnson Foundation State
Coverage Initiative Demonstration Grant via a subcontract to the Institute
from the West Virginia Health Care Authority.


The authors would like to thank Mountain State Blue Cross Blue Shield for
providing data, information, and assistance with evaluation activities,

Fred Holliday, WV Office of the Insurance Commissioner for providing his
expertise on the ratings and filings for the WVSBP,

David Lomely who provided assistance with the claims data analysis,

Abby Meadema who helped conduct panel interviews, and

Katherine White, Executive Secretary, who scanned data forms, typed
comments, helped with survey mailings, and generally provided
administrative assistance with whatever else was needed.
  ROBERT C. BYRD H EALTH SCIENCES CENTER
  INSTITUTE FOR H EALTH POLICY RESEARCH
      3110 MacCorkle Ave., SE
        Charleston, WV 25304
            304-347-1382
Web: www.hsc.wvu.edu/wvhealthpolicy

								
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