Study Finds Disparity in HMO Services : Health: Los Angeles-based Medicare Advocacy Project says plans vary greatly in the treatment given to Medicare beneficiaries.
Los Angeles-based researchers reported Friday that a wide disparity exists in the way medical services are delivered by health maintenance organizations to Medicare patients in California, with some HMOs much more likely to approve coronary bypass and other major surgeries than their competitors.
The study by the Medicare Advocacy Project, a nationally known, nonprofit organization that represents Medicare clients, found that one HMO was almost six times more likely to perform bypass surgery than a competing plan and called the low number of surgeries performed by the second plan “troubling.” The authors, which studied 10 HMOs, declined to identify the individual plans.
The report said that the same HMO that performed the highest rate of bypass operations also removed gall bladders and undertook major joint and limb operations at a rate that was twice the average of its top two competitors.
The study also found that some hard-sell HMOs also have a much harder time hanging onto their clients than others.
The study is believed to be the first in the nation to compare HMOs on such things as surgeries performed and patient satisfaction. The researchers relied on voluntary participation from the HMOs and information obtained by court mandate from the federal Health Care Financing Administration, which oversees Medicare managed-care plans.
As a result of the limited amount of information, the report’s authors cautioned that they were unable “to draw any firm conclusions about access to, and quality of, care provided by Medicare HMOs.” They said the survey suggested the need for further investigation by federal health officials.
One official familiar with the Medicare managed-care program said the study raised some important questions but also cautioned about drawing too much from the report.
“You can’t look at any one factor, such as bypass surgeries, to assess an HMO. There are too many other factors. The trap is that the report presents too much of a simplistic view of the world,” he said.
Managed-care plans, representing ever-growing numbers of public and private patients, differ from the traditional fee-for-service system, in which patients choose doctors and are billed for each service. Under HMO plans, individuals, employers or government agencies pay a set monthly fee and then are covered for an agreed-upon level of service.
Advocates contend that HMOs provide a cost-effective method of care, based on prevention and hands-on case management.
Critics say people are being forced into managed-care plans by employers or state and federal governments seeking to save money. They contend that managed-care plans make their profits by keeping patients out of hospitals or away from expensive medical specialists.
Medicare Advocacy Project provides counseling, education and legal assistance to about 6,000 Medicare beneficiaries in Los Angeles County each year and undertook the study after many clients asked for objective comparisons of various plans, said Geraldine Dallek, director of the organization.
Although data was hard to come by, Dallek said that based on what the researchers could obtain, “we found there are some huge differences.”
The comparison of surgery rates was limited to the three largest Medicare HMOs in the state, which represent more than 80% of all the Medicare patients surveyed in the various HMOs.
The researchers said they expected that hospitalization rates “would be fairly consistent among HMOs” but instead found “significant variations.”
In an area of direct comparison between HMOs, the report found that during 1991, patients of some HMOs left their plans in much larger numbers than those enrolled in other plans, an exodus attributed to confusion and widespread dissatisfaction among clients.
Dallek, whose report was highly critical of marketing and hard-sell practices of HMOs, said that during 1991, 40.7% of the clients who dropped FHP did so within three months of joining the plan. By comparison, Bridgeway lost 9.3% of its dropouts in the first three months.
“That many people leaving so fast is a sure sign that there are problems,” said Dallek. She said that FHP has since made substantial improvements and has a much better record.
Dr. Gary Goldstein, FHP’s senior vice president in charge of health care, attributed the loss to a $2 increase in co-payments required of Medicare patients. But he also conceded that the firm’s sales people were being more carefully trained.
HMO Dropouts These figures show the number of Medicare patients who dropped out of leading health maintenance organizations during the first three months of enrollment in 1991, compared with all dropouts in the first 13 months. The numbers are believed in part to be an indication of dissatisfaction with the plans.
LEFT PLAN PCT. OF HMO AFTER 3 MONTHS TOTAL WHO LEFT Aetna/Partners 655 23.9 Aetna Northern Calif. 41 10.1 Bridgeway 25 9.3 FHP 9,542 40.7 Inter Valley 145 19.6 Kaiser Permanente 620 13.0 Qual-Med Health Plan 151 38.1 Secure Horizons 1,908 20.7 United Health Plan 585 32.6
Source: Medicare Advocacy Project Inc.
