Focusing on Quality : Clinton Health Reform Adds Urgency to Efforts by HMOs

The billboard shows a telephone cord tangled into the shape of a hangman’s noose and the headline “Just Get Off the Phone With Your Health Plan?” The message of the advertisement for health insurer Takecare Inc. is obvious: Some health plans are not “customer-friendly.”

Spurred in part by President Clinton’s health reform initiative, which would create “report cards” to measure the quality of health care, HMOs and other managed care plans are grappling with how to improve customer service and gather data about the effectiveness of the medical care they provide.

HMOs are surveying members to detect weak spots in customer satisfaction, they are sending doctors to “charm school” to improve their bedside manners, they are upgrading telephone systems to answer calls more quickly, and they are installing powerful computer systems to track patient records and doctors’ treatments.

HMO officials emphasize that quality issues are not new to the industry. But they concede that the Clinton reform plan adds new urgency to their efforts.

“Health reform has caused us to take a different look at quality to try to find where we can improve,” said Ria Carlson, a spokeswoman for FHP Inc., a Fountain Valley-based managed care company.

Many health care experts see quality as the key battleground for managed care programs under the health reform plan proposed by the Clinton Administration. The plan--formally presented to Congress on Wednesday--would create regional or state alliances responsible for purchasing health care for a certain population. It would also establish the health plan report cards, which would provide information on patient satisfaction and the performance of health plans, doctors and hospitals.

“HMOs are anticipating national health care reform and they want to be part of the alliances, “ said Bob Pollock, principal at the Los Angeles office of William M. Mercer Inc., a health care consulting firm. “If they’re not in the alliances, they will fall by the wayside.”

Moreover, many health reform initiatives under way or already at the state level also call for various types of medical performance report cards.

But reform isn’t the only reason for this push for quality by health insurers. The fierce competitiveness of the California health care market forces them to seize any opportunity to best their rivals. Takecare’s new ad campaign, for example, plays on the public perception that HMOs, as one billboard suggests, sometimes treat their customers like a piece of meat. The Concord, Calif.-based HMO seeks to portray itself as more customer-friendly.

Employers--who usually decide which health plans will be offered to their workers--are also playing a role in the effort. In the past, employers often were more concerned with a health plan’s cost savings or the location of its doctors and clinics. As employers gain more experience with managed health care, however, they are asking tougher questions.

“In the last few years, larger, more sophisticated employers have started to look at the accrediting process for physicians or the mechanisms for measuring medical outcomes,” said Glenn Meister, a principal with consultant Foster Higgins & Co. in Los Angeles.

But Meister and others say that much of the information on issues such as the effectiveness of medical care lack credibility due to the absence of commonly accepted standards for measuring quality. The Clinton plan attempts to solve that problem by creating federal quality standards. The regional alliances, in turn, would collect data on the quality of health plans and publish report cards to help consumers choose among plans.

A sample report card circulated by the Administration includes such questions as the percentage of health plan members who are satisfied with their primary care physician, how long it took to get an initial appointment with a primary care doctor, the percentage of pregnant women receiving early prenatal care and the death rate of patients after a heart attack.

Ronald Pollack, executive director of Families USA, a Washington-based consumer group that backs a Clinton-style reform plan, said such information is sorely needed.

“We don’t today have accurate or systematic ways of gauging qualities among specific health plans,” he said. “As a result, consumers often are unable to be adequately informed about quality.”

Health care experts say such information is also crucial because there are wide gaps in patient satisfaction among insurers. “It even varies among the same HMOs,” said Pollock, the Mercer consultant. “You can find Kaiser locations that are exceptional and some that are less than exceptional.”

Kaiser is “very aware of the competition and you know the dog is biting at your tail,” said Dr. Joel Hyatt, assistant to the associate medical director for Kaiser Permanente-Southern California.

Patient surveys have been common practice at Kaiser for years, Hyatt said. But recently the health giant has zeroed in on patients’ attitudes toward their primary physicians. Members are queried about their doctor’s general expertise, whether they were treated with respect and courtesy and whether the physician was a good listener.

“These things sound pretty subjective, but people are pretty good at telling you whether their expectations were met,” Hyatt said.

Among other steps to improve customer service, Kaiser has tackled a nagging problem: making itself easier to reach by telephone. “For most people, the main contact with any health care organization is the telephone,” Hyatt said. “We know we have problems with telephone access, but there has been real and measurable progress.”

At Pacificare of California, surveys found that roughly 80% of complaints involved communication snafus between members and doctors and their staffs. In 1991, the health plan sent personnel at half a dozen troublesome medical groups to a program dubbed “The Art of Caring.” The result: Complaints fell 40%, Pacificare says.

As a result, the Cypress-based HMO expanded the number of medical groups attending the caring classes, and complaints are still down sharply, said Dr. William Osheroff, vice president and medical director.

“A lot of physicians’ offices didn’t see patients as customers,” Osheroff said. “This program is designed to help care givers and others understand that there are needs independent of medical ones--the need to be spoken to with respect, not be put on hold for a long period, and that waiting times are sometimes a problem.”

Meanwhile, Cigna is working to shorten the wait for physician referrals, the No. 1 gripe of the health plan’s members. “It is not uncommon now for a customer to wait a week to 10 days for a non-surgical, routine referral,” said Bert B. Wagener, president of Glendale-based Cigna Health Care of California. That’s too long, said Wagener, who aims to cut the wait to no more than three days next year--and eventually to just a day.

Some experts believe that HMOs will face a tough challenge to retain a feeling of personal care as they grow larger. There has already been a wave of mergers in the HMO industry, and most observers expect a continued shakeout as large insurers swallow up smaller ones.

“The worst thing that can happen to an HMO is to become a clinic-like atmosphere where people wait in line and can’t get an appointment for a long time,” said Pollock, the Mercer consultant.

Added Robert Fahlman, vice president of marketing at Takecare: “In any industry, a critical mass is effective to a point, and beyond that you lose effectiveness. It’s like comparing the Postal Service to UPS.”