Despite the rapid pace of change in the health industry, insured Californians generally are satisfied with the cost and quality of their medical care, a Los Angeles Times poll has found.
But many Californians are profoundly confused about the nature and extent of their health coverage. Some remain hesitant to join health maintenance organizations--despite those plans’ popularity with their own members--and they worry about their ability to control the quality of the care they receive.
The poll of 3,297 adults, conducted by phone in late June, is one of the most extensive looks ever at California residents’ attitudes about and experiences with the health care system.
The responses reflect the profound changes being wrought in the state by managed care--the now-dominant health plans that limit patients’ choice of providers and typically place a gatekeeper between the patient and access to specialists, tests, surgery and other out-of-the-ordinary treatment.
Only 50% of the insured Californians surveyed said they were in their health plan because they preferred it. For 36%, their plan was the only one available to them, and another 11% said they had the only coverage they could afford.
(About 23% of those contacted said they had no health insurance, the same percentage of uninsured as identified in a recent statewide study by UCLA.)
In another measure of respondents’ ability to direct their own health care, 36% said they had little or no control over the care they receive.
Fully 38% of the insured said they had to change doctors when they enrolled in their current plan--and about half those people said the change posed a problem. Twelve percent of the insured said their insurer had refused at some point to cover treatment or tests the patient considered necessary; similarly, 11% said it was difficult to obtain a referral to a specialist or authorization for treatment. And 15% said it was hard to get an appointment for a checkup or other routine medical care.
However, large majorities said their health plans did a good or excellent job on these measures. And overall, 81% ranked their plans good or excellent on offering a choice of health care providers, with 17% scoring their plans not so good or poor.
The highest levels of dissatisfaction were reported by people in transitional forms of managed care--not HMOs, but plans such as “preferred provider organizations,” which give patients a wide choice of doctors but whose premiums, deductibles and other out-of-pocket costs have been rising quickly.
Most members of these plans--85%--said they provide excellent or good health care. But participants in the middle-ground plans were least satisfied with the cost of their health care, the information provided about how their coverage works and even their ability to choose among doctors and hospitals. Forty-one percent of people in these health plans said they would change plans if they could, versus 29% of all Californians.
By contrast, HMOs--the plans that most sharply limit patient choice but also have the lowest out-of-pocket costs--are very popular with their members.
The poll found that 92% of HMO members describe their health care as excellent or good, versus 89% of all insured respondents. Eight of 10 HMO members would recommend their health plans to other people, slightly more than the proportion of all Californians who would do so.
Californians who don’t yet belong to HMOs are skeptical of their virtues, though; 23% of insured respondents who don’t now belong to HMOs said they would view it as a problem if they were required to join one, versus 12% who were untroubled at the prospect.
The general satisfaction expressed by those polled was tempered by the respondents’ pervasive confusion about their health coverage and how it works.
Times interviewers conducted follow-up interviews with numerous respondents whose inconsistent answers indicated they did not understand their insurance plans, said Susan Pinkus, assistant director of The Times Poll. Many had to find paperwork or contact their employers to determine what kind of coverage they had, she said.
Even with the follow-up, more than one in four insured respondents--26%--could not say for certain if they belonged to an HMO, preferred-provider organization or a hybrid known as a point-of-service plan. The insurance status of these people was determined by an additional series of questions.
Not surprisingly, healthy people gave generally higher marks to the health care system. But the 19% of insured respondents who indicated they were in ill health expressed somewhat higher levels of dissatisfaction.
Among ill HMO members, 13% said the quality of their health care was less than good, versus 6% of healthy enrollees. The divergence was roughly the same between healthy and ill enrollees in other types of plans.
The Californians most satisfied with their health coverage, the poll found, are senior citizens enrolled in Medicare HMOs--plans such as Secure Horizons and Care America 65 Plus, whose commercials are a familiar part of the media landscape.
A self-selecting group--68% said they were in their plan by choice, rather than default--the seniors gave their coverage the highest ratings for quality, cost, hospital care, preventive treatment and ease of use.
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How the Poll Was Conducted
The Times Poll interviewed 3,297 California adults by telephone, June 17 through 25. Of those interviewed, 2,750 respondents have health insurance, including 2,012 in managed care and 738 in a traditional insurance plan. Of the managed care participants, 1,381 are members of health maintenance organizations. Telephone numbers were chosen from a list of all exchanges in the state. Random-digit dialing techniques were used so that listed and non-listed numbers could be contacted. The sample was weighted slightly to conform with census figures for sex, race, age and education. The margin of sampling error for the total sample and for all respondents with health care insurance is plus or minus 2 percentage points; for certain sub-groups, the error margin may be somewhat higher. Poll results can also be affected by other factors, such as question wording and the order in which questions are presented.
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Health Care in California
In the most comprehensive survey ever of Californians’ attitudes toward and experiences with the health-care system, The Los Angeles Times Poll found insured residents generally satisfied with the quality and cost of their medical care. People in ill health are somewhat less happy with their care, however. And some Californians are concerned that managed care is limiting their control over their medical coverage.
THE INSURANCE LANDSCAPE
Almost three-quarters of insured Californians--and more than half of all residents--belong to some kind of “managed care” plan that limits their access to providers in exchange for lower costs. These plans have largely displaced traditional fee-for-service insurance.
Managed Care: 55%
Traditional insurance: 22%
Most Californians in managed care belong to health maintenance organizations, the most restrictive--but least expensive--plans.
Non-Medicare HMOs: 59%
Medicare HMOs: 10%
* Includes preferred-provider organizations and point-of-service plans.
QUALITY OF CARE
While most insured Californians are happy with their care, there is dissatisfaction with the provision of routine care, and substantial numbers would not recommend their health plan to someone else.
Q. How would you rate the quality of your health care coverage?
HMO Other Traditional members managed care insurance Ill Well Ill Well Ill Well Excellent 33% 34% 32% 30% 33% 37% Good 54% 59% 51% 57% 53% 52% Not so good 9% 3% 10% 7% 9% 4% Poor 4% 3% 7% 2% 4% 2%
Q. Would you recommend your health plan to other people?
HMO Other Traditional members managed care insurance Ill Well Ill Well Ill Well Yes 74% 79% 60% 72% 71% 76% No 15% 16% 24% 19% 24% 17% Don’t know 11% 5% 16% 9% 5% 7%
Q. Did you have to change doctors when you enrolled in your current health plan?*
Non-Medicare Medicare HMO Other managed HMO members members care Yes 43% 35% 28% No 55% 60% 68%
Q. If so, did you consider that change of doctor a problem?*
Non-Medicare Medicare HMO Other managed HMO members members care Major problem 20% 9% 25% Minor problem 27% 25% 31% No problem 52% 66% 43%
LOSS OF CONTROL
Some Californians say their power to make choices about their health care is restricted.
Q. How would you rate your health plan on providing choice--that is, an adequate selection of doctors, hospitals and medical services?
HMO Other Traditional members managed care insurance Excellent 33% 26% 50% Good 48% 46% 38% Not so good 12% 20% 7% Poor 5% 5% 3%
Q. Did you choose your current health care insurance policy because you preferred it or because it is the only one available to you or because it is the only one you could afford?
HMO Other Traditional members managed care insurance Preferred it 59% 37% 44% Only available 29% 46% 42% Only affordable 10% 14% 11%
COST OF CARE
Senior citizens who belong to HMOs are the group most pleased with the cost of their health care.
Q. How would you rate the cost of your health care coverage given the services provided?
Medicare Other Non-Medicare HMO managed Traditional HMO members members care insurance Excellent 31% 45% 27% 28% Good 55% 49% 50% 52% Not so good 8% 3% 13% 10% Poor 3% 3% 6% 4%
* Not asked of respondents with traditional health insurance
Note: Some columns do not add to 100% because of “not sure” and declined responses.
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Minding the Store
Q. If you had a problem with the way your health care plan was treating you, what agency would you complain to?
Don’t know: 75%
Not sure: 8%
Department of Health Services: 4%
Health Care Financing Administration: 2%
Department of Corporations: 1%
The percentage of Californians with each of the following characteristics who are enrolled in an HMO:
Single parents: 57%
Non-U.S. citizens: 43%
Self-described liberals: 54%
Self-described conservatives: 49%
Union members: 56%
White-collar workers: 56%
Ages 18-29: 42%
Age 65+: 51%
Q. How would you rate your health plan on providing prescription drugs?
HMO Other* Traditional** Excellent 47% 34% 32% Good 41% 47% 38% Not so good 4% 10% 10% Poor 2% 4% 8% No prescription coverage 2% 1% 4% Don’t know 4% 4% 8%
* Other Managed Care
** Traditional insurance
Source: Los Angeles Times telephone poll of 3,297 adult Californians, June 17-25.
“All in all, I feel that basically the HMO system is a good one if it works as it should . . . . Unfortunately, this is not true in all cases. The lure of profits can be very seductive. In theory, the system is practical and promotes good health. In practice, it may not.”
Sue Ruttenberg, Health Net member in Irvine
“Throughout my husband’s 16 1/2-year illness, we experienced many critical moments with his tratment, numerous blood transfusions and surgical procedures vital to prolonging his life. These procedures were carried out with professionalism and great care.”
Arlene D. Anthony, Kaiser member in Newhall
“Guidelines for People with HMOs . . . : Don’t let them beat you down!! It’s us against them.”
Diana Higashi, Walnut