Lost in the HMO Maze
A four-year study published Wednesday in the Journal of the American Medical Assn. found that chronically ill patients who were elderly or poor fared much worse in HMOs than did their counterparts in traditional “fee-for-service” insurance programs.
Compared to those in the traditional plans, twice as many elderly patients said their health declined during the study period, while six times as many poor patients said their health deteriorated. Participants suffered from diabetes, heart problems and other chronic diseases.
Responding to the study, some physician advocates said the disparities could be partly due to a system common in managed care that gives doctors a certain amount of money each year per patient. This encourages physicians to economize by ordering fewer tests and other medical procedures and by spending less time with each patient.
In contrast, many studies have found that for patients who require fewer medical procedures, HMOs are as good as--and sometimes better than--traditional insurance.
HMO representatives like Susan Pisano of the American Assn. of Health Plans rightly faulted the study for relying mostly on patients’ self-reports, without independent medical evaluation. The JAMA researchers simply asked 2,235 patients a series of questions about their health in 1986 and again in 1990. It is possible that some of the patients, uncomfortable with the less personal, rapid world of managed care, offered unrealistically negative self-assessments.
Even critics of the study, however, agree that HMOs, whose enrollees have so far been mostly healthy and assertive working people, may not be sensitive to senior citizens and poor people who find it hard to negotiate the maze of managed care.
It is important that HMOs begin cultivating this sensitivity, for the percentage of elderly, sick and poor people in their ranks is rapidly growing. Spurring this growth are the attempts of state and federal governments to control the spiraling costs of Medicare by moving its typical elderly or disabled recipients into managed care.
To woo these potential members, the HMOs have launched savvy advertising campaigns. But to properly treat them, the JAMA study suggests, HMOs will have to also encourage their physicians to balance cost-cutting objectives with serving the people least able to advocate for themselves.
