Survey Finds Wide Distrust of HMO Care

By DAVID R. OLMOS

Nov. 6, 1997 12 AM PT

TIMES STAFF WRITER

While HMOs are winning the battle in the marketplace, they are faltering badly in their attempts to gain the confidence of Americans fearful that managed care is eroding the quality of the nation’s health care system, according to a national study released Wednesday.

In the most comprehensive survey to date of public attitudes toward managed care, researchers at Harvard University and the Kaiser Family Foundation found among other things that:

* Fifty-one percent of respondents say managed care has lowered the quality of medical care for the sick, compared to 32% who say it has improved the quality.

* Fifty-five percent say they are worried that if they become ill, their managed-care plan would be more interested in saving money than in providing the best medical treatment.

* Fifty-five percent say managed care has not made much difference in health care costs, while just 28% say it has helped keep medical costs down.

“The overall image of managed care is decidedly more negative than positive,” said Drew E. Altman, president of the Kaiser Family Foundation, a Menlo Park, Calif., health care charity that is not affiliated with Kaiser Permanente, the nation’s largest HMO. Americans “are concerned that managed care is more concerned with cutting costs than about them.”

The study examined what is sometimes referred to as the backlash against managed care--a growing public dissatisfaction with an industry that has achieved breathtaking growth during the past several years. The anti-managed-care sentiment already has sparked tougher state and federal regulation, including laws mandating minimum 48-hour hospital stays for mothers and newborns.

Congress is considering additional proposals to regulate managed-care plans, including a broadening of employees’ rights to bring malpractice lawsuits against health plans. And President Clinton’s Commission on Quality is drafting a “consumer bill of rights” that will include such recommendations as improving access to medical specialists for chronically ill patients, addressing a frequent complaint about HMOs.

In California, a Managed Care Task Force formed by Gov. Pete Wilson is expected to issue a report in January about how to regulate the state’s powerful HMO industry.

The Harvard-Kaiser researchers said they were mildly surprised that Californians’ attitudes toward managed care, which they studied separately, were not significantly different from the nationwide results. Pioneered by Kaiser Permanente more than 50 years ago, managed care has a long history in California.

More than 90% of Californians with insurance are enrolled in HMOs or some other form of managed care. By contrast, HMOs are still a relatively new phenomenon in many parts of the country. Managed-care companies have frequently argued that much public dissatisfaction stems from unfamiliarity with HMO systems, which limit patients’ choice of doctors and impose other, often unpopular, restrictions.

“I look at California’s results and say, ‘They’re not getting used to it,’ ” said Robert J. Blendon, a professor at the Harvard School of Public Health and co-author of the survey. “In the state with the longest experience with HMOs and managed care, people are still very anxious about what happens to them when they’re sick.”

The comprehensiveness of the Harvard-Kaiser study will likely make it influential in the national debate over managed care, lending support to proponents of tighter regulation. The study’s results are also likely to send a sign to politicians that managed-care reform is popular with many Americans.

“This is a serious problem but not yet a crisis for this [managed-care] industry,” Blendon said. “The industry still has a chance to head this off at the pass.”

Despite a clearly negative public view of managed care, the survey’s findings on support for regulation were mixed. The survey found that 52% of respondents said the government should play a role in protecting consumers from unfair treatment by their managed-care plans. But 40% said government regulation would raise health care costs too much.

“There doesn’t seem to be a consensus here about what it is people want to have happen,” said Susan Pisano, a spokeswoman for the American Assn. of Health Plans, an industry group that has tried to head off legislation by promoting voluntary programs by HMOs to protect consumers.

The study’s results suggest that the managed-care industry may be able to kill or weaken reform efforts by arguing that regulation will raise medical costs and taxes, some observers said.

Indeed, some of the same insurance and employer groups that employed a similar strategy to help defeat Clinton’s health care reform plan in 1994 are preparing a new campaign to block attempts in Congress to set federal quality standards for health plans.

The study showed a higher degree of dissatisfaction with managed care than previous, less comprehensive surveys. But Pisano noted that even this study found that the majority of respondents--regardless of which type of health insurance they have--would give their own health plan a letter grade of “B” or higher.

Those with traditional insurance were more satisfied than those enrolled in managed-care programs. While 76% of respondents with traditional fee-for-service insurance gave their plans a grade of “A” or “B,” just 66% of those in managed care did so. Likewise, only 19% of those with traditional insurance gave their plans a “C,” “D” or “F” grade, compared to 32% of those in managed care.

Especially troublesome for the HMO industry were the study’s findings about how Americans perceive the quality of medical care in managed-care programs. The industry has frequently contended that patients in HMOs receive as good or better medical care than those in traditional insurance.

Critics, however, have claimed that HMOs have diminished medical quality, especially for the sickest patients, by denying access to needed medical care.

A recent study authored by health researchers at UC San Francisco concluded that the evidence on HMO quality is “mixed.” Analyzing findings from 37 prior studies on HMO quality, researchers Harold Luft and Robert Miller concluded that the evidence showed “no pattern of worse HMO quality of care.” On the other hand, the authors noted that several studies have found that elderly or chronically ill patients experience worse health results in HMOs than in traditional plans.

That survey, published in the journal Health Affairs, found that “HMOs produce better, the same and worse quality of care, depending on the particular organization and particular disease.”

The Kaiser Family Foundation, though independent of Kaiser Permanente, is a health care philanthropy begun by Henry J. Kaiser, the late industrialist who founded what would become Kaiser Permanente.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Americas’ Views on HMOs

A national survey found that most respondents enrolled in managed-care plans are more critical of the quality of medical care than those with traditional insurance. Most believe that insurers themselves are the biggest beneficiaries of any cost savings from such plans, and most support government regulation.

HOW THEY GRADE IT

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Managed-care People with Grade enrollees traditional coverage A 22% 33% B 44% 43% C 22% 15% D 8% 4% F 2% 0%

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Note: “Don’t know” responses not shown

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MANAGED CARE’S IMPACT

Time doctors spend with patients

Decreased: 61%

Increased: 16%

Ease of seeing medical specialists

Harder: 59%