Study Finds Misunderstandings Over HMO Policies

Misunderstandings among patients and doctors are a source of much criticism about health maintenance organization restrictions over access to medical specialists, according to a study commissioned by one of the biggest U.S. buyers of health insurance.

A research group set up by the California Public Employees’ Retirement System, the second-largest health benefits purchaser after the federal government, found that criticism against HMOs for not providing easy access to specialists was compounded by misunderstandings about how the referral process is supposed to work.

“There is a need for better communication aimed at both enrollees and physicians,” said Janet Backes, a spokeswoman for California Health Decisions, a nonprofit policy group that helped conduct the survey. “All parties involved--the health plans, medical groups, individual physicians and patients--need to understand the process and know what their responsibilities are.”

Preliminary findings from the study were presented to CalPERS’ Health Benefits Committee on Tuesday. They come as time runs out for Congress to resolve differences over legislation to give patients greater say over health-care decisions by their HMOs.

Consumer advocates said HMOs need to do more than improve communication. “Maybe there is some degree of misunderstanding, but clearly there are other things in the system that are not working properly,” said Betsy Imholz of Consumers Union.

CalPERS said its research group will try to identify solutions to the problems it’s discovered, implement them through pilot projects and recommend practices for the country’s HMOs to adopt.