HMOs Perform Best for the Healthy, Doctors Say

Managed health care appears to be fulfilling its promise of improving preventive care for healthy people, but there is no such certainty of good treatment for patients who develop serious medical problems, two new studies show.

The nation’s physicians overwhelmingly view managed care plans as reducing the quality of care they are able to give their patients, according to a nationwide survey of nearly 1,100 doctors by the Kaiser Family Foundation.

Almost nine of 10 doctors said that they had patients who had been denied coverage for services by a health plan during the last two years. In nearly half of those cases, the denials resulted in a “serious decline” in the patient’s health, the doctors said.

The most frequently denied treatment, the survey found, was prescription medication. Nearly half of the doctors said that their requests for referrals to specialists were denied.

The most effective HMOs, according to a second report, by the National Committee for Quality Assurance, are highly aggressive in their use of key preventive measures, such as the use of beta blockers for people who have had heart attacks and eye exams for those with diabetes. These two screening measures prevented 1,800 cardiac deaths and kept 800 people from going blind last year, according to the committee.

The committee’s report covered 400 health plans that enroll more than 70 million people, about 90% of all Americans who belong to health maintenance organizations and other managed care networks.

Together, the two studies painted a picture of the nation’s health care system at a critical juncture.

“Managed care embodies the best and the worst in American medicine,” said Drew Altman, president of the Kaiser Family Foundation (a health policy think tank unrelated to the Kaiser Permanente health maintenance organization), which did the physician survey. “The status quo isn’t good enough. . . . This is about what patients are entitled to in the health care system.”

Although managed health care has become the dominant form of care nationwide, it has evidently failed to win the confidence of doctors and the public. The belief that health plans are making decisions based on profits, not patients’ needs, appears to have persisted and even deepened.

“Denials of medically necessary care is the No. 1 concern of physicians and patients across the country,” J. Edward Hill, a family physician and a trustee of the American Medical Assn., told the news conference at which the Kaiser survey was made public.

Managed care plans have accomplished one goal--holding down soaring health care costs--but have limited access to expensive treatments and tests. As employers have forced their workers away from traditional fee-for-service insurance plans, the share of Americans under age 65 in some form of managed care has soared to at least 75%.

HMOs have a demonstrable advantage over traditional fee-for-service medicine in preventive care. For example, according to the report by the National Committee for Quality Assurance, beta blocker usage after a first heart attack was 81% among HMO members. An earlier study found that only 36% of patients in traditional fee-for-service medicine received beta blockers.

“When people get these services, they do better,” said Dr. Jim Marks of the U.S. Centers for Disease Control and Prevention. The screening and prevention steps are “relatively simple common measures” that should be used by all doctors for all patients, he told a news conference at which the committee’s report was presented.

The committee’s report card is a vital tool for companies in deciding which health plans to offer their workers, said Veronica Goff, vice president of the Washington Business Group on Health, a coalition of 35 major firms. “This is exactly what employers have wanted to see for a long time, a large database, most of it audited.”

The committee, which provides accreditation of health plans, was created with foundation and industry contributions to provide a neutral source of information. This year’s report, the third annual, depended on an audited selection of patients’ records from health plans.

Kaiser Permanente was the highest-ranking plan for most categories among California HMOs. More than 56% of its California members with diabetes received eye exams last year, compared with a national average among HMOs of 43%. More than 90% of members who had suffered a heart attack were being treated with beta blockers, compared with a national average of 81%.

Doctors and administrators at Kaiser said that the health maintenance organization’s structure is key to its high rankings.

Kaiser operates its own hospitals and clinics and relies on a single, large group of doctors.

“We are able to identify where we want to make improvements and then drive the entire system to make those improvements,” said Dr. Phil Madvig, associate executive director of the Permanente Medical Group in Northern California.

By contrast, health plans that operate with looser networks of doctors and hospitals find it more difficult not only to persuade doctors to comply with new guidelines but also to gather information from individual physicians on how treatment actually is being provided, said Milt Schwarz, West Region Quality Director for Aetna U.S. Healthcare.

For example, Schwarz said, Aetna scored below the national average on the overall rating of health plans, in part because participating physician groups did not always allow consumers to obtain referrals to specialists easily. The health plan’s policy is to allow physicians to make most referrals on the spot, Schwarz said, but many of the independent practice associations that dominate care in California have more restrictive policies.

Several plans refused to participate in the survey or participated but requested that their data be kept confidential.

Blue Shield of California, for example, submitted data but refused to allow it to be released, in part out of concerns that the information would inappropriately present the company in an unflattering light, said spokeswoman Laura Perry.

Wellpoint Health Systems made a similar decision, and Maxicare of California did not participate.

Emma Hoo, senior manager for the Pacific Business Group on Health, an employer group that is one of the state’s largest purchasers of health benefits, said that many employers intended to discourage membership in plans that did not participate in the study.

Pacificare, which did not participate in previous studies, did submit data for 1999 but, because of a “miscommunication,” the California results were left out of the report, said the HMO’s medical director, Sam Ho. He said that the company, which scored above the national average on most measures, would gladly supply its results upon request.

At the root of the furor over managed care is a tug of war between doctors and health plans over who ultimately should decide what care patients should receive.

The Kaiser Family Foundation’s survey, a random sample of 1,053 doctors and 78 nurses, disclosed some striking data about which types of services are most often denied.

Six of 10 doctors reported denials for prescription drugs. Four in 10 said that health plans had denied requests for diagnostic tests and procedures.

Nearly one in three reported regular denials--monthly or even weekly--of requests for referrals to specialists.

Doctors resoundingly said that managed care had diminished the quality of health care for the sick and had stripped physicians of their freedom to adapt treatment plans to patients’ individual circumstances.

At the same time, however, nearly half of the doctors surveyed said that managed care provided more preventive care and health screenings.

The Kaiser study was denounced immediately by the insurance industry for failing to reflect the positive impact of managed health care on the cost of care and on eliminating unnecessary procedures.

“The attitudes of doctors do not jibe with peer review journals. . . . The care in managed care is just as good as it was before managed care,” said Don Young, chief operating officer of the Health Insurance Assn. of America.

“Managed care has brought costs under control, and it has allowed thousands of Americans to keep their health insurance,” Young said.