HMOs Still Have Work to Do, Survey Finds

The managed care industry endured a barrage of criticism throughout the ‘90s that sparked legislative reforms that continue today. But despite new laws and the industry’s own efforts to become more consumer-friendly, health experts are questioning how effective the changes have been so far.

Nearly half of Americans report some type of problem with their health plan. A much smaller, though significant number of people say those problems are leading to serious medical and financial woes. The sickest patients still have trouble getting access to care--a frequent criticism of HMOs--even though some health plans have taken steps to address the obstacles.

Many states have enacted laws designed to help consumers resolve health plan disputes, such as guaranteeing the right to an independent review when medical services are denied. Even so, most patients remain unaware of their rights.

The issues are underscored in studies issued last week by the Kaiser Family Foundation, a nonprofit health policy organization not affiliated with the Kaiser Permanente HMO, and Consumers Union, publisher of Consumer Reports magazine. A report on the studies appears in the magazine’s July issue.

A national poll by the Kaiser Family Foundation found that slightly more than half of Americans reported some type of problem with their health plan in the prior year, ranging from difficulty getting care to billing disagreements.

More troubling, about 21% of the people who reported problems with their health insurance said that their health declined as a result.

And 6% of those with problems said their health decline had led to a long-lasting disability. That figure translates to about 4 million Americans.

Helen Schauffler, a health policy researcher at UC Berkeley, said the number of people reporting problems leading to a disability is disturbing.

“Our health care system is supposed to make us better or maintain our health,” she said, “not make it worse.”

Who Was Surveyed?

The Kaiser study surveyed 2,500 U.S. adults with health insurance from October to December 1999. The poll did not include adults over age 64. The survey looked at people with all types of health insurance, including traditional fee-for-service plans, which generally allow patients to see any doctor they choose.

More than 90% of insured Californians are enrolled in some form of managed care plan, which limits members’ choice of doctor. Nationally, the comparable figure is about 70%.

Larry Levitt, director of the Kaiser Foundation’s Changing Health Care Marketplace Project, said the poll showed that people in all types of insurance plans--not just HMOs--are having problems. But people enrolled in HMOs were more likely to report trouble getting access to medical care than those in plans that have looser restrictions on doctors and other services.

Although acknowledging that most of the reported difficulties “amount to more of a hassle than a horror story,” Levitt said he was struck by the substantial number of people who reported serious consequences as a result of problems with their health plans, such as lost time from work, deteriorating health or financial losses. A third of those who reported a problem during the prior year, for example, said their medical care was either delayed or denied.

Schauffler, who is director of Berkeley’s Center for Health and Public Policy Studies, noted that a 1997 state-sponsored poll of Californians found that 42% of insured adults reported some problems with their health plans--a lower figure than the 51% who reported problems in Kaiser’s national poll.

Schauffler noted that California legislators have tried to address some of the problems found in the 1997 poll by passing consumer reforms, such as a law that gives HMO members the right to appeal health plan decisions to an independent review panel. That law--similar to ones in place in more than 30 other states--doesn’t go into effect until January.

The Challenge Ahead

While noting that the Kaiser Foundation survey found that 83% of Americans reported positive experiences with their health plan, HMO officials said the findings indicate more work needs to be done to address consumer issues.

“If people are denied care they really need, then [even] 1% is too high and the industry has to work to get that down,” said Walter Zelman, president of the California Assn. of Health Plans, a Sacramento-based industry group.

Whether due to their own experiences or a lot of negative publicity, consumers often worry that managed-care plans have an economic interest in denying necessary services. Zelman said many Californians unfairly blame their HMOs, not realizing that health plans in the state have turned over most of the responsibility for medical decision making to medical groups, which sign contracts with HMOs in order to see the insurers’ patients.

It is doctors, not “imaginary bean counters in an HMO,” making medical decisions, asserted Zelman.

But Schauffler said it’s too easy for the HMOs to shift responsibility--or blame--onto doctor groups. Consumers sign up with and pay their insurance premiums to health plans, not medical groups, so it is the plans’ responsibility to ensure that members get the services they need.

Levitt said the Kaiser Foundation survey may also reflect heightened consumer consciousness about health care: “Managed care is dinner-table conversation, whereas it wasn’t a few years ago. People are recognizing more that they’re having problems.”

The findings, he said, demonstrate that “the backlash against managed care and the drive for patients’ rights legislation is not being driven by anecdotes, but by real experiences.”

Terri Ann Kitowski, a Sacramento teacher, is a case in point. She has long suffered from a painful jaw condition that makes it difficult for her to open her mouth or eat a meal. Her primary care doctor recommended surgery for her condition in 1998. But finding the proper specialist to perform the surgery proved difficult: Each of the three surgeons she found quit her HMO before the surgery could be performed, all of them complaining about the low fees paid by her HMO.

The HMO wanted her to travel 100 miles away for treatment, but she refused.

After months of letters and phone calls--and the assistance of a consumer rights organization in Sacramento--she was denied permission to see a local doctor outside the plan’s physician network. More recently, the plan referred her to another surgeon at UC Davis. Now, two years later, she still hasn’t had her surgery.

Health plans and their trade groups agree they need to improve patient outreach.

Responsiveness

The American Assn. of Health Plans, a Washington, D.C.-based trade group that represents most of the nation’s biggest health plans, is working with its members to improve its responsiveness to patients and to set up ombudsman-type programs to resolve any grievances.

“Typically, what happens is you get information when you join and you don’t necessarily read it,” spokeswoman Susan Pisano said.

“At minimum,” Zelman said, “we have to have a process in place where people know where they can go with a complaint in the health plan, and get an answer quickly.”

Managed care must also overcome big public-relations problems.

Many patients distrust managed care because of “draconian, poorly thought-out decisions which gained a lot of press,” such as drive-thru deliveries that limited new mothers to a single night in the hospital after childbirth, said Geraldine Dallek, project director of the Institute for Health Care Research and Policy at Georgetown University in Washington.

“Managed care is going to be judged on how well it serves chronically ill and sick people,” Dallek said. “It’s a no-brainer to be able to provide care to healthy people. Time after time, poll after poll, you see the same results: People who are sicker and in poorer health have more problems getting care they need.”

Meanwhile, as health plans scramble to improve access, they also struggle to control costs. These two efforts are often at odds, since easing restrictions to improve access can raise medical costs.

Americans traditionally are reluctant to give an inch when it comes to their health: “We have never confronted whether we need to have some rationing,” Dallek said. “The health care system has left it to managed care to do it, and we’ve not liked it.”

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Health Plan Problems

A national survey found that 51% of adults reported problems with their health plans. Of those, 21% said the difficulties resulted in declining health.

76% No decline in health

21% A decline in health, which includes the 6% whose decline led to permanent or long-lasting disability

3% Don’t know of decline or didn’t respond

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Source: Kaiser Family Foundation National Survey of Consumer Experiences With Health Plans, June 2000. Poll conducted October-December 1999 of 2,500 adults ages 18 to 64.

Resolving Problems

Of those who reported a problem, 86% said they took some action to get it resolved.

Contacted someone other than their physician: 73%

Referred to health plan documents for information: 46%

Asked a friend or family member for help: 25%

Contacted someone outside the plan: 21%

Changed health care plan or provider: 10%

Filed a formal appeal: 6%

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Source: Kaiser Family Foundation National Survey of Consumer Experiences With Health Plans, June 2000. Poll conducted October-December 1999 of 2,500 adults ages 18 to 64.