HMOs rate poorly on prevention

Times Staff Writer

Many Californians enrolled in healthcare plans are receiving inadequate preventive care, a government report said Thursday.

The eight largest plans in the state fail to ensure that their 12 million members are sufficiently tested and treated to prevent and detect major diseases and reduce unnecessary expenses, according to the California Office of the Patient Advocate’s report, called the Health Care Quality Report Card.

The report compared how often the plans, along with about 200 physician groups, met 31 clinical quality standards, such as immunizing infants and screening adults for cancer, in 2006.


It found that almost one-third of middle-aged women hadn’t had a mammogram to screen for breast cancer in the last two years, for example, and that almost half of plan members older than 50 hadn’t been tested for colorectal cancer.

“As standards of care, they pretty much should happen 100% of the time,” said Ted vonGlahn, director of consumer engagement for the Pacific Business Group on Health, which helped prepare the report. “When you look at the averages, it’s pretty sobering.”

Each health plan’s individual rating was determined by comparing its performance on the 31 care standards with national averages. The overall clinical quality rating was expressed on a scale of one to four stars. No health plan received four stars, or an “excellent” rating.

Health Net and Kaiser Permanente each received the highest score for overall clinical quality, notching three out of four stars, or a “good” rating.

The rest -- Aetna Health, Blue Cross, Blue Shield, Cigna, PacifiCare and Western Health Advantage -- were given two stars, for “fair.”

“The bottom line is there is room for improvement,” said Dr. John Zweifler, a medical consultant for the Office of the Patient Advocate. “We can do better.”


Jerry Flanagan, a patient advocate with the Foundation for Taxpayer and Consumer Rights, said the report let health plans off too easily by failing to take them to task for what he called their “worst behavior.”

For instance, he said, the report didn’t make note of the cancellation of sick patients’ coverage, for which Blue Cross and Kaiser have been sanctioned, or the troubled kidney transplant program at Kaiser.

“This vague and incomplete analysis gives consumers a false sense of security about the quality of HMOs,” Flanagan said.

The report rated the health plans for consumer satisfaction based on a member survey. Most received three stars. Two -- Blue Cross and Cigna -- received two stars.

Aetna was the only plan with a single star, or a “poor” rating, on consumer satisfaction.

“It certainly indicates that we have some work to do,” Aetna spokeswoman Rachelle Cunningham said.

She said the company was trying to improve its payment of claims and to answer enrollees’ calls faster.


Blue Cross said it was also taking the feedback to heart.

“Our medical staff is engaged and reviewing the report so that we can continue to improve our scores,” said Shannon Troughton, a spokeswoman for Blue Cross parent WellPoint Inc.

Blue Shield spokesman David Seldin said that although it was up to physicians to make sure care standards were met, health plans could help. For instance, Blue Shield participates in a pay-for-performance program that rewards physicians who meet standards most often. This year, the health plan will pay $31 million in bonuses to high-performing physician groups.

The California Medical Assn., a physicians’ organization, criticized the report, saying it failed to query doctors in detail about the care they provide.

Association President Dr. Anmol S. Mahal blamed health plans for what he called inadequate payments to pediatricians and other primary care physicians for preventive care, such as childhood vaccinations.

“For-profit HMOs are making billions of dollars in profits, often at the expense of quality healthcare for their enrollees,” Mahal said.

The report card, also available in Spanish, Chinese, Vietnamese and Korean, can be found at or by calling (866) 466-8900 for a free copy by mail.