Sickest may be quickest to lose out with HMOs

Staying Ahead

April 14, 1997|By Jane Bryant Quinn | Jane Bryant Quinn,Washington Post Writers Group

SOLID evidence exists that for some patients, health maintenance organizations (HMOs) can be hazardous to health. They don't take good care of the most vulnerable among the sick.

In a recent study of the chronically ill, the elderly and the sickest poor fared much worse in three urban HMOs than their counterparts did in traditional health plans, reports John Ware, senior scientist at Boston's New England Medical Center.

On the other hand, younger patients in his study -- who had higher average incomes and whose chronic illnesses weren't as bad -- did just as well in the HMOs and at lower cost. So HMOs -- good HMOs -- can be a reasonable option for working people.

Older people, however, have to think carefully about whether to join.

At present, HMOs serve more than 13 percent of the Medicare population. They're concentrated in the West, with California in the lead. In the East, the top states are Florida, Pennsylvania and Massachusetts, according to the industry's trade group, the American Association of Health Plans (AAHP).

There are pluses and minuses to Medicare HMOs.

The big plus is cost. Medicare HMOs give you Medicare Parts A and B (for hospitalization and doctor bills), coverage for all Medicare deductibles and co-insurance, plus benefits that traditional plans for the elderly don't include: things like annual physicals, eyeglasses, dental coverage and low-cost prescription drugs. You also get preventive care.

Premiums may go up and free services decline if Congress, as expected, cuts payments to Medicare HMOs. But the plans will still be attractive financially.

You can join a Medicare HMO with no waiting period and regardless of health, unless you have kidney failure or are in hospice care.

You pay your Part B Medicare premiums (currently $43.80 a month). But you don't have to buy a Medigap policy to help pay the bills that Medicare doesn't. The HMO is both Medigap and Medicare, rolled into one.

Two-thirds of Medicare HMOs charge zero monthly premiums, the AAHP says. Most of the rest charge between $20 and $60. There might also be co-payments for every doctor visit, in the range of $2 to $10.

Another plus is paperwork. There isn't much. In fact, there may not be any at all.

The minuses fall into two categories. One is sales, the other is care.

Enormous deceptions have been recorded in surveys by "mystery shoppers," who listen to pitches by salespeople who may bill themselves as "Medicare consultants."

For example, they may not explain that you're locked into seeing the doctors on the HMO's list. If you go to an outside specialist without authorization, neither the HMO nor Medicare will pay.

Your own doctor may be on the list. But once you join the HMO, he or she may have to give you less treatment, or different treatment, than you got under regular Medicare.

You're entitled to urgently needed care when you're temporarily out of town. But your HMO may argue over whether your problem was really "urgent."

If you spend part of the year away from your HMO's service area, no one will normally cover your medical expenses. A few HMOs -- notably those run by Blue Cross/Blue Shield -- are setting up "guest" arrangements for each other's members.

As for quality of care, there's evidence that the oldest patients and the disabled get poorer access to care in HMOs than in traditional plans, Diane Archer, head of the Medicare Rights Center in New York City, told my associate, Kate O'Brien Ahlers. The industry cites other studies showing, for example, that elderly people with cancer are diagnosed earlier in HMOs.

By law, Medicare beneficiaries have appeal rights if they're refused a service they think they need. But a Tucson, Ariz., judge ruled last October that the HMOs' current appeals system isn't working.

Cases may go on for months. In the meantime, the patient's health may deteriorate beyond repair. The Health Care Financing Administration, which administers Medicare, is planning a speeded-up system, with a 72-hour limit for resolving most cases. But how well this works remains to be seen.

For more information on Medicare HMOs, send for the brochure, "Medicare Health Maintenance Organizations: Your Rights, Risks and Obligations," $3 from the Medical Rights Center, Box RRO, 1460 Broadway, Eighth Floor, New York, N.Y. 10036.

Pub Date: 4/14/97

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