HMOs get mixed reviews in report Type of plan, where you live affect quality

October 02, 1997|By Diana K. Sugg | Diana K. Sugg,SUN STAFF Sun staff writer M. William Salganik contributed to this article.

In one of the first comprehensive looks at the kind of managed health care Americans are getting for their money, a disturbing picture emerged yesterday in a national report: Quality depends on where you live and what plan you're in.

From children's ear infections and mammograms to waits for appointments and flu shots, the National Committee for Quality Assurance gathered reams of data from 370 health maintenance organizations that collectively cover more than 45 million Americans.

The fledgling effort is a major step toward a crucial goal: being able to compare health plans on quality, just like consumers and companies now do when buying cars and refrigerators. But the report offers something for everyone in the health care equation. HMOs are using the numbers to figure out where they need to deliver better care. Public health officials will gauge which policies or programs they may tailor to certain needs.

For years, rocketing health costs demanded everyone's attention, and the fallout changed the health care landscape forever. Employers, trying to save money, put millions of their employees into managed care plans. Now, with complaints stacking up in benefit managers' offices, companies want to hold plans accountable for the kind of care they give.

"Everybody agrees that managed care and cost-cutting approaches cannot continue unless we have a quality measure infrastructure in place that will help us know when we're cutting fat or when we're cutting into the bone," said Dr. Jonathan Weiner, professor of health policy and management at the Johns Hopkins School of Public Health.

One theme in the report: Consumers in HMOs are generally satisfied with their care. More than 85 percent said they don't have trouble getting necessary care and 56 percent said they were satisfied overall with their HMOs. But only 39 percent rated their plan as "very good" or "excellent" on availability of information.

While everyone involved says the science of measuring quality is in its infancy -- and those on both sides of the issue debate how good the numbers are -- raw percentages do tell a story: There are human consequences to health plans treating similar patients differently.

Heart attacks

Consider the case of the heart attack.

It's one of the leading causes of death in the United States. Every year, 1.5 million Americans have heart attacks. Studies have shown that an inexpensive class of drugs called beta blockers protect these patients from future attacks and death. But among people enrolled in some HMOs in Texas, Alabama, Louisiana and other Southern states, fewer than 20 percent of heart patients receive the drugs, according to the report. That compares with just 25 percent in traditional fee-for-service care and 90 percent in some of the country's best performing health plans. The national average is 62 percent.

If all plans performed as the best ones do, experts said, several thousand people who die of heart attacks every year would be saved.

HMO officials said some of their numbers may be low because their data systems were set up years before performance statistics were put in place and they may not be collecting every instance. Others pointed to physicians practicing differently. Some plans -- such as those that serve elderly and inner city populations -- tend to have more sick patients.

Dr. Stephen Gottleib, director of the cardiac care unit at the University of Maryland Medical Center, said some physicians are holding on to a mistaken impression that many people can't use the drugs. But Gottleib said beta blockers help the vast majority of heart attack patients, particularly diabetics, people with pulmonary disease and poor heart function.

He theorized that some patients may not be getting the drug because they're seeing primary care physicians, rather than specialists. Studies have shown cardiologists understand the necessity of beta blockers more than primary care doctors do, Gottleib said.


Another example is the annual eye exam for people with diabetes.

The condition is the leading cause of blindness in the nation. But it can be prevented in diabetics if eye damage is picked up and treated with a laser.

The standard of care is an annual exam, and even more frequently for certain diabetic patients. Some health plans checked as many as 75 percent of people with diabetes, and others checked as few as 10 percent. Fee-for-service care checked 11 percent.

The national average was 38 percent. Experts say that adds up to hundreds of cases of preventable blindness every year.

One local physician, who declined to be identified, said that in many health plans, "It is not made easy and not made routine to have those follow-ups."

But NCQA and HMO officials stressed that the report is a starting point, and a way for health plans to do internal checks on their performance.

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