Consumer complaints against HMOs rise Regulators are troubled that disputes focus on refusals to provide care


WASHINGTON -- State health insurance regulators report surging numbers of formal complaints from patients and doctors against health insurers, primarily health maintenance organizations.

They say they doubt that the rise implies a deterioration in care. They tie it to greater public readiness to fight HMOs and to insurance commissioners' efforts to encourage people to file complaints.

What troubles regulators is a broad shift in the nature of the disputes, which have changed from conflicts over who should pay for care, usually after it has been provided, to conflicts about denials and delays of care and about medication and forms of treatment.

"Before, it was about who pays," said Patricia Butler of Boulder, Colo., a health care analyst and consultant to insurance commissioners. "Now it's about whether you get the service at all."

Insurance regulators say the formal complaints represent possible violations of law and health-plan provisions, and are culled from trivial and unsupportable claims. Depending on the state, 40 percent to 80 percent of the complaints are resolved in favor of the patient or the physician filing them.

No one records national trends in the number of complaints, but the National Association of Insurance Commissioners predicts that 35,000 will be filed this year.

In interviews with 12 insurance departments of mostly populous states with dense concentrations of managed care, those of New York, Connecticut, Illinois, Texas, Ohio and Maryland said complaints had grown at least 50 percent over the past one to three years, far faster than the growth of enrollment in managed care plans.

Only Minnesota reported a decline; other states with increases were Arizona, Florida, New Hampshire, Oregon and Washington.

New York reported a sixfold rise in claims against managed care organizations from 1996 through September. It said 76 percent of the 20,089 claims filed over the period had been settled in favor of the consumers and doctors bringing them.

Neil Levin, the state's insurance superintendent, ascribed much of the increase to the travails of one leading HMO, Oxford Health Plans, and to fee disputes with physicians.

In Texas, complaints from consumers have been climbing, to 846 in 1996 from 131 in 1993. In the fiscal year ended in August, the number leaped to 4,914, largely because of a new law allowing complaints by physicians.

Insurance industry executives say that in spite of the rise, independent surveys regularly show that 80 percent to 90 percent of managed care enrollees are satisfied with their care, a figure that has changed little in a decade.

Charles Kahn, chief operating officer of the Health Insurance Association of America, said that 35,000 complaints a year from the 77 million enrollees whose insurance is subject to state regulation is not a large number.

"You should have zero tolerance for problems," he said. "Inevitably there are going to be some."

That 80 percent of managed care enrollees are satisfied with their care obscures the views of a less satisfied 10 percent or 15 percent who make much use of the organizations, said Karen Pollitz, an analyst at the Institute for Health Care Research and Policy at Georgetown University.

"In any health plan," she said, "the vast majority are healthy and are not using the services."

Pub Date: 11/01/98

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