In Maryland's annual checkup of HMOs, Kaiser Permanente posted the most top scores and Preferred Health Network the most low marks in the report issued yesterday, just as last year. But consumer behavior in response to the rankings has often been at odds with the results.
The HMO report card hasn't resulted in consumers switching in large numbers from low-ranked plans to high-ranked ones. Consumers' satisfaction with their health maintenance organizations is on the decline, even as the plans overall have been scoring higher on various clinical measures than a few years ago.
But state officials said the assessment, launched by an insurance reform law a decade ago as health maintenance organizations grew in popularity, have brought more accountability to the industry and produced an overall improvement in care.
"I'm proud today to be a Marylander, and to sit on a committee that oversees health care, and to be able to say, `We're doing much better,' " state Sen. Delores G. Kelley said at a news conference yesterday releasing the report card.
Kaiser earned 10 "star performer" designations for posting above-average scores on the same measure for three years in a row, more than any other HMO.
State average scores have shown steady gains in the past few years on measures such as immunization rates and administering the proper medication to heart attack patients, said Barbara McLean, executive director of the Maryland Health Care Commission, which prepares the report.
The HMOs themselves, and scholars and consumer advocates nationally, agree that the report cards have produced more focus on quality.
Public reporting "creates accountability for these programs, and encourages them to compete in a positive way," said Dr. Peter Lurie, deputy director of the Washington-based Public Citizen's Health Research Group.
On the other hand, in Maryland and nationally, there is little evidence that the report cards have driven consumers and employers to switch health plans (although some HMOs have trumpeted their rankings in advertisements such as ones used by Kaiser two years ago proclaiming, "We don't mind if our patients see stars.")
"As far as consumers using them, they really have been a bust," said Trudy Lieberman, director of the Center for Consumer Health Choices of Consumers Union. Her New York-based group has helped develop report cards for Consumer Reports magazine and other organizations.
In part, Lieberman said, that's because some reports haven't been as clear as consumers would like. But others contend that it's also because both employers and individual consumers look first at price, then at which doctors and hospitals are in the HMO's network - and only then at quality. According to the state's consumer surveys, 73 percent of Marylanders are offered two or more health plans by their employers.
Ellen Valentino said in her two years as Maryland director for the National Federation of Independent Business, her members - small employers - have asked her for all sorts of documents and reports, but never the HMO report card. "The focus is so fixated on the rising costs that quality has taken a back seat," Valentino said.
John Miller, executive director of the Maryland Health Care Coalition, a group of large employers, said although some of his members give the state report card to employees during enrollment periods, they don't use it in choosing which HMOs to offer. More than a dozen of his members, however, use a performance questionnaire with more detail than the state report card. "The idea is not to drop somebody who's not performing well," Miller said. "The idea is to raise performance."
Rita Costello, senior vice president for marketing at CareFirst BlueCross BlueShield, said at information sessions, consumers typically ask, " `What are my benefits?' `Is my doctor in the plan?' `What's my out-of-pocket cost?' Rarely do you see an employee at a health fair asking: `What are your scores?' "
Although report card marks don't translate directly into membership, the HMOs say they watch the results closely.
"We're out advertising in the marketplace, and the HMO report card is one way we and the public can assess how we've been doing what we say," said Elizabeth Sammis, director of government programs for Mid Atlantic Medical Services Inc. (MAMSI), which owns two HMOs covered in the report - M.D.-Individual Practice Association and Optimum Choice.
The two MAMSI plans have shown substantial improvement in scores since the report cards began in 1997. The state rates each HMO as above average, average or below average on 30 measures - some, such as immunizations, from audited medical records, others based on a state-commissioned survey of member satisfaction.