Barbara Feder Ostrov & Julie Sevrens Lyons

San Jose Mercury News

SAN JOSE, Calif.: Some California HMOs are falling short on their mandate to provide good preventive health care, state health officials say, so much so that they want to require insurers to file public plans that spell out the care they’ll provide.

The state agency that oversees HMOs said Wednesday that some California HMOs are not aggressive enough in fighting preventable illnesses, and there are wide differences in how insurers cover preventive care. Those lapses and disparities make it harder for the 23 million Californians on HMO rolls to get cancer screenings, immunizations and other care to keep them healthy, officials with the state Department of Managed Care said.

Health interventions that might help stave off lung cancer or childhood diseases, for example, are spotty, according to statistics presented by the department. Help with quitting smoking, considered vital to fighting heart disease and many types of cancer, is covered for only about 30 percent of HMO patients who get their health coverage through work. There are also wide disparities in how HMOs cover childhood vaccines to prevent diseases like polio or measles.

For HMO patients, “you don’t just have a right to health care when you’re sick, you have a right to stay healthy in the first place,” said Daniel Zingale, chief of the department.

Zingale is proposing that all California HMOs develop detailed plans for improving and paying for preventive health care, submit them to the state and report on their progress a year later.

The effort may be the first of its kind in the nation: California’s Department of Managed Health Care, opened in 2000 by state lawmakers, is unique in its patient advocacy mission. The proposal could become a formal state regulation within a year, after public and HMO input, Zingale said.

Insurers have fought the Department of Managed Care on other regulation efforts, even questioning the department’s right to oversee them. But there was less immediate opposition to the preventive care proposal, perhaps in part because when HMOs burst into California’s insurance market in the 1970s and ’80s, preventive health care was their key selling point.

“We’re supportive of it, but cautious,” said Michael Chee, a spokesman for insurance giant Blue Cross. “It sounds like a lot of things we’re already engaged in, not only as a company but as an industry.”

Zingale said he wants HMOs to focus on these four areas in their initial plans, and more conditions may be included later.

They are:

– Smoking cessation: Only 30 percent of patients in employer-sponsored HMOs have coverage for smoking cessation programs, according to University of California-Berkeley researchers.

– Chlamydia screenings: Only 19 percent of sexually active women aged 16-20 in California HMOs receive screenings for this common and often asymptomatic sexually transmitted disease, according to insurance data collected by the National Committee for Quality Assurance, which rates health plans.

– Colorectal cancer screening: About 65 percent of California’s HMO members receive screening for this common and fatal type of cancer, according to the Pacific Business Group on Health.

– Childhood immunizations: Zingale said a 2001 HMO report card prepared by his agency found major differences in how California HMOs provide access to childhood vaccines.

Among the quarter of a million calls the Department of Managed Care has received since it started, patients have complained about long waits for cancer screenings and that their HMO won’t cover stop-smoking plans, Zingale said. California’s HMOs on some measures provide better preventive care than their counterparts in other states, Zingale said, but “there’s room for improvement.”

The insurance industry’s response was less acrimonious than in past battles with Zingale’s department, although there were still mixed opinions.

Walter Zelman, president of the California Association of Health Plans, questioned how much responsibility HMOs should have for making sure patients get preventive care when patients frequently switch insurance plans.

Certainly, this is an area some HMOs could improve upon, Zelman said, but he said he doubts the current proposal will be effective.
“There are some marketplace pressures that are pulling health plans and society as a whole away from prevention,” Zelman said. “Those plans that are trying to encourage prevention these days are swimming upstream.”

Kaiser Permanente, a non-profit, combination insurer-health provider that has long emphasized prevention, welcomes Zingale’s proposal, said Dr. Robert Pearl, chief of the Permanente Medical Group. Kaiser provides chlamydia screenings at more than double the rate of other HMOs, according to the insurer.

However, some patient advocates seemed pleased by a renewed emphasis on preventive health care. Some HMOs have created disincentives for physicians to offer preventive screenings and other services by offering low reimbursement rates, said Jamie Court, executive director of the Foundation for Taxpayer & Consumer Rights.

“It’s about time,” Court said. “This is long-awaited relief for patients.”

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The Department of Managed Care’s Web site is http://www.hmohelp.ca.gov and its 24-hour consumer hotline (888) HMO-2219.