The state of HMOs;

Published on


San Jose Mercury News

While California’s HMO patients gave their health care plans improved ratings this year compared with last year, the actual quality of care provided left significant room for improvement, according to a study released Tuesday.

The Office of the Patient Advocate, a branch of the state’s Department of Managed Care, released its fifth annual HMO Report Card. The study, based on both clinical and patient satisfaction data, looks at the state’s 10 largest HMOs, with about 12 million members. The report card evaluates four broad areas. Three of them — care for staying healthy, care for getting better, and care for living with illness — are based on patient records and other data. The fourth area, member satisfaction, is more subjective, based on patients’ response to annual surveys from HMOs.

The HMOs are given a rating of poor, fair, good or excellent in each area.

Among seven major HMOs that serve Santa Clara County, most seem to be doing better at pleasing their patients. Four of the seven received higher marks in member satisfaction than in 2004. Kaiser Permanente of Northern California and PacifiCare both received excellent ratings — one notch better than in 2004. Aetna, Blue Cross, Blue Shield and Health Net each were rated good by their members, with Aetna and Blue Cross showing improvements from 2004. Members of Cigna rated their health plan fair, unchanged from 2004.

The results were more uneven in the three categories of quality of care. When it came to care for getting better — or care while actually sick — three of the HMOs (Aetna, Blue Cross and Blue Shield) saw their ratings slip, while three stayed the same at good. Kaiser got an excellent rating, unchanged. When measuring how well they cared for patients living with long-term illness such as asthma and diabetes, three health plans (Blue Cross, Cigna and Health Net) improved to excellent, while the other four were unchanged.

In the care for staying healthy category, which excludes the sick and those with long-term illness, all seven were rated fair, with Kaiser slipping a notch from good the year before.

The OPA was not able to explain the disparity between improved perception of health care and the actual reality. But Ed Mendoza, interim director of the Office of the Patient Advocate, noted that member perceptions are not based on the objective standards found in other areas of the study. The clinical care studies look at standards set by the Office of the Patient Advocate for routine care, such as colorectal cancer and chlamydia screenings, and whether they are being properly administered. “The members don’t know the standards and rely on their physician to tell them what they need,” he said.

The report — which included more detailed results on specific tests and illnesses — pointed out areas for improvement, the authors said. The areas for improvement included antibiotic treatment for children with throat infections and eye exams for diabetics.

The report was issued to coincide with open enrollment period, from September through December, when consumers can switch health care plans with their employers.

The HMO report card not only rates the quality of care received from health plans but also rates medical groups.

Peter Lee, president of the Pacific Business Group on Health, which helped compile the report card, noted the importance of picking the right doctors’ practice.

“Medical groups are just as important if not more important than health care plans,” said Lee, whose organization puts out a similar health care evaluation called Healthscope. “The reality is that choices are just beginning with a health plan.”

However, some questioned how useful or helpful the report card really is. Jerry Flanagan of the Foundation for Taxpayers and Consumer Rights said the report card provides a meaningless comparison of HMOs and does a better job at promoting the health care companies than exposing actual problems.

“The information is more like social promotion than about giving patients information regarding threatening problems,” said Flanagan, health care policy director for the non-profit organization.

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