That simple insight has transformed NEWSWEEK’S 1997 HMO rankings, which follow this story. Using methods developed by David Lansky of the Oregon-based Foundation for Accountability (FACCT), a designer of quality measures for health plans, NEWSWEEK surveyed the 150 largest plans in the country. We requested data on 43 key activities, from immunizations to mental-health care. Our rankings cover the 88 plans that supplied enough information to be fully judged. As in last year’s ranking, each plan get s a grade for overall quality. But this year we went farther, assessing each plan’s success at promoting health, treating acute illness and helping people live with chronic conditions. To make the analysis more useful, we separated children’s care from a dults’ care, and we converted the numerical scores for each plan into letter grades that run from A to D.
The new rankings are designed to help you fine-tune your search for a plan. Given a choice between HIP Health Plan of New York and Empire Blue Cross Blue Shield–both C-rated on overall quality–you’d likely be indifferent. But glance over at the A DULTS column. HIP gets a C, while Empire’s score is D. There’s no question which you should join if you’re single or childless. Keep in mind that we graded on a curve. So, while 18 plans received A grades for overall quality, their actual scores ranged f rom 70 percent to 81 percent. The quality gap between plans with different grades can be enormous. An A rating may signify that a plan is performing three or even four times better than a plan with a D.
Our table will get you started, but no report card can tell you everything you need to know about a health-care plan. Before joining an HMO, you should assess your biggest medical risks (a family history of breast cancer, for example) and take stoc k of special health concerns such as infertility, migraines or depression. Once you assess your needs, the following family profiles should help you find a plan whose strengths match your needs.
Young and Growing Families
You’re young, you’re healthy, but you’re still a huge consumer of health-care services. Why? Simple: childbearing requires a lot of medical attention–for mother and babies alike. Here’s how a family of two young adults (between the ages of 24 and 40) with young children–or plans to have children–can find the best HMO.
Recognize the importance of prenatal care. Countless problems can be averted with attentive care during pregnancy, but HMOs don’t always provide it. According to Quality Compass, a 329-plan database assembled by the National Committee for Quality A ssurance in Washington, D.C., the top scorers in the country–with 98.6 percent prenatal screening or better–were Matthew Thornton (Massachusetts), Principal Health (Delaware) and Columbia Medical Plan (Maryland). Ask your prospective HMO what percentag e of pregnant members get prenatal care during the first trimester, and look for a rate of at least 87.5 percent.
Don’t accept needless surgery. Even routine procedures such as Caesarean sections invite complications. There are two signs that an HMO has done everything it can to avoid needless surgery. First, a top plan will have a C-section rate of below 15 p ercent, according to Sheffler & Associates, a health-benefits consultant in Arlington, Mass. (the national average is 21 percent). Second, the plan will be able to tell you its VBAC rate, or the percentage of women who deliver vaginally having previously had a C-section. If an HMO even knows its VBAC rate, that suggests it is making efforts to minimize needless surgery.
Insist on satisfied specialists. Look to see how many of the Ob-Gyns and pediatricians on a plan’s roster are accepting new patients. If most of them have their welcome mats out, chances are they’re satisfied with the policies and compensation. Oth erwise they’d find a way to bar new patients.
Demand vaccine vigilance. If an HMO scores below Quality Compass’s average of 65 percent on childhood immunizations, beware. The country’s top-scoring plans are Cigna HealthCare of Oklahoma, Healthsource New Hampshire and HMO Blue in Massachusetts, with rates of 92.9 percent to 93.9 percent.
Check out a classic kids’ condition. Asthma is rampant and on the rise in America. Even if your kids don’t suffer from it, an HMO’s response to asthma is an excellent barometer of its approach to childhood conditions. To prevent emergency hospitali zations and missed school days, doctors have to teach parents and children to manage the disease. A good HMO will have an asthma program that includes specialized care and leading-edge medications such as Flovent and Serevent.
Middle-Aged Parents With Teens
If you’ve been healthy through your 20s and 30s, all you’ve needed is infrequent and routine health care. If your genes blessed you, that’s all you’ll require for years to come. But if cholesterol and calories flock to you, you’re vulnerable. So ar e your teenage kids, who may need counseling, drug and/or alcohol intervention or abortion services. No parent wants to admit that a child might need such help, but you should be in a position to provide it. Here’s how middle-aged parents (between the ag es of 40 and 64) with teenage children can find the best plan.
Shop for early heart care. Nearly a million Americans die each year from coronary-artery disease. An additional 800,000 undergo angioplasty or coronary-bypass surgery every year. At their best, managed-care companies flag members at risk of heart d isease and intervene early to change their eating and exercise habits. The top scorers in the country measure cholesterol levels in 88 percent or more of their eligible members, according to Sheffler & Associates, and offer incentives to help members red uce their risk. They also work aggressively to keep people with diseased arteries from suffering heart attacks. One litmus test: what is the plan’s policy on statins, a new class of powerful, but expensive, cholesterol-lowering drugs?
Study a plan’s cancer-screening efforts. A broad signal of a plan’s seriousness in tackling breast cancer is a high mammography rate. In a good plan, 85 percent of women 52 to 64 will have had a mammogram within the last two years. The national ave rage is only 70 percent. Cervical-cancer screening (a Pap test) should be even more well entrenched than mammography at health plans. Sheffler’s best practice rate: 85 percent. Nationally, HMOs averaged just 70.4 percent.
Reject high hysterectomy rates. Hysterectomy is the leading cause of hospitalization among women in this age group, and the operation is often performed needlessly. A low hysterectomy rate signals a modern understanding of women’s health issues. Th e most conscientious HMOs perform just 4.3 hysterectomies each year for every 1,000 members age 45 to 64. The national average is nine per thousand.
Seek an aggressive addiction program. Substance abuse ranks among the top five causes of hospitalization for boys and men age 14 to 64. Look for a plan that maintains its own addiction program instead of farming the problem out to a managed-behavio ral-health company. The best chemical-dependency programs treat members at varying levels of intensity, incorporate professionals from various disciplines and make sure treatment continues for years.
Think of teens’ needs. You, of course, are your child’s first line of defense against problems like substance abuse and unwanted pregnancy, but an HMO can help immensely. Find out what a plan asks its primary-care physicians to assess during your c hild’s yearly physicals. Docs who openly discuss smoking, drug use, sex and depression with young patients can spot problems early and help you intervene.
Families With Chronic Illnesses
Nearly 100 million Americans suffer from chronic diseases or disabilities. They, more than anyone, need treatment that improves daily life while reducing the need for more drastic measures later. But for all their talk of health maintenance, manage d-care plans often avoid chronically ill patients until emergencies arise. Families of children with diabetes, cystic fibrosis, cerebral palsy or muscular dystrophy face particularly difficult issues. Here are some steps to help you uncover the quality y ou deserve.
Beware of faux HMOs. Many HMOs are really old-fashioned insurance companies in a new guise. Instead of monitoring and coordinating all aspects of your health, they simply contract with independent doctors–and shower them with incentives to minimiz e costs. If you have a longstanding relationship with a doctor you trust, you may be better off joining the plan that allows you to stick with him or her. Otherwise, I recommend looking for a ““staff model” HMO rather than a network of independent physic ians. A staff-model HMO hires its own doctors and is far more likely to have perfected the multidisciplinary cooperation that a complex chronic condition requires.
Seek people like yourself. Does the HMO you’re considering have other members with your condition? If so, you’re more likely to receive competent care. Ask how many of the plan’s members share your problem. ““If they can’t tell you, that’s a warnin g sign,” counsels Teresa Fama, deputy director of Chronic Care Initiative in HMOs, a program of the Robert Wood Johnson Foundation. Next, find out if the plan has a special ““disease management” program for your condition. One of the most impressive exam ples is Harvard Pilgrim Health Care’s decade-old program for HIV-infected members. A team of infectious-disease specialists, hematologists/oncologists, nurses and assistants helps the plan’s primary-care physicians minister to 750 plan members with HIV. This effort to integrate the care these patients receive has not only reduced hospital admissions but cut the average stay–from 8.5 days in 1991 to 5.2 days in 1995.
An HMO that doesn’t have a special program for your particular condition may nevertheless have a ““case management” program for chronically ill patients. If so, you should make sure it incorporates outpatient care and not just hospitalization, whic h is where most case management is concentrated. Also ask about the ratio of case managers to members. In high-quality programs the managers–typically nurses or social workers–carry small caseloads. They handle no more than 40 members apiece, and they spend at least half their time in direct client contact.
Senior Citizens
Retirees have never faced a thornier tangle of choices. With Medicare drifting slowly toward bankruptcy, the federal government is anxious to channel seniors into managed care’s cost-conscious arena. But managed care’s record with seniors is short and spotty. Medicare HMOs can be an excellent option for healthy seniors; the plans offer vision care, pharmacy and other benefits that aren’t available under traditional Medicare. But the fact is, seniors have more health problems than young people, so Medicare HMOs have stronger incentives to stint on care. Here’s how to find one worth joining.
Look for a holistic approach. A healthy lifestyle can dramatically improve your functioning in later life–and early detection can improve your odds of beating cancer and other life-threatening diseases. A good Medicare HMO will offer assistance on both fronts. It will have programs devoted to stopping smoking, weight and cholesterol reduction and the safe use of medications. And it will offer free prostate-, colon-, breast- and lung-cancer screenings in addition to regular health checkups.
Demand old-age experts. As a senior, you should search high and low for a Medicare HMO that understands the importance of team medicine. The ailments of old age require the coordinated efforts of many specialists, including some that aren’t normall y found in an HMO: geriatricians, social workers, financial advisers, dietitians and physical therapists.
Don’t fall for freebies. It’s not uncommon for an older person to take 15 to 20 different medications. Because traditional Medicare doesn’t pay for drugs, an HMO’s $500-a-year prescription benefit can sound fabulous. Many HMOs offer an appealingly generous drug benefit to draw you into the plan, then fall short when it comes time to deliver. How? Their pharmacy doesn’t offer the precise drug you take. It carries a substitute. Find a plan that carries your specific medications, even if your out-of-pocket costs are higher. And ask what happens if the dispensary drops your drug. Will the plan take special steps to acquire it for you? Will it reimburse you for buying the drug on your own?
The ideal HMO is not only generous with drugs but smart about them. Many drugs have harsher effects on elderly patients than on young ones. And because seniors take so many medications, they’re at constant risk of adverse interactions. All told, dr ugs are implicated in 20 percent of all hospital admissions among Medicare patients. A good pharmaceutical plan will provide an electronic patient profile that pharmacists can check to see if a drug is suitable for someone of your age, sex, size and heal th condition. The plan should also provide an electronic dispensing record that lists every medication you’re taking.
Consult the record. Good HMOs have always been willing to share information on their performance, but Medicare HMOs now have no choice. Under new rules adopted this year, the federal Health Care Financing Administration (HCFA) requires that Medicar e HMOs furnish extensive data on their members’ health status and satisfaction, as well as an array of other quality measures. Sometime next spring, the HCFA will start posting some of it on the Web (www.hcfa.gov). To find out if an HMO you’re considerin g has ever been disciplined for failing to provide medically necessary services or other infractions, check the Cumulative Sanctions report at www.dhhs.gov/progorg/oig.
As HMO information begins to flood databases and Web sites, your first instinct may be to run and hide. But take heart. New data-taming techniques, such as the FACCT framework used in our table, will help you be smarter about picking a plan that fi ts you. General Motors and the American Association of Health Plans, for example, intend to make HMO shopping easier for their members and employees by adopting FACCT’s system. As more big-bucks buyers follow their example, picking an HMO will become a r ational exercise with a rational result–and no more dirty little secrets.
