“The free market doesn’t reward high quality; it rewards lower costs,” one prominent health-care researcher lamented to me. “But don’t quote me,” he said, “or I’ll lose my job.”
Neither he nor I mean to suggest that cost saving dooms first-rate medical treatment. Efficiency can serve quality, as long as the judgments are truly made in the patient’s interest. But you can’t be sure that’s always the case. Employers pick health plans based on service and price. They get assurances of quality but no proof.
The “what, me worry?” school says that employers will migrate toward better plans because a healthier work force improves the bottom line, tra la, tra la. But the bottom-line guys don’t necessarily sing that song. Extra days lost to sickness may cost less than paying the upfront price of more elaborate care. In the true cost-benefit world, freedom from pain and disease isn’t an end in itself. It’s an optional feature of a work force–like corporate blazers–that a company may or may not decide to buy.
You think I’m too tough? Consider the six-year-old accreditation program for managed-care plans run by the National Committee for Quality Assurance (NCQA). It’s considered a floor for what a quality plan should offer. So far, 18 percent of all HMOs have received full accreditation, an additional 17 percent have temporary accreditation of some kind and 4 percent have flunked. Nearly 50 percent haven’t bothered to apply.
I asked health-industry analyst Douglas Sherlock, of the Sherlock Co. in Gwynedd, Pa., what difference accreditation makes to an HMO’s success. The answer: zip, zero, none. There’s no correlation between a plan’s level of accreditation and its profitability or membership growth. Those with the NCQA’s full seal of approval do no better than those without.
This helps explain the horror stories you read in the papers: HMOs switching drug prescriptions–and occasionally harming a patient–because they got a cut-rate deal from a particular drug manufacturer; patients misdiagnosed by a generalist because the budget for specialists is small; sick patients refused costly treatments while their anguished relatives appeal.
Managed-care folk say that these stories are anecdotal, and besides, poor care exists in traditional plans, too. But in traditional plans it’s random and unplanned. Under modern medical rationing, doctors earn bonuses for treating less. That’s not the same as giving poorer care, but it could be.
Solid evidence exists that for some patients, HMOs can be hazardous to health. In a recent study of the chronically ill, the elderly and the sickest poor fared much worse in three urban HMOs than their counterparts did in traditional plans, reports John Ware, senior scientist at Boston’s New England Medical Center.
On the other hand, younger patients in his study–who tended to have higher incomes and whose chronic illnesses weren’t as bad–did just as well in the HMOs and at lower cost. So despite the griping, HMOs–good HMOs–are a reasonable option for working people.
The question is, what’s a good HMO? Right now it’s hard to tell. The HMOs’ own happy-patient surveys are almost entirely self-serving. The medical data that exist don’t measure what we most want to know–namely, which plan delivers better results from its doctors, its hospitals and its particular treatment rules.
What’s needed are quality rankings–like restaurant rankings–widely distributed to health-care consumers. That would help the market work. For com- petitive reasons, employers would pick more A-plus plans. B-minus plans would change or die.
A budding health-care-quality movement hopes to bring such report cards to life. Three main contenders are in the field:
The NCQA, which already collects data on the medical and customer services offered by 40 percent of the plans. Right now its lists of findings don’t tell anyone much. But it’s working toward simpler measures that include medical results.
The new Medical Outcomes Survey, constructed by John Ware. It evaluates people’s general health and might show which plans do the best for their members over time.
The new Foundation for Accountability (FACCT). It develops standards for judging how well HMOs handle specified illnesses. (FACCT helped NEWSWEEK rate HMOs–issue of June 24, 1996.)
Believe it or not, most plans don’t know how well they’re actually doing their job–assuming their job is to be making you well rather than getting their stock prices up. The better plans would presumably gather the data, if asked. Others would yell that no one should break up the sacred insurer-patient relationship (the relationship used to be doctor-patient, but that was then).
Here’s where the government may help. Starting this year, the Health Care Financing Administration (HCFA), which administers Medicare, will require performance data from all HMOs that take Medicare patients. They’ll have to respond to a customer-satisfaction questionnaire, provide NCQA-style data and participate in medical-outcomes surveys. Next year, HCFA may require FACCT data, too. But alas, Medicare won’t quit paying HMOs with poor results. “If we did, we might hear from that organization’s members of Congress,” says Bruce Fried, director of HCFA’s managed care. (See how well your so-called “representatives” look after you?)
There’s a larger context to these embryonic measures of quality. You’re seeing the start of a massive movement for “patients’ rights.” At the very least, plans should have to be accredited, says Karen Davis, president of the Commonwealth Fund. If audited quality data are disseminated, too, the public’s growing mistrust of its employee plans might be assuaged.
