Worst HMOs Don't Let Public Know Their Flaws

Study finds low-ranked plans don't report quality; critics say findings based on old data

TUESDAY, Sept. 24, 2002 (HealthDayNews) -- Health plans that score poorly on a key gauge of the care they provide are many times more likely than others to stop reporting their ranking publicly the next year, a new study has found.

Plans that ranked in the bottom third of performance in 1997 were between three and four times more likely to stop reporting in 1998, the study showed. Those in the cellar in 1998 were almost six times more likely to keep quiet in 1999.

Health maintenance organizations, or HMOs, are not required to collect or release data on the quality of care their physicians collectively offer. But the National Committee for Quality Assurance (NCQA) does have a voluntary system to assess such aspects of plans as the availability of preventive tests for breast and cervical cancer, childhood immunizations and the number of heart attack patients offered life-saving beta-blocker drugs.

Plans that score poorly on the NCQA scale can be considered riskier for patients than those that do better, said Dr. Danny McCormick, a Harvard University physician and lead author of the study, which appears in tomorrow's Journal of the American Medical Association.

"If you're in one of the health plans that reports year after year and scores are good, I think you're in good shape," McCormick said. But if you're in a plan that stops reporting, either push to have the ranking released or "vote with [your] feet and look elsewhere."

Dr. Gordon Schiff, director of clinical quality research in the department of medicine at Chicago's Cook County Hospital -- one of the nation's largest public health systems -- said the findings expose a "giant, gaping hole in marketplace medicine.

"If the theory of the current system is that people are supposed to be choosing health plans based on quality" with the help of NCQA rankings, "the whole thing is exposed as a sham, a game manipulated by HMOs," Schiff said.

McCormick and his colleagues analyzed NCQA reporting by HMOs between 1997 and 1999 using the independent group's "HEDIS" data collection system.

The first year, 329 plans publicly disclosed their scores. But in 1998, 161, or about half, stopped doing so. And of the 298 plans that disclosed in 1998 -- including a number of holdovers from the previous year as well as new HMOs -- 23 percent failed to report publicly in 1999.

Plans that scored in the bottom third on the NCQA ranking, which included more than a dozen categories of care, were 3.6 times more likely to stop disclosing in 1998 than those in the top tier of performance. The lowest scores in 1998 were 5.7 times more likely than high-ranking plans to go silent in 1999.

Bottom-tier plans had lower rates of childhood immunization, Pap smears and mammography than the HMOs that did better on the NCQA rankings. They were also about 30 percent less likely to offer diabetic members routine eye exams, and about one-third to 40 percent less likely to provide beta-blockers for heart attack patients -- although these drugs reduce the risk of death from an attack by about one-quarter.

"These are clearly things with very large potential impact on health," McCormick said.

Critics of the study, however, said it relied on stale data.

Brian Schilling, a spokesman for the NCQA, said since 1999 the group has required public release of performance scores to plans that want accreditation, which is considered a marketing plus. Between 2001 and 2002, only five plans declined to have their ranking listed, Schilling said. "It's a really different picture" since the late-1990s, he said.

Susan Pisano, a spokeswoman for the American Association of Health Plans, defended the managed care industry. She also criticized the researchers for using old data and accused them of wielding a "political" ax.

The most recent NCQA report for 2002 shows across-the-board improvements in the average score of the nation's health plans in 12 key care measures, including cholesterol screening, asthma medication use and chicken pox vaccine coverage for children and adolescents, Pisano said.

She also noted that for 13 plans included in the report, beta-blocker coverage for heart attack patients was 100 percent, and coverage was 92 percent for the entire industry.

"We're for accountability, we're for reporting, but we think the discussion should not be confined to just America's health plans," said Pisano. Doctors and hospitals should have to report their performance too, but they currently do not, she added.

What To Do

To find out more about health plan quality, visit the National Committee for Quality Assurance or the Institute for Healthcare Improvement. For more on the managed care industry, try the American Association of Health Plans.

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