HEALTH PLAN RATINGS: U.S. News Profiles Unique HMO
In an ongoing look at the state of managed care in connection with their comprehensive ranking of the nation's HMOs, U.S. News & World Report takes a look at a very different managed care plan. Community Medical Alliance of Boston is a nonprofit HMO that serves only quadriplegics, "a population that many HMOs do not want because of their complex and costly needs." By stressing preventive care, including house calls by physicians and nurse practitioners to prevent costly hospital stays, CMA was able to reduce patient costs to $1,199 per month -- "about $1,100 a month lower than the costs for similar Massachusetts Medicaid patients still in fee-for-service plans" and almost half of the $2,228 that CMA receives from the state. U.S. News reports that "[a]lmost the entire savings" comes from CMA spending the bulk of their resources on "home health care, durable medical equipment like customized wheelchairs and special mattresses, primary care and mental health services." CMA also directs many patients to non-physician care providers: "Nine times out of ten, a patient sees a nurse practitioner, not a doctor." And the high level of specialization that comes from only treating quadriplegics imparts a high level of expertise. CMA head Dr. Bob Master, who ran the state's Medicaid program from 1985 to 1988, doesn't like to think of himself as "a missionary for managed care," but the larger industry players are taking notice. In 1996, Neighborhood Health Plan purchased CMA, and last November, "Harvard Pilgrim Health Care signed an agreement of affiliation" with NHP, in an attempt to spread the CMA model. Harvard Pilgrim hopes to use CMA's cost-saving methods "to avoid ... big losses" that have hurt other Medicaid HMO plans. But Master warns that for-profit HMOs may be loathe "to try the CMA model. The potential profits are too small; the upfront costs make it risky" (10/5 issue). Click here for U.S. News' complete rankings.
In a related article, the magazine takes stock of managed care reform efforts across the country, reporting that "[w]hile Congress remains deadlocked over the details of a sweeping 'patients' bill of rights,' a majority of states have sidestepped partisan politics to enact a host of new protections and rules governing [HMOs]." All states that have taken action "require HMOs to have grievance procedures so patients can challenge denied treatments or benefits ... a majority ban 'gag' clauses that restrict doctor-patient communication," and "Maryland has HMO report cards." Giving enrollees the right to sue their health plans is the "stickiest" reform for states, but 29 state assemblies have introduced legislation giving them that right, and Texas recently had its law upheld in federal court. So far, the reforms have not had a substantial impact on insurance premiums. U.S. News predicts that patients' rights will stay on "the political burner," because state efforts at reform are ultimately limited by the 1974 Employee Retirement Income Security Act, which insulates 51 million "'self-insured' employer plans" from most legislation, leaving one in three Americans "untouched" (Lord, 10/5 issue).
Almost 150 managed care plans that participated last year in the National Committee for Quality Assurance surveys -- on which the U.S. News rankings are based -- declined to do so in 1998. For example, "[o]f the 11 top-ranked plans in Florida last year, eight are missing from the rankings. Of the 15 plans that were listed under Texas, 12 are gone." U.S. News reports that many HMOs decline to provide information to NCQA's database, known as Health Plan Employer Data and Information Data Set (HEDIS) because they "believe the way the media use [HEDIS] data is unsophisticated and unfair, and they blame NCQA for making that possible." Dr. Tony Kotin, CMO of Prudential Health Care, which declined to allow NCQA to publicly release its HEDIS data, said: "It was your report in U.S. News that triggered the decision. You portray performance in a certain way, Newsweek portrays it in another way. NCQA doesn't adjust the data by demographics or by type of plan. And it is not a level playing field in that there are many plans that don't report and don't even monitor HEDIS data." He added that the company provides its HEDIS information on its website, www.prudential.com/healthcare/ (Comarow, 10/5 issue).