QUALITY: Doctors Detail Discontent with HMOs
Almost nine out of 10 doctors in a major survey released yesterday say their patients have been denied coverage for care over the last two years, with nearly half saying they are so frustrated that they have exaggerated the severity of a patients' condition just to obtain approval. The survey, designed by the Henry J. Kaiser Family Foundation and the Harvard School of Public Health, details the "frequency of coverage denials, and the effect these denials have on the health of patients." Kaiser Family Foundation President Drew Altman said, "This level of conflict and administrative haggling between doctors and plans can't be good for our health care system or for patients who are often caught in the middle."
Battles "over prescription drugs are the most common complaint, with 61% of doctors saying that, at least once a month, they have to argue with an HMO over a prescription." Forty-two percent of doctors argue with HMOs over approval of diagnostic tests at least once a month, while 29% have disagreements over specialist referrals at least that often. Almost half said when such denials occur, the consequences are at least "somewhat serious" (Abate, San Francisco Chronicle, 7/29). About two-thirds of doctors said they sometimes contact a health plan on their patients' behalf. "In their most recent dispute, doctors said 42% of cases were resolved in the patients' favor," while a compromise was reached 21% of the time (Appleby, USA Today, 7/29). In fact, a full 48% of doctors and 46% of nurses said they have exaggerated the severity of a patients' condition to obtain coverage.
Pros and Cons
On managed care in general, 95% of doctors said managed care has led to too much time being spent on administration rather than on patient care. Sixty-nine percent of nurses said it has led to inadequate nurse staffing levels. An overwhelming 72% of doctors and 72% of nurses said managed care has hurt the "quality of health care for people who are sick." These sentiments were more pronounced among specialists and among doctors who deal with more than one HMO (study, 7/28). Providers did have some kudos for managed care, however. Almost half of doctors and nurses said it increased the likelihood that patients would receive preventive care. Sixty-eight percent of doctors and 51% of nurses said "managed care had increased the use of practice guidelines and disease management protocols" (Toner, New York Times, 7/29). The survey of 1,053 physicians and 768 nurses was conducted by the National Opinion Research Center between Feb. 11 and Jun. 5. Questions were restricted to those patients under 65 years of age. The margin of error for the doctors' survey is +/- 3% and +/- 4% for the nurses' survey. The entire survey, including charts and topline data, is available at www.kff.org or by calling 800-656-4533 (release, 7/28).
The Great Debate
At a news conference yesterday, Kaiser Foundation President Drew Altman said, "Some tension [between insurers and providers] is to be expected. But the degree of conflict reflected in this survey suggests we're in a whole new world, and it's hard to argue it's good for the health care system" (Rovner, CongressDaily, 7/28). "Denials of medically necessary care is the No. 1 concern of physicians and patients across the country," added Dr. J. Edward Hill, a trustee of the American Medical Association. But industry representatives said the study's findings fly in the face of existing research. Don Young, COO of the Health Insurance Association of America, said, "The attitudes of doctors to not jibe with peer review journals. ... The care in managed care is just as good as it was before managed care. Managed care has brought costs under control, and it has allowed thousands of Americans to keep their health insurance" (Rosenblatt/Rubin/Bernstein, Los Angeles Times, 7/29). Noting that four out of five Americans say they are satisfied with their health coverage, HIAA President Chip Kahn added, "At the end of the day, what is more important than the perceptions of providers are the opinions of consumers, along with objective, unbiased data" (release, 7/28). American Association of Health Plans President Karen Igangni, citing several other opposing polls and surveys, said the Kaiser findings "are subject to misinterpretation unless they are evaluated in the context of two important facts: first, the compelling body of research about misuse, overuse and underuse of health care services that has been summarized by the President's Advisory Commission on Quality, the Institute of Medicine, and researchers in leading academic centers around the country, and second, other research that suggests that an overwhelming majority of patients in health plans are receiving the care they need" (release, 7/28). (Both the AAHP and HIAA Web sites contain detailed rebuttals of the survey.) CongressDaily reports that as the survey is being released while Congress debates managed care reform, it "is certain to fuel the polarization between health care providers who are pushing for stronger protections and insurance companies who say no new regulations are needed" (7/28).