care organizations, Kaiser HMO model is the best, UC Berkeley
Catherine Zandonella, Media Relations
- Not all managed care plans are created equal, according
to a consumer study conducted by researchers at the University
of California, Berkeley. The study finds the managed care
model where patients experience the fewest problems getting
care is the all-inclusive HMO plan typified in California
by Kaiser Permanente.
professor Helen Halpin Schauffler and her colleagues at the
UC Berkeley School of Public Health surveyed 1,201 randomly
selected, insured adults about the difficulties they'd encountered
with managed care organizations over the past year.
found that 42 percent of those surveyed reported one or more
problems with their managed care organization, ranging from
billing errors to limited access to specialists to denial
of treatment. The results will be published in the January
issue of the journal Medical Care.
three types of managed care surveyed, the staff/group model,
in which the doctors exclusively see patients from one HMO,
received the fewest consumer complaints. Kaiser Permanente
is the largest such plan in California. Other staff/group
HMOs include the Group Health Cooperative of Puget Sound in
Washington and the former Harvard Community Health Plan in
Massachusetts. Student health centers at universities often
operate on a similar model.
belonging to staff/group HMOs reported fewer problems with
billing and claims, better coverage of important benefits,
and fewer misunderstandings of coverage as compared to the
other two types of managed care organizations. The results
are consistent with the one-stop-shopping structure of the
staff/group HMO structure, Schauffler said. The fact that
Kaiser patients reported less confusion about their benefits,
she said, may be due to the longer time Kaiser patients stay
with their plan.
two other types of managed care organizations faired worse
than the Kaiser model.
provider organization (PPO), an association of doctors who
have contracted with an insurance company to provide services
at a discounted fee, ranked second in overall consumer problems,
the study found. However, the problems were more often administrative
in nature rather than about having access to care. While PPOs
allow patients to choose their own physicians and do not require
referrals to specialists, the plans can be more expensive
and cover fewer services. The study found that patients reported
fewer delays in getting needed care, fewer difficulties getting
the most appropriate care and fewer cases of being forced
to change doctors in PPOs. However, PPO patients reported
greater numbers of problems in billing and in understanding
their benefits. Examples of PPOs include those for Blue Cross
of California and Blue Shield of California.
you want is choice and access, the PPO is best option, if
you can afford it," said Schauffler.
place was the independent provider association (IPA) or network
HMO. The IPA/network HMOs usually require a primary care physician
to act as a gatekeeper of medical care. Unlike the staff/group
HMO, physicians in IPA/network HMOs usually contract with
many different plans. Most people in the United States who
are in HMOs are in an IPA/network model. Examples of this
type include HealthNet, PacifiCare, Blue Shield of California
and Blue Cross' CaliforniaCare.
common complaints were difficulties in getting referrals for
specialists and difficulty in selecting a doctor or hospital.
IPA/network HMO members also reported a higher rate of being
forced to switch doctors. "The process of getting a referral
from the primary care physician can be so cumbersome that
care is often delayed," said Schauffler, "which can have a
significant effect on patient health."
34 percent of patients reported problems with the Kaiser-type
HMO, versus 43 percent for the PPO and 46 percent for the
plans were similar in the rates at which consumers reported
being denied care or treatment, being forced to change medications
or experiencing language and communication barriers.
study was conducted in California, Schauffler said the results
may apply nationwide to the ongoing debate in the U.S. Congress
over managed care reform. While California leads the nation
with 92 percent of its insured, non-elderly population enrolled
in managed care organizations, there is a nationwide trend
towards increased managed care.
results already have been used to influence legislative decisions
in California. The California Legislature enacted laws over
the last two years requiring HMOs to provide continuity of
care for patients whose physicians were dropped from the plan
and standing referrals to specialists for persons with chronic
conditions. Another provision holds health plans or their
medical directors liable for harm resulting from their decisions.
Many of these laws have only recently taken effect. "We are
eager to follow up and see if these regulatory changes have
an impact on consumers' experiences in managed care," said
for this research was provided by the California HealthCare
Foundation, the California Managed Health Care Improvement
Task Force, and The California Wellness Foundation.