Introduction
An emotional debate over the issue of quality of care delivered by HMO's has reached deafening proportions recently. National and state governments have responded with legislation intended to curb alleged abuses by HMO's. If you would like to learn more about HMO medical insurance, review a related article on "Selecting Medical Insurance." The following essay is intended to provide you with an objective analysis on the issue of quality of medical care delivered by the HMO's.
Background
It is a fact that there exists a potential financial conflict of interest between the patient and the providers of medical services when those medical providers are "capitated" or paid a fixed fee monthly to provide medical services to the patient. Those who are providing the care in a capitated arrangement are paid the same amount whether they provide services to one patient or a thousand patients. If a health care provider withholds necessary medical services, money can be saved at the expense of quality of care for the patient.
The "battle lines" are therefore drawn between the HMO insurers, doctors, and hospitals providing care and the patients along with their representatives such as consumer advocate groups and the government. Fortunately, there are several agencies that monitor and regulate the various providers of medical care. These include the National Committee for Quality Assurance (NCQA) a non-profit organization that monitors quality of care provided by HMO's. Doctors are also put through quality assurance screens produced by the HMO's themselves along with peer review from the hospital and oversight by their state boards of quality assurance. The hospitals are overseen by both state regulators and a national accreditation organization (JCAHO).
Medical Outcomes Studies
The medical literature had initially failed to show any significant differences in medical outcomes between the traditional fee for service patient and the HMO patient until a recent study published in The Journal of the American Medical Association on October 2, 1996. The results of this study were widely cited in newspapers and television. The study examined the medical outcomes of patients from several groups over a four year period from 1986 to 1990. It was concluded that the elderly and the poor had significantly worse physical health outcomes when under the care of HMO's as compared to those cared for under a fee for service arrangement. The authors of the study speculated that previous studies did not follow patients for a long enough period of time to provide a valid comparison.
Critics of this study contend that the data reflects quality of care back in 1986-1990 which is not a valid comparison today with the evolution of more rigorous quality controls placed on the HMO's and the providers. It also should be pointed out that the majority of HMO patients in this study belonged to what is known as "staff model HMO's" such as Kaiser, whereas the "Independent Practice Associations" has grown tremendously since that time which is a network of community physicians banded together to provide HMO care.
A more recent article that appeared in the July 1999 issue of The Journal of the American Medical Association concluded that for profit HMOs scored consistently lower in quality measures when compared to non profit HMOs.Conclusions
For the majority of patients, it appears that HMO's can provide good routine medical care. What is not clear is how well chronic or severe illnesses are handled. Clearly, further studies need to be done to monitor quality of care in an HMO setting. The public should be cautious about generalizing anecdotal reports on poor outcomes for HMO patients as evidence of HMO's providing substandard care. Many of my physician colleagues also have become angry with HMO's because of their lower reimbursement of fees, increased paperwork, and delays in granting requested tests or procedures for their patients. Some physicians therefore, are quick to blame HMO's for all the problems in medicine that they face.Recommendations
If it is at all possible, the public should try to choose the fee for service option when choosing a health insurance plan because it offers the greatest freedom of choice. The data on quality of care in an HMO is unclear as mentioned above, but by choosing a good primary care physician, you should be able to receive good quality medical care even in an HMO setting. Your primary care physician should be able to put aside financial greed and deliver cost effective quality medical care for you.
Lloyd Ito, MD
8/3/99