Thursday, March 28, 2013

Fwd: qotd: HMOs score poorly on access

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-------- Original Message --------
Subject: qotd: HMOs score poorly on access
Date: Thu, 28 Mar 2013 12:35:24 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

State of California
Office of the Patient Advocate
HMO Quality Ratings Summary - 2013

"Health Care Quality is getting the right care at the right time."

* poor
** fair
*** good
**** excellent

First rating is for "HMO provides recommended care,"
and the second rating is for "Getting care easily":

*** * Aetna Health of California, Inc.
*** * Anthem Blue Cross - HMO
*** ** Blue Shield of California - HMO
*** * Health Net of California, Inc.
**** ** Kaiser Permanente - Northern California
**** * Kaiser Permanente - Southern California
*** * Sharp Health Plan
*** * UnitedHealthcare of California
*** ** Western Health Advantage

Comment: California's Office of the Patient Advocate defines health
care quality as getting "the right care at the right time." So how well
are the HMOs doing?

To assess whether or not the right care is being provided, the HMOs
report their compliance with standard Health Plan Employer Data and
Information Set (HEDIS) measurements. The HMOs make certain that their
health care professionals are aware of the 37 HEDIS measurements that
will be made, and that they know that it is important to be certain that
compliance is documented.

All ten of the California HMOs were able to document that they were
either "good" or "excellent" at providing the right care for these 37
measured clinical recommendations. No measurement was made of the
hundreds of thousands of other clinical decision processes that take
place. It remains debatable as to whether 37 HEDIS measurements are
adequate to determine if the HMO is always good or excellent at
providing the right care, but there are those of us who have our doubts
(pardon the cautious, restrained language).

So regardless of whether or not it was the right care, was it provided
at the right time? Patients were surveyed about "experiences in getting
appointments with doctors and other providers when needed and getting
tests, treatments and other care without delay." No HMO was rated
excellent; no HMO was rated good. Three were rated fair, and seven were
rated poor. At least from the patients' perspective, care was not being
provided at the right time.

Under a single payer system, patients have free choice of their health
care professionals and institutions. HMOs take away that choice,
subjecting patients to severe financial penalties should they obtain
care outside of the HMO. The results of this survey suggest that, once
HMOs have captive patients, they limit access by limiting system
capacity and by establishing queues that are beyond the tolerance of
their patients.

The delegated model of HMOs has no place in a single payer system since
they function more as intrusive private insurers rather than as truly
integrated health care delivery systems.

HMOs that are fully integrated health care delivery systems, such as
Kaiser Permanente, do have a place in a single payer system. Right now,
Kaiser is heavily dependent on workers enrolling in Kaiser's plans
through their employment, often choosing Kaiser as their least-worst option.

Once we have a single payer system with patients choosing their health
care based on perceived quality, to compete successfully with the rest
of the health care delivery system, Kaiser will have to show that they
can deliver the right care at the right time. After all, that's what
single payer is all about.

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