HMO policy makers fail to hear complaints

I am the research director for Minnesota COACT, Citizens Organized Acting Together. We represent 16,000 Minnesotans. For the past 10 years, we have worked to save family farms and to establish a system of universal health insurance. I have written about 80 articles on health care reform over the last 10 years, including one for the New England Journal of Medicine last year and another for the March 1999 edition of the Washington Monthly, due out next week.
Since 1995, Health Maintenance Organizations have suffered a torrent of bad publicity. Patients and doctors are complaining more often about the quality of care offered by HMOs and traditional insurers, like Blue Cross Blue Shield, that have adopted HMO cost-control techniques. Congress and state legislatures have responded by passing modest patient protection laws. Democrats in Congress, and Attorney General Mike Hatch in Minnesota, have introduced bills to permit patients to sue HMOs for malpractice.
HMOs oppose all but the weakest patient protection laws and they are dead set against legislation authorizing HMO malpractice suits. HMOs insist that patient protection laws are unnecessary and those who say otherwise have been unduly influenced by news accounts of patients abused by the organizations. HMO advocates denounce horror stories as “mere anecdotes” that do not accurately represent the quality of care offered by HMOs. I have two objections to this line of reasoning. First, the argument that HMO horror stories are overblown ignores the fact that these stories are consistent with common sense, polls and scientific studies.
Let us start with common sense. Ask yourself, what do I think is likely to happen to quality of care at an insurance company that adopts HMO cost-control techniques? If doctors are given economic incentives to deny care, if HMO employees who have never laid eyes on a patient are allowed to overrule doctors and if doctors’ and nurses’ workloads increase drastically, is it not reasonable to expect quality to decline? Shouldn’t I anticipate a flood of HMO horror stories?
It is not possible in the limited space I have to review the numerous polls and the scientific literature on HMO quality of care, so let me offer typical examples of each:
¹ A 1997 Lou Harris poll found that 54 percent of Americans believe the spread of managed care is harmful to them.
¹ A 1996 study published in the Journal of the American Medical Association found that elderly patients were twice as likely to suffer deterioration in their health over a four-year period if they were enrolled in HMOs than if they were enrolled in traditional fee-for-service insurance companies.
My second objection to the HMO industry’s contempt for anecdotal evidence is that it amounts to a double standard — one for HMOs and one for critics of HMOs. Contrary to HMO propaganda, no conclusive evidence exists today, nor has any ever existed, that indicates the organizations save money without harming quality of care. Thus, when HMO advocates lobbied Congress in the early 1970s to enact legislation subsidizing the creation of an HMO industry, they relied heavily on anecdotal evidence. The same was true n the 1990s when the organizations lobbied Congress and state legislatures to pass legislation that would force or induce doctors and patients to join HMOs. As HMOs spread, no one in the HMO industry demanded a halt to the HMO juggernaut until scientific studies proved that HMO payment methods did no harm to patients.
Therefore, Health Maintenence Orgainzation advocates are in no position now to insist that lawmakers remain inert until HMO critics produce scientific research showing the organizations’ abuse of patients is widespread. But to repeat: scientific evidence indicating HMO care is often inferior now exists.
I am not claiming that every HMO horror story is true. I am saying the deluge of bad publicity HMOs have gotten in the last four years is not a figment of the media’s imagination. I am saying that the steady flow of HMO horror stories, coupled with common sense, polling data and scientific studies constitutes compelling evidence that quality of care is at risk in our HMO-dominated system. I am saying we need a new system, and, until we get a new system, we need meaningful patient-protection laws.
Kip Sullivan is the research director for Minnesota COACT, Citizens Organized Acting Together.