The comforting part of this strategy is that it makes new-era health care feel so much like old-era health care. You can keep seeing your regular doctor choose among an army of physicians, just like in the old days. But there’s a steep price for that liberty: having a wide choice of doctors doesn’t mean you’re getting topnotch health care. In fact, there’s plenty of evidence that HMOs with thick rosters of doctors are laggards in the quality sweepstakes. Who’s winning? The kind of HMO you’ve been diligently shunning, one that limits your choice of doctors and makes you travel to a central clinic. Known as staff- or group-model HMOs, “these organizations almost always offer superior-quality health care,” says Sue Sheffler, a corporate-benefits consultant in Arlington, Mass.
To understand why this class of managed-care companies is trouncing the others, you have to know the secret truth about an HMO: its sole mission is to make doctors practice medicine the way it wants. And that’s not easy. HMOs with big lists of doctors, like Aetna U.S. Healthcare or PruCare, assemble their networks by mailing out masses of contracts to individual doctors or small group practices. Or they make a deal with an independent practice association, doctors who’re banded together to negotiate with HMOs. The doctor-HMO relationship is arm’s length, at best. So how do these plans try to control the way a doctor works? Money, primarily. The contract specifies how much he’ll get paid to care for a certain number of patients and the bonuses he can earn for hitting quality targets. But most HMO doctors don’t serve a single master. The average doc worked simultaneously for 13 HMOs last year, according to the American Medical Association. Imagine how easy it is to change your work habits to fit 13 sets of criteria each day.
Now compare that multitasking doctor with one at Kaiser Permanente, one of the oldest HMOs in the country. This doctor is a salaried employee, and he actually knows other doctors in the plan because they all work in the same building. What makes him convert to Kaiser-style medicine? Not money. Bonuses are tiny. Kaiser doctors alter their habits because they collaborate with their peers-and with the HMO–to determine which treatments work best. And because they’re in one spot, it’s relatively simple to capture their successes and failures in a database. “It’s much easier to raise health-care quality in a staff or group model,” says Bruce Bradley, director of managed-care plans for General Motors.
Think these little details don’t make much difference? Look at the Mayo Clinic, the 105-year-old medical institution in Rochester, Minn. How are its doctors paid? With a salary, “because it removes financial incentives from medical decisions,” says Dr. Michael Wood, who’s on Mayo’s board. Where do they toil? In one big facility, pooling information on patients and techniques. Though they may have to travel to Mayo, patients like having many specialists under one roof.
Numbers tell the story, too. Kaiser regularly beats Aetna U.S. Healthcare in key quality measures, according to analysts Sheffler & Associates: lower Caesarean section and hysterectomy rates, more cervical-cancer screenings and mental-health follow-ups. Ninety percent of pregnant members in 12 Kaiser plans received first-trimester prenatal care in 1995. The average for six Aetna U.S. Healthcare plans, according to the Sheffler study, was 81 percent. Nine percentage points means a lot over millions of people. Aetna U.S. Healthcare says its system-wide first-trimester rate is actually 82.5 percent and that the difference between its score and Kaiser’s isn’t statistically important. And overall, says Dr. Arthur Leibowitz, the HMO’s chief medical officer, “I don’t think that group and staff HMOs generate higher quality.”
But from where I sit, they do. Still, not everyone should switch. You should avoid new plans, which need time to get the kinks out. If your doctor knows you extremely well, you may do better following him. And if you find an excellent nonstaff HMO, such as Tufts in Boston or Lifeguard in San Francisco, stick with it. But if you’ve picked an HMO solely because it’s giving you “so much choice,” think again.
FINDING TOP-QUALITY HMOS Plans that offer you the broadest choice of doctors usually don’t give the best care. Here’s how to get it:
Choose an HMO with doctors on staff: Plans whose doctors work exclusively for the HMO, called staff or group model plans, score highest in quality measures.
Look for a ‘mixed’ HMO: In this next-best alternative, some doctors are staff, some not, but all must meet tough standards.
Check quality scores: Ask your employer for comparative data, using measures called HEDIS (for Health Plan Employer Data and Information Set).
