Doctors and Medicine: Health Care in a New Age

Doctors and Medicine: Health Care in a New Age

Expect more information, more choices, and more tough decisions

Efforts to remake the health care system may seem to have filtered in Washington, but beyond the Beltway there is a fundamental shift occurring in the way in which Americans get their health care. For the average consumer the financial pressures to enroll in a health management organization or other managed-care plan will continue to intensify, but the employers and insurers most affected by the tab will hold health care providers to much greater accountability for cost increases and the quality of care.

“Report cards” prepared by large health care buyers such as companies, pension funds, and the government, as well as studies by public interest groups, universities, and foundations will provide consumers with far more information with which to compare fee structures and quality of care at hundreds of managed-care organizations nationwide. The report card are likely to include data on everything from waiting times to get an appointment to what the success rates have been for procedures such as open-heart surgery to how a particular plan is judged by its patients on overall “customer satisfaction.”

One study, commissioned by the Federal Office of Personnel Management to help government employees choose a health care plan wisely, gathered extensive data on the experience of federal workers at over 250 prepaid health plans or options across the country. The plans involved enroll approximately 65 percent of all persons currently covered by HMOs in the United States. The data should make it easier for both federal employees and other consumers to compare the quality of health care options available to them.

Ramsden Park in Toronto. Photo by Elena

One major corporation, American Express, has not only asked employees to rate their health plans, but, after using this information to develop a consumer satisfaction index for 52 HMOs around the country, offered discounts to workers who enrolled in the top-ranked plans – and charged higher plans to those who chose the low-scoring programs.

Some states, such as California, New York, and Pennsylvania, are even beginning to require that hospitals publish statistics on the medical outcomes and expense of particular surgeries. One of the most important efforts to provide accountability has been launched by the National Committee for Quality Assurance, a nonprofit group established by a consortium of managed-care companies to develop reporting standards and oversee accreditation of plans within their industry.

The organization has been devising report cards that it hopes will enable health care consumers to reliably compare the performance of managed-care plans nationwide on such things as enrollee satisfaction with access to and quality of care; the plan’s record in providing preventive services such as childhood immunizations, cholesterol screenings, and mammograms; the frequency with which the plan performed certain medical procedures such as bypass surgeries and angioplasties; the extent of the plan’s physician turnover; and its overall financial health. Twenty-one major managed-care plans recently participated in a pilot test of the report card’s effectiveness, and the committee hopes to make such report cards an industry standard within the next several years.

The accountability movement is sure to boost the dramatic growth that has occurred in HMOs and managed-care plans in recent years. According to the newsletter Health Trends, dozens of millions are enrolled in traditional HMO plans, and the newsletter predicts that many more may be enrolled in the near future.

HMO deserve much of the credit for the gradual easing of health care cost increases over the last several years. While those cost increases still exceed the general rate of inflation, for several years now the Labor Department’s index of medical price inflation has been declining. The Congressional Budget Office recently estimated that the best-run HMOs can reduce a patient’s use of services by 12 percent over what would have occurred in non-managed-care programs. Much of these savings comes from reducing the length of hospital stays. Because of such efficiencies, insurance premiums for managed-care plans can sometimes be as much as 15 to 20 percent lower than traditional fee-for-service plans.

The new health-care landscape

Fee-for-service: Private care where the patient chooses any doctor he or she wants to see. The patient pays according to the service rendered.

Health Maintenance Organization (HMO): Managed care where the patient is limited to seeing doctors employed by the HMO, and there is a set fee for the visit, no matter what service is performed.

Preferred Provider Organization (PPO): Managed care where the patient chooses from a list of specific doctors in his or her area, and pays a set fee for the consultation, no matter what service is performed.

Point-of-Service: Managed care where the patient chooses from a list of doctors a primary care physician who coordinates all of his or her care. Patients who want to see a specialist must obtain the primary care physician’s approval first.