Just a few years ago, almost every employer offered a fee-for-service plan, where you pick your own doctors and the company helps pay. Today, that’s down to 60 percent and falling fast. Around half of the larger employers let you select between fee-for-service and some sort of managed-care or health-maintenance organization (HMO)–the most popular being those that permit ,some form of choice. HMOs, for example, may offer a “point of service” option. which pays part of the cost if you want an opinion from a doctor outside the plan. But these medical freedoms will not last. Fee-for-service is dying and point-of-service will vanish, too, in the view of Tom Beauregard, a health-care specialist with the consulting firm Hewitt Associates.
Barring a comeback of the Clinton plan, employees will eventually be gathered into compulsory HMOs. Your company, not you. will decide on the doctors you can use. Employers need some basis for choosing the limited plans they’ll provide. So they’re working with the industry to develop “medical report cards,” which will rate each health plan’s quality and service along with its cost. Consumers could use ratings, too, when choosing individual plans.
But how good are the report cards? This movement is in its infancy, so right now their quality is poor. Some are little more than marketing tools. They produce cheery member-satisfaction ratings–do the nurses smile? do the doctors get to the appointment on time?–that tell you zip about quality. Some plans trumpet medical data that appear to have meaning but actually don’t. Does a large number of heart-bypass surgeries mean that the medical team is hot? Or are they merely operating more than they should? In almost no case are health-quality claims checked by an outside auditor. You’re relying on the medical plans to grade themselves.
The professionals are struggling to develop more credible standards for comparing one health plan with another. The New England Medical Center, for example, is working on better measures of customer satisfaction. The National Committee for Quality Assurance (NCQA), which accredits health plans based on their quality controls, is reexamining its criteria for judging quality of care. In January, 21 major health plans will publish experimental report cards based On some of the NCQA performance measures–the first time employers will have seen comparable rankings on plans. Even the venerable Joint Commission on Accreditation of Healthcare Organizations, which accredits mainly hospitals, has just approved a new scoring system for the groups it accredits. The scores, alas, don’t tell you much. Philip Boyle, a consultant on medical ethics at the Hastings Center in Briarcliff Manor, N.Y., says it’s pitiful how little information you can get on the quality of hospital care. HMOs have seen need for public accountability, “but doctors and hospitals,” he says, “are panicked beyond belief.”
What’s especially tricky is that health-care providers don’t agree on how quality should be measured. Take what’s becoming a popular performance standard for preventive care–the percentage of women over 50 who have mammograms in the current year. A plan with high numbers is presumed to be better than a plan with low ones. But neither number tells you whether the women’s X-rays were properly read or whether those with cancer have access to aggressive, life-extending treatments.
Many providers won’t divulge information they can’t control. Consider the Center for the Study of Services, in Washington, D.C., which has gathered member-satisfaction ratings for some 250 health plans that are used by federal employees (the employees will get the results this month, when they choose their plan for the upcoming year). Sixty plans wouldn’t let their members answer the questionnaire. I wonder what they were worried about. One plan wanted to block any data it didn’t like.
And then there’s the Hudson Valley (N.Y.) magazine, which sought to publish quality measures of its region’s hospitals. Editor Susan Agrest got no cooperation until she agreed to let a local trade group, the Northern Metropolitan Hospital Association (NMHA), help write the questions she could ask. NMHA president Arthur Weintraub says that hospitals had started calling him, so he “made some suggestions as to how the survey could be improved.” Agrest’s article got blasted by the hospitals anyway, for including New York state data on the portion of each heart surgeon’s patients who died after coronary-artery bypass surgery (the data is adjusted for patient risk). One furious letter writer, whose staff included a surgeon with higher-than-average mortality rates, accused her of being “anti-doctor and anti-hospital.”
There’s where the rubber hits the road. Consumers want to know who the better doctors are; doctors want nothing to do with public quality measures. They all know which of their colleagues should be selling shoes instead of taking out gallbladders, but they’re willing to let the layman enter surgery blind. Congress has established a National Practitioner Data Bank, which collects information on malpractice awards and disciplinary actions. Nearly 69,000 professionals were listed in the past four years. Hospitals have to check the bank before granting doctors admitting privileges. But the public can’t get the names.
If you have to choose a health plan today, you don’t have an awful lot to go on. Ask if it’s accredited and what percent of its doctors are beard-certified (which means they’ve passed tough exams in their fields). Inquire about the percentage of members and doctors who quit the plan each year. If you’re handed a report card, see if it warns you of the data’s limitations. The report-card movement has the potential for raising standards of care throughout the health-care system. But it’s not there yet.
