With the release yesterday of the third annual report card on Maryland's HMOs, one theme has emerged: Local plans generally deliver better care than their larger, national counterparts.
Regional plans such as Capital Care, Delmarva, Preferred Health Network and George Washington University Health Plan routinely performed above average.
Giants Aetna U.S. Healthcare-Maryland, Prudential and United HealthCare scored consistently below average on a range of quality-of-care measures.
The trend is troubling, since increasingly, these smaller health maintenance organizations are being bought up by national managed-care plans.
In the past few years, HMO officials have blamed poor data collection and other reasons for low rankings. But legislators and others said yesterday that they no longer have an excuse.
"If you get a bad grade now . . . after three years, you can't blame it on the teacher," said Casper R. Taylor Jr., speaker of the House in Maryland's General Assembly and a key player in health issues.
HMO officials, explaining they were working to do better, defended their health plans.
"We believe any type of reporting has validity, and any type of reporting has problems," said Carol Rohn, director of quality improvement for United.
For example, she said, it doesn't make sense that United recorded an 82 percent childhood immunization rate in the state's Medicaid program, a typically hard group to reach, but posted just 49 percent in the report card for private patients -- all by the same group of doctors.
Maryland is among a few states to develop report cards that give consumers objective ways to compare health plans. By law, each of Maryland's 15 commercial HMOs is required to submit figures, which are audited, on a range of measures such as adolescent checkups and mammograms.
In addition, to collect information on customer satisfaction, the state hired an independent organization to survey about 1,240 members in each HMO.
Such reports are useful, but measuring quality is an evolving science, experts say. Eventually, health quality groups want to offer consumers ratings of doctors, based on how their patients fare.
While yesterday's report presented one year of data, the significance is in three-year track records -- some consistently good, others consistently bad, said John M. Colmers, executive director of the state's Health Care Access and Cost Commission, which developed the report cards.
Some of the more dismal ratings included Aetna U.S. Healthcare-Maryland, which ranked below average for each of the three years in childhood immunizations and breast cancer screenings.
"We think we did pretty well," said Walter J. Cherniak Jr., a regional spokesman for Aetna U.S. Healthcare.
"In a lot of cases, we believe our actual performance is better than the data would indicate. We need to do a better job of gathering and compiling the data."
United rated below average in the past two years for adolescent checkups, cervical cancer screening and prenatal care in the first trimester.
Dr. David Yalowitz, United's chief medical officer, said there might be some data problems, but his plan was "concerned" by its ratings. "We're not going to hide behind the veil of data collection," he said. "We're accountable for stepping up to the plate."
He said United had begun a system of sending letters to members who are due for preventive care, and to the doctors of those patients. That system, put in place last October after six months of planning, was too late to show results in this report card, which uses 1998 data, he said, but it should give United better marks next year. This winter, United is preparing report cards on each doctor.
Kaiser Permanente was an exception to the poor performance of national plans, consistently posting above-average marks in most categories. Mona Miller, a spokeswoman for Kaiser, said the report card was an indication that the HMO's "group model," in which most care is provided by full-time physicians in Kaiser centers, "encourages communication among professionals."
Locally, Delmarva ranked consistently above average in breast cancer screening, adult checkups and follow-up after mental illness.
Dr. Jon Shematek, medical director for quality improvement for CareFirst BlueCross BlueShield, which owns Delmarva, FreeState and Capital Care, says the three HMOs have been testing prevention efforts.
For example, he said, Capital Care had an immunization registry that began at birth and worked mostly by notifying parents when shots were due, while FreeState started in the second year of life and concentrated on notifying doctors.
Now, he said, both plans use the elements that worked best in each -- starting at birth but including doctors in the system.
This year's report card includes three new measures and two new plans -- Innovation Health and Principal Health Care of Delaware. The Web site also features an interactive piece that allows employers to create customized report cards.
Tens of thousands of Marylanders, including nearly 80,000 state employees, are soon heading into an open enrollment period in which they must select a health plan. Last year, about 140,000 of the report cards were distributed, and the Web site recorded about 10,000 hits a month.
"The next generation of this information is whether or not the purchasers or consumers act on it," said Colmers.
So far, it is unclear how much the guide sways the choices of consumers and their employers. So many factors influence the selection of a health plan: cost, convenience, a friend's recommendation.
Initial reports aren't encouraging. Even though people say quality is their biggest concern, three-quarters would opt to go to a hospital they are familiar with over one rated much higher in quality by experts, according to a 1996 study by the Kaiser Family Foundation.
People generally don't use report cards or numbers to make judgments on health plans and most other purchases, said Dr. Robert J. Blendon, a professor of health policy and political analysis at Harvard University School of Public Health.
But with time and advertising, he said, people start to pay attention.
Dr. Dennis Batey, president and chief executive officer of Preferred Health Network, a small local HMO, said PHN, which scored above average on 11 measures, provides copies of the booklet to insurance brokers and does "a low-key media campaign in the days and weeks that follow the release," featuring PHN's performance.
Membership has grown from 54,000 two years ago, when the first report card was issued, to more than 72,000 now, he said. It's impossible to tell how much of the growth was produced by the report card, Batey said, but "it certainly helps."
Ernest B. Crofoot, senior health care coordinator for the AFL-CIO's Maryland and D.C. chapters, said his members read the guide cover-to-cover.
"My members grab them like crazy. I can't keep enough of them," Crofoot said. "I wish I could carry more."
Robert Davis, executive director of the Maryland Health Care Coalition, a nonprofit organization that represents about 60 employers, said businesses have taken the report card back to managed-care plans and pressured them to do better.
"It is important. Nobody wants to send their employees to the lowest-ranked HMOs; that's the bottom line," Davis said. But he said large employers usually offer more than one choice, so they might not drop a poorly performing plan, knowing that workers can switch on their own.
Shematek, of CareFirst, said that when he speaks to employers, "our larger accounts have the report card results and will question us about particular rates."
But as many as half of all workers have only one health option, and their employer makes the selection. For those small businesses, the information is useful, but only one piece of the puzzle, Davis said. A good plan might not be offered in a rural area. Or it might be too expensive.
By 2001, the commission will produce similar report cards -- with audited data -- on Maryland's hospitals, nursing homes and ambulatory surgery centers.
Pub Date: 9/22/99