Saying that after four years, consumers can look at the results "not as a snapshot, but as a trend," Maryland issued its annual HMO report card yesterday - and for the first time designated "star performers" among the state's health plans.
And while state health officials didn't single out the HMOs that consistently ranked below average, anyone willing to go through the 166-page report can easily find that information.
"Health plans should begin to reap the rewards - or suffer the consequences," said John Colmers, executive director of the Maryland Health Care Commission, which prepares the report.
Stars were awarded in six different areas (for example, prenatal care), and Kaiser Permanente won them in all six. Delmarva Health Plan, which operates on the Eastern Shore, got three. George Washington Health Plan won two; FreeState and M.D.-IPA got one each.
At the other end of the scale, Aetna's Prudential plan and United Healthcare each scored below average three straight years on two measures. Aetna U.S. Healthcare, Aetna/NYLCare and Cigna each had consistent low scores in one category.
Colmers said consumers should ask questions when HMOs score very differently. For example, he pointed out, Kaiser completed 82 percent of needed childhood immunizations last year, and FreeState Health Plan 76 percent. At the other end of the scale, Preferred Health Network completed 48 percent and Prudential 43 percent.
In this year's survey, three HMOs, Kaiser, Delmarva and M.D.-IPA, ranked above average on a majority of the 29 measures of health care and consumer satisfaction.
Those that ranked below average on 10 or more of the measures included two plans, NYLCare and Prudential, that have been acquired by Aetna U.S. Healthcare but still report their scores separately, and Preferred Health Network, a local plan that had been among the top scorers in past years.
The scores are based on counting health care delivered - how many women got tested for cervical cancer, how many adults were screened for cholesterol problems - and on surveys of patient satisfaction.
When Maryland began issuing report cards four years ago, it was the first state to do so, and it has refined and added measures over the years. This year, in addition to singling out "stars" for the first time, the report card added measures on care for chronic diseases, such as asthma and diabetes.
"It's really state of the art - a step ahead of what's done nationally and in other states," said Pete Borchardt, an Easton benefits consultant specializing in HMOs.
"We think it's having a significant impact," said Dr. Donald E. Wilson, dean of the University of Maryland School of Medicine and chairman of the health care commission. "People know, rather than think, what's going on."
Colmers said the commission's Web site, which contains the full report and allows consumers to customize reports for themselves, had 160,000 visits over the past year. The commission distributes about 50,000 consumer guides; they are available in all state libraries and are free to anyone who calls to request one. The full 166-page "comprehensive performance report" goes primarily to benefits managers.
Despite four years of report cards, insurance brokers and the HMOs themselves said there has not been a noticeable shift of business in Maryland from low-scoring plans to high-scoring ones.
"It has a bigger impact on the HMOs than on employers," said Jon Gabel, vice president for health care studies at the Health Research and Education Trust, which studies how employers choose health plans to offer to their workers.
The HMOs, he said, "take it seriously and put a lot of money into it, and it has had real impact," with measures of care going up over the past several years.
In Maryland, the average score went up this year on every care measure except childhood immunizations.
Large employers with more-sophisticated benefits departments are much more likely to use health quality data, Gabel said. His surveys show that among small employers, only about 10 percent are even familiar with HMO accreditation.
Dennis B. Mather, president of the Maryland Association of Health Underwriters, an insurance trade group, said, "In the small-employer market, the primary driver is price."
HMOs, however, said they believe employers are paying more attention to quality. "I'm not sure they're moving membership, but they're certainly asking a lot of questions," said Dr. Jon Shematek, medical director for quality improvement for CareFirst BlueCross BlueShield, which operates Delmarva, FreeState and Capital Care HMOs.
Report cards "are better than not having anything," said Judy Waxman, deputy executive director of Families USA, a Washington-based health care advocacy group. But, she warned, "To some degree, when the plans know what the questions are going to be, they work on those" to the exclusion of other types of care.
For example, she said, an HMO might push women to get mammograms - which count on the report card - but not put the same effort into having members get comprehensive exams - which are not measured.
Consumers should not rely on the report card exclusively, Waxman said. "If you're going to pick a plan, you want to talk to your doctors," she said. "Are they on the plan? Are your prescriptions on the plan? Are there problems with reimbursement?"
HMOs have strongly supported the report cards. As consumer criticism of HMOs grew over the past few years, the industry found report cards a way to show quality, and a more palatable alternative than stronger regulatory legislation.
Walt Cherniak, regional spokesman for Aetna U.S. Healthcare, said report cards "demonstrate the value of managed care, because only in managed care can you look at these measures."
The HMOs also said they had been working hard to bring their scores up, through initiatives such as postcards reminding women to get mammograms and "disease-management" programs to make sure people with chronic conditions get tests and medications.
The improvement in scores "shows the maturing of the numerous health promotion initiatives we've put in place," said Elizabeth Sammis, a spokeswoman for Mid Atlantic Medical Services Inc., a Rockville company that operates M.D.-IPA and another HMO that had higher scores this year, Optimum Choice.
Dr. Dennis Batey, president and chief executive officer of Preferred Health Network, said he thought his plan's scores may have slipped in part because of a change in computer systems, which may mean it wasn't getting a full count.