Patients in smaller HMOs are happier with their health plans, but one of Maryland's largest HMOs provides the best clinical services, according to a state report card released yesterday.
In a survey this year of the care provided to 2.2 million patients in nine health maintenance organizations, subscribers were asked how they would rate their plans.
Two of the state's smallest HMOs - Delmarva Health Plan, part of CareFirst, and Coventry Health Care - were the only ones to receive top scores. But Kaiser Permanente, the state's second-largest HMO, scored above average in a majority of clinical-services measures.
The Maryland Health Care Commission's sixth annual report compares HMOs in customer-service categories such as consumer complaints and quick access to care, and in clinical categories such as prenatal services and immunizations.
State officials said that the scores have gradually improved since the report cards began.
"There clearly is an effort to improve performance, and we are getting to where we want to be in terms of health care," said Barbara Gill McLean, the commission's executive director.
Despite the fact that HMOs were created in part to avoid costly emergency room visits, the report showed an 11 percent increase last year in the number of HMO members using emergency rooms. That jump exceeds the 7.7 percent growth statewide in emergency room visits by all patients, regardless of insurance.
McLean said there are "a lot of theories" about why more HMO patients are using emergency rooms but no clear explanations for the trend.
Lynn Garrison, program manager for the health care commission, said one reason more people are going to emergency rooms is that many small medical clinics closed because of financial problems in recent years.
"If it's after hours and you can't see your doctor, there's really no place else to go," he said.
Dr. Brian Browne, chief of emergency care at the University of Maryland Medical Center, who oversees seven emergency departments across the state, said the number of emergency room patients has been rising steadily since the mid-1990s.
"We're after-hours care," Browne said. "We're critical care and we're convenient care."
The report card was based on mail surveys of 950 patients per HMO earlier this year, on statistics provided by the health plans and on medical records.
Maryland Individual Practice Association Inc., a moderate-size health plan, scored above average in eight clinical areas. Aetna U.S. Healthcare, the state's largest HMO, scored above average in seven.
Preferred Health Network, among the state's smallest health plans with 67,000 subscribers, received the poorest overall score, scoring below average in 19 categories and above average in only two.
Dr. Daniel Winn, senior medical director for CareFirst, which has run PHN for the past two years, said the HMO collects medical data differently, and that may have hurt its scores in the clinical categories.
"We are now learning [our reporting procedure is] not as reliable as it needs to be," he said.
Another CareFirst HMO, BlueChoice, with 251,000 subscribers, also fared poorly, scoring above average in only four categories and below average in 12, according to the report card.
Winn said BlueChoice suffered from the fact that it is a newly created entity made up of two defunct HMOs - Freestate in Maryland and CapitalCare in Washington.
"It's a new product and we were experiencing more problems than we would have liked," Winn said, adding that CareFirst will open a new call center near the end of the year to help boost customer service.
Maryland was the first state to issue an HMO report card, and state officials say it is a vital tool because nearly half of the state's population subscribes to an HMO.
Dr. Michael Moriarty, vice president of Kaiser, said that as a result of patient concerns in previous report cards, Kaiser began giving patients information folders this year after every doctor's appointment - with directions to labs where work must be performed, an explanation of the course of treatment and a phone number for any questions.
"It's somewhat an issue of pride, and we want to do well in them," he said.
But consumer advocates say Maryland's report card would be more useful if it included preferred-provider organizations, a less restrictive form of health insurance. Managed-care organizations that cover Medicaid and Medicare patients also were not included in the survey.
Trudy Lieberman, director of the Center for Consumer Health Choices at Consumers Union in New York, said the Maryland study would also be more valuable if it took prices into account.
"Most people are not looking at the report cards, most people are looking at benefits and costs, and this report looks at quality," Lieberman said. "That's really the flaw in the whole report-card business - [surveyors] are not looking at all of it in its totality."
The process of evaluating HMOs is still in its infancy, said Maulik Joshi with Boston's nonprofit Institute for Health Care Improvement.
"The measurement is getting more and more mature, but it's not there like it is with cars, where it's standardized. We're just building now in health care," Joshi said.
He said factoring in prices could be tricky because different employers will pick up different portions of the plans' costs.
To review Maryland's HMO report card, call 1-877-245-1762 or see http://www.mhcc. state.md.us