Letter to the New York Times in response to July 15th article,  "Patients With Rare Illnesses Fight New H.M.Os to Get Treatment"

July 18, 1996
Andrew Webber
Senior Associate for Quality Policy
485 Words

Dear Editor:

Elisabeth Rosenthal's July 15th article, "Patients With Rare Illnesses Fight New H.M.O.s to Get Treatment," is a poignant reminder that managed care can create significant barriers to health care services, particularly for populations most in need - the disabled, chronically ill, poor, frail elderly and individuals with rare diseases.

In their marketing pitches, HMOs often regale the public with statistics of high enrollee satisfaction rates. For the general population, with common illnesses and routine medical needs, HMOs may be fine. But the real litmus test for HMOs, and other forms of managed care plans, is how they serve the most vulnerable populations.

Ms. Rosenthal diagnosed the problem but what about the cure? Here is a recommended start on needed consumer protections and quality assurance mechanisms:

First, enrollees in HMOs should be entitled to a grievance and appeals system in which an independent peer panel referees cases involving services denied by the plan. As described by a patient in Ms. Rosenthal's article, the current grievance and appeals practice allows the HMO "to play judge and jury in your care."

Second, HMOs increasingly are required to survey a sample of their enrolled population to rate customer satisfaction. This effort should be expanded to require HMOs to survey enrollees that are chronically ill and those that leave plans. Survey results, available to plan participants and potential enrollees, would give us answers to two important questions: Do the chronically ill believe that they are receiving needed services? Are the sick being driven out of plans because they represent costly care?

Third, the technical conundrum of adjusting premium payments to HMOs to reflect the relative health or sickness of enrolled populations (otherwise known as "risk-adjusted" payments) must be addressed. Can there be any doubt that an HMO plan that builds a reputation for providing comprehensive and compassionate treatment for AIDS, and enrolls a disproportionate share of individuals with AIDS, should be compensated for their higher costs of treatment?

Finally, enrollee access to needed care, particularly for vulnerable populations, should be routinely monitored by independent entities. Such a system would require HMOs to collect and report minimum data for each patient visit. This data could then be used to produce comparative reports on the utilization and outcomes of care for the chronically ill and be made available to consumers to help guide plan selection.

HMOs, as integrated systems of care, have the potential to become bold pioneers in patient care to the chronically ill. Some plans are breaking new ground in designing multi-disciplinary approaches to disease management and should be applauded. But the incentives of managed care also have the potential to underserve people, particularly those most in need.

It is time to put quality health care before profit and revenue margins. Consumers are joining forces across the country to fight for responsible legislation to regulate the managed care industry. Will our elected leaders do the right thing and join us?

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