How to Choose an HMO

These 11 indicators offer a rough gauge of key areas that should be scrutinized when choosing an HMO.

1. Look for a 15- to 20-year history.
   Age is not a virtue by itself. But 15 to 20 years of maturation in your region of the country enables an organization to figure out a few things, including how to pay and retain good doctors and hospitals. An HMO that has solid relations with those front-line providers can usually deliver better and more coordinated care than an HMO that has just begun working with its doctors and hospitals.
2. Don’t go with a for-profit HMO and doctors with financial risk.
   A for-profit HMO is dramatically different from a not-for-profit plan. While both have an incentive to keep costs down, the not-for-profits in this country tend to be far more focused on members’ well-being.
3. Demand a fully accredited plan and reporting on FACCT measures.
   A plan that’s accredited by the National Committee for Quality Assurance is doing a great deal to improve the quality of its care. But a truly excellent plan is willing to hold itself up to an even higher standard of quality. The Foundation for Accountability (FACCT) is a Portland, Oregon, coalition of companies and consumer advocates which has begun formulating new quality measures. FACCT is asking an HMO not only how successful it has been in keeping breast cancer victims disease-free for five years, for example, but how the women felt about the information, communication, and services they received during treatment. Any HMO that is planning to answer such questions is exemplary—and any that is already doing so is extraordinary.
4. Don’t agree to high heart bypass and angioplasty rates.
   The national averages are 4.1 per thousand for bypasses and 4.8 per thousand for angioplasties. Look for a plan with rates that are lower.
5. Require high cervical and breast cancer screening rates.
   Use GTE’s best practice guidelines as your benchmarks: at least 85 percent of all women between the ages of 52 and 64 have had a mammogram during the prior two years, and at least 85 percent of all women between the ages of 21 and 64 have had a Pap test during the preceding three years. The national average is 70 percent for both, but that’s much too low.
6. Don’t accept a high proportion of C-sections.
   C-sections involve anesthesia, major surgery and longer recovery periods with more complications than normal deliveries. Look for a C-section rate of 15 percent or less of all childbirths. The national average is 20.7 percent.
7. Seek high diabetic retinal testing rates.
   Nationally, HMOs test only 37 percent of the appropriate diabetic population each year. Top HMOs are screening 64 percent.
8. Don’t skimp on mental illness.
   The question: how many of the HMO’s members who have been hospitalized with a mental disorder received a follow-up phone call or had a follow-up appointment within 30 days of their discharge? The national average is only 75 percent.
9. Find a plan with available doctors.
   Ask, “How many of your doctors have ‘open panels,’ or are accepting new patients?” Opt for an HMO with at least 90 percent open panels.
10. Don’t join a plan with unhappy doctors.
    Ask the HMO for its annual physician turnover rate. If more than 10 percent of an HMO’s doctors leave during a year, ask the HMO why. A second approach is to ask your HMO if it surveys its physicians about how happy they are with the HMO and, if so, to give you the results. If they are willing to disclose the results, chances are you’ll only get to see the most positive aspects of the doctors’ answers. Still, it’s worth a try. Finally, you should skip the HMO’s survey if you’re lucky enough to live in a region where an independent-minded consumer advocate group or medical association has surveyed physicians about HMO quality.
11. Look for highly satisfied members.
    Never use satisfaction surveys as a stand-in for an evaluation of overall quality, because they rely on members’ perceptions, not hard-core data. Nevertheless, satisfaction surveys can give you an excellent picture of how responsive an HMO is in answering the phone, fielding questions, and otherwise supporting its members.
    
    The best HMOs will have a high percentage of members who deem themselves “completely satisfied,” and a low percentage of those who are dissatisfied. Shoot for a better-than-average rate of 65 percent to 75 percent for the combined categories of “completely” and “very” satisfied.

SOURCE: Excerpted from “Choosing and Using an HMO.” Copyright 1998 by Ellyn Spragins. Published by arrangement with Bloomberg Press. Available at better bookstores and through Amazon.com. May not be modified, copied, reproduced, uploaded, posted, transmitted, or distributed in any manner.