Employers and representatives of large-employer purchasing groups say they are deeply concerned about HMO bashing in the media.
Businesses have enjoyed premium reductions driven by managed care, and large employers have invested time and money in initiatives to measure and monitor quality. They don't want a return to the old, inefficient system.
It's not yet clear what damage the negative stories have done. Because the bulk of them have appeared recently, employers are just beginning to marshal their response.
The problem of negative press coverage was raised last October in an environmental analysis prepared by the Pacific Business Group on Health, a San Francisco-based purchasing group.
"Since that time, (negative press) has escalated tremendously, so the concern has been heightened," said Patricia Powers, executive director of PBGH. "These stories are not balanced."
Even employees at large, sophisticated companies that provide plenty of information about their HMOs can read the horror stories and think, "The doctor is not on my side," said Pamela Kalen, executive director of the Managed Health Care Association, a Washington-based group of 100 large employers committed to managed care.
Many surveys have shown that managed care has been mostly good news for payers that want their employees to receive high-quality, cost-effective care.
"We're dismayed with these stories that give such a negative view of something that can be wonderful," said Helen Darling, manager of healthcare strategies and programs at Xerox Corp.
"There are some bad apples out there, but the best medical care is in a good organized system," Darling said. "In most markets, good managed care is a big step forward for people" who often were forced to deal with "a good-old-boy" network of physicians and "not very good" specialists, she said.
Added PBGH's Powers: "People on our board, the vice presidents of (compensation) and benefits, they will hear from their work force directly if quality of care is suffering, if employees can't get a referral. They aren't getting those phone calls. In fact, people are more frustrated in non-HMO plans-or fee-for-service-where you have hefty payments even before you get service."
But employers also understand that the success of managed care in curbing waste, monitoring quality and delivery, curtailing double-digit medical inflation and making healthcare affordable is not sexy.
The result is lopsided media coverage. For example, a Los Angeles Times series on managed care last summer sprang from a Times poll showing that 92% of Californians in HMOs were satisfied with their plan. "Based on that poll, the Times produced a series focused on the 8%" who were dissatisfied, said Raymond Carter, executive director of the Integrated Healthcare Association. The IHA is a Pleasanton, Calif.-based group of hospitals, systems, physicians and HMOs formed to discuss and advocate on healthcare issues from a broad spectrum of perspectives.
Employers say unbalanced coverage reached its nadir in a dramatic January piece in Time magazine. It told the heart-wrenching story of a woman dying of breast cancer who was denied a bone-marrow transplant by Health Net because it was an experimental procedure. The story also wove in the tale of Health Net executives' rise to riches.
At a PBGH meeting late last month, "some of (our members) were waving the Time magazine story" in frustration, Powers said.
In the story, Health Net's coverage decision was used to discredit the entire managed-care industry. But that decision was taken out of context, because Woodland Hills, Calif.-based Health Net approved 179 bone-marrow transplants from 1992 to 1994, 55 of them for breast cancer patients.
Missing from the story, which makes HMOs sound like a sinister plot against "the essential goodness" of America's doctors, is awareness of the painstaking effort by physicians that underlies HMO rationing decisions.
For example, at Blue Shield of California, which is perhaps unique in having meetings of its technology committee open to the public, patterns of treatment are "hotly debated," said Cora Tellez, senior vice president and region chief executive for the San Francisco Bay Area. "Decisions are made through a very thoughtful process" and are based on extensive research, she said.
The Time report allows much of the criticism of managed care to be voiced by specialists who complain that they are getting fewer referrals. These are not disinterested parties, but they add to the lopsided image of managed care reflected in the press.
The Group Health Association of America has retained the Sacramento-based consulting firm Goddard Claussen/First Tuesday to lead its public relations campaign to redefine the perception of managed care.
Richard Claussen, a partner at Goddard Claussen, said the HMO industry is in a worse bind than other industries with public image problems.
"There's a very organized effort by other healthcare players to attack managed care because they have a strong stake in doing so, and you haven't seen that in other battles," Claussen said. "There are two competing, well-organized sides. And you have a fundamental change going on in the delivery of healthcare." That puts the industry on the spot, he said.
An industry source who wished to remain unidentified said that one good thing about the bad press was that "most open enrollments had ended by mid-December, before it hit the fan." But it has hit, and employers are now considering their response. "We want to get some of the truth out about managed care," Powers said. "Part of it is educating consumers and journalists. There are ways to look at what's really happening in managed care without blowing up one incident and making it a generalization for all of managed care."
PBGH's board will take up the issue at its March meeting, she said.
Blue Shield's Tellez said, "We're having discussions with large employer groups to talk about what together we could do" to counter the bad press.
Demonstrating quality is the best way to silence bad press, she said. But cost-conscious employers still are not willing to pay-through higher premiums-to develop quality measurements, she said.
Blue Shield is making that investment on its own, talking to physicians about best practices and "how we can help them improve," Tellez said.
Employers themselves need some bolstering, since the programs they have embraced are being attacked as unethical. So the Managed Health Care Association has asked Berkeley, Calif.- based ethics consultant John Golenski to brief members in May.
Golenski believes the new medicine requires a wider ethic.
"Managed care requires physicians to expand their notion of duty beyond patient advocacy to include payers, associated providers and other patients under population-based medical practice," Golenski recently told industry executives at the University of California, Irvine, Health Care Forecast Conference.
Darling believes that Xerox's employees, who receive ample information about their health plans, "have less of a problem" with unbalanced media stories. They also have a wide choice of HMOs as well as fee-for-service insurance."We do work very hard at making sure they understand we are picking good plans," she said.
For example, if an HMO has a center of excellence, Xerox lets employees know "so they can see we chose the best," she said. Xerox is working on getting information on how health plans select hospitals. The company will pass that along to employees.
In California, the Integrated Healthcare Association's first project has been to get basic information on managed care out to the public by distributing a packet of materials. Members "decided the absolutely first thing they needed to do was to engage the legislators and the public in a dialogue about the advantages and the problems of managed care," Carter said.
Journalists who've just received the packet have begun calling the IHA, he said.