A recent Sachs Group study based on Scarborough Research Corp. data from 27 markets found respondents had a low overall perception of the value of their HMOs.
They also were lukewarm-"neither satisfied nor dissatisfied"-about their HMOs' access and convenience.
Despite their unwillingness to say they were satisfied in those areas, respondents in most markets said they were "somewhat satisfied" with their overall quality of care as well as the clinical quality of their providers, the Sachs study showed.
The markets were chosen for the survey because they are among the largest in the nation and have moderate to heavy managed-care penetration, according to Evanston, Ill.-based Sachs Group, a healthcare information provider.
Sachs culled its information from some 40,000 healthcare questionnaires completed by respondents in 1995. Some 85,000 questionnaires were mailed.
The study is an important barometer because the general population in those 27 markets is one that perhaps has not been heard from adequately in consumer-satisfaction surveys.
Sachs Senior Vice President Gary Pickens said 78% of the adults in those 27 markets-and in the United States as a whole-work for companies that employ 500 or fewer people.
Many surveys of consumer satisfaction with commercial HMOs that aren't conducted by the plans themselves have involved large employers. There's evidence that the involvement of benefit managers at big corporations in the careful selection and monitoring of HMOs and the HMO information they offer their employees results in better care-or at least a perception of better care.
For years, such giant corporations as Xerox, Digital Equipment and GTE have been surveying their employees' satisfaction with HMOs. Generally, these large employers have reported high employee satisfaction with HMOs.
The Sachs study is the largest population-based healthcare satisfaction study focusing on local markets conducted so far, according to Sachs Vice President Les Stern.
Sachs will repeat the study this year by covering those markets and six more.
Respondents rated their satisfaction with an HMO's access, convenience, quality and general perception of value on a scale from 0 to 5.
A rating of 0 indicated they had no experience with what was being asked; 1 meant they were very dissatisfied with that aspect of the plan; 2, they were somewhat dissatisfied; 3, neither satisfied nor dissatisfied; 4, somewhat satisfied; and 5, very satisfied.
The general perception of value in all 27 markets fell between the ranges of "somewhat dissatisfied" and "neither satisfied or dissatisfied," with markets scoring from 2.69 for Houston to 2.95 for Detroit.
The scores for HMOs' access couldn't quite reach the "somewhat satisfied" mark, ranging from 3.51 for Houston to 3.98 for Detroit.
In the area of convenience, the range was somewhat higher, with 3.60 for Houston to 4.06 for San Diego.
The markets did better in the area of perceived quality, ranging from 3.83 in Houston to 4.29 in Denver, with an average of 4.11 for all 27 markets.
No markets scored a perfect 5 in the areas measured, which seems to run counter to some plans' claims.
And in five markets-Dallas; Houston; Kansas City, Mo.; Orlando, Fla.; and St. Louis-no plan scored statistically better than the market average in any of the areas measured.
Stern said the message for health plans in the study is the intangible of "quality is not as important as access and convenience" in consumers' perception of their health plan's value.
Even with the changes that have come with managed care, "there may still be an assumption (among consumers) that they will get quality of care" because that can't be strictly defined, Pickens said.
Therefore, they respond that they are "somewhat satisfied" with their plan's quality.
"But when you ask them nitty-gritty questions about access and convenience, they understand that," he said. If they are dissatisfied in those areas, that translates into a low perception of value.
In the survey, respondents -were asked questions about their satisfaction with access to providers, flexibility in changing doctors and in use of services, ease of getting referrals, and waiting times for appointments when they were sick and for routine visits.
And they were asked about their satisfaction with the convenience of claims handling and member services.
Sachs Group President Michael Sachs said the results of the survey show that "a lot of health plans and integrated delivery systems do not provide the level of access and convenience that consumers want."
The study identified HMOs that got significantly higher than average satisfaction ratings in their markets in the areas of access, convenience, quality and general perception of value. These plans made the Sachs Honor Roll (See chart, p. 108).
All but three of the nine plans on the Sachs Honor Roll have full, three-year accreditation from the National Committee for Quality Assurance, which would indicate that NCQA standards translate into bottom-line consumer satisfaction. One plan received one-year accreditation.
It's important to note that the plans on the honor roll are measured against their markets because the study showed wide variations in satisfaction among the 27 markets in the four areas measured. That means in some markets "the bar is lower" for plans to get good scores, Pickens said.
The variation in satisfaction across markets can be caused by many factors, he said. For one thing, healthcare "is not a homogeneous product, like soup," he said. Plans and delivery systems are better organized depending on the market.
Another factor is the "underlying attitude" of respondents in different markets, Pickens said. Their attitude is based on their education, knowledge and perception.
According to researchers at Scarborough Research, a New York-based company that provides qualitative research information on consumer habits and spending for media buyers, respondents in certain markets "always rank everything lower," perhaps because they are more informed-or more cynical, he said.
In terms of their attitude toward healthcare, people's expectations change as the level of managed care deepens, Stern said.
"For healthcare, that's a key. Generally we see that the longer managed care has been around, the more demanding people get. If you look at satisfaction levels, they go down in more mature markets."
A report Sachs is now preparing shows that, based on 22 satisfaction measures, satisfaction in the most mature managed-care markets, such as Los Angeles, Minneapolis and San Diego, is lower than in less mature markets like Denver and Detroit.
Stern believes the main reason is that in mature markets, "the last people to go into HMOs are the ones that want to go in the least"-the ones who complain that "now my employer won't give me a choice." Those negative attitudes drag down satisfaction rates in mature markets, he said.
He said studies have shown that people given a choice of whether or not to join an HMO will be 10% to 15% more satisfied with their care than those not given a choice.
But lower satisfaction with HMOs in more mature managed-care markets does not show that people become more dissatisfied with HMOs the longer they are in them, Stern said.
Sachs' research has found the longer people are in HMOs the more satisfied they say they are, he added.
For example, 67% of people in HMOs for less than one year rated their overall coverage good or excellent. That figure was more than 80% for people in HMOs for five years or more, Stern said.
Several Kaiser plans made the honor roll, showing consumers appreciate a model that provides "convenient care all in one place." Other delivery systems require a member to visit several locations and to "get this approved or that approved," Sachs said.
Sachs said he was surprised that New York-based Oxford Health Plans did not make the honor roll because it is "clearly a top-rated plan" in most surveys.
In the Sachs survey, Oxford plans were rated "very good" in their markets, but "they weren't so much better than everybody else," he said.
Low satisfaction with access and convenience shows "the fragmentation of the delivery system," Sachs said. "Just calling it integrated doesn't make
it less fragmented. This is a major challenge for providers and health plans."
Plans that offer low prices and convenient, accessible care "are the ones that are going to win. Providers have to re-engineer the delivery system so it's less fragmented, which means multispecialty clinic settings like Kaiser, offering primary care that's convenient as well as after-hours care," Sachs said.
The discrepancy in "perception of value" between employees at large companies and respondents to the Sachs survey perhaps can be explained by the fact that large employers have made major efforts to monitor the HMOs they offer employees. And they have given their employees plenty of information on the plans available to them and how they work.
Large employers have been the drivers behind the NCQA's self-graded report cards, called the Health Plan Employer Data and Information Set, in which individual HMOs report on their own performance.
The new version of HEDIS, due out by summer, will for the first time contain a report on consumer satisfaction.
A Washington Business Group on Health/Watson Wyatt survey released in March showed 58% of large employers-with 10,000 or more workers-use HEDIS to evaluate health plans, compared with only 6% of employers with fewer than 1,000 workers.
Large employers also provide HEDIS data to their workers more often than do smaller employers, Watson Wyatt said.
Large-employer purchasing groups like Pacific Business Group on Health also have invested millions of dollars in "a dozen quality projects" with the HMOs that serve their members, said Executive Director Patricia Powers. PBGH, based in San Francisco and representing 29 private and public purchasers, also has negotiated contracts with HMOs that include performance targets.
By and large, employees of big companies can't help but benefit from the fact that their employers are evaluating their HMOs and holding them to quality standards. At the very least, the employees' perception is that their employers care about the quality of healthcare being provided. Either way, consumer satisfaction is the likely result.
"I agree with the premise that employees whose employers carefully screen HMOs would be more apt to believe they are receiving better care and more apt to score higher on satisfaction surveys," said Lewis E. Devendorf, a principal at William M. Mercer, a New York-based employee benefits consulting company.
With price factored into the value equation, large employers are apt to choose the best plans in their markets. Benefits managers like Bruce Bradley, corporate manager of managed care at GTE in Waltham, Mass., are emphatic about meticulously choosing plans that contribute to their employees' health.
In an interview earlier this year, Bradley said, "My message to the providers is to focus passionately on improving healthcare with a real focus on better outcomes, on (what makes) their patients functionally better."
Couple that with the abundance of information big companies give their workers and it's likely those employees will be more satisfied than the respondents from Sachs' general population.
But Devendorf said he can't go so far as to declare that employees at big companies receive better care as a result of the careful monitoring of their benefits managers.
"Monitoring can't always result in better care. There are no guarantees in life," he said.
Whether or not an employee at a big company is actually receiving better care "is an issue that is highly provider-dependent and highly variable," he said.
As part of the Mercer Value Process, a tool that helps employers select health plans, Mercer identified "seven quantifiable elements of quality and cost" an employer can consider. One of those elements is health management, or what the plan does to keep participants healthy, and HMOs are getting better at that, Devendorf said.
But it is still difficult to measure another of those elements: care management, or the care being delivered at any given time to a particular patient.
No matter what quality measures the plan has in place, the care given by an individual doctor is still largely uncontrollable.