Massachusetts physicians sent HMOs a crystal clear message in 1996: They weren't happy with the state's leading health plans.
So after three years of collaboration between the Massachusetts Medical Society and the health plans, officials may have been expecting to be thrown a bone.
It didn't happen.
Physicians in Massachusetts, one of the most heavily managed care states in the nation, are even more unhappy than they were three years ago.
The 1999 study, conducted by the MMS and HMOs and released last month, found that physicians' ratings of the state's largest health plans are more negative than they were in 1996, the last time the survey was conducted.
"Current problems with managed care are pervasive and systemic rather than plan-specific," the study authors wrote. "Further evidence of the systemic nature of these problems is seen in the fivefold increase over the past three years in the proportion of primary care physicians that are 'very dissatisfied' with managed care in general."
Physicians were surveyed about the state's four largest health plans: Harvard Pilgrim Health Care, Tufts Association HMO, HMO Blue and Fallon Community Health Plan.
The results were not a surprise.
"There's a growing sense of frustration on the part of the physicians in the state," says Virginia Latham, M.D., president of the medical society. "The overwhelming sense of fatigue, the inability to do what people really want to do, the discouragement that's leading physicians to opt for managerial positions and move to other states."
HMO officials said they expected the results.
"The environment here in Massachusetts has been tumultuous in the past year," says Philip Boulter, M.D., chief medical officer and vice president of Tufts Health Plan, the state's second-largest plan. "It was not surprising to see that the survey validated feelings that the physicians are generally unhappy."
Regardless of the health plan, physicians voiced concerns about support for preventive care, availability of mental health services and difficulties in appealing denied claims. Physicians also were negative about fee schedules and capitation rates. The report's authors point out that "physicians did not single out any particular health plan as being worse than its competitors."
The study included responses from 966 primary care physicians and 460 specialists affiliated with the four HMOs and the state's fifth-largest managed care organization, Health New England.
Although primary care physicians overall rated the plans as "good or very good" for availability of specialist referrals, they rated them "fair" to "poor" for the availability of behavioral health services.
After the 1996 study found negative attitudes toward managed care, the MMS worked with health plans to improve relationships and streamline operations, including developing credentialing forms and working to relieve administrative burdens.
Latham says she didn't see improvements.
The HMOs are going to have to provide adequate reimbursement for physician services and further eliminate the hassle in providing care for their enrollees, she says.
"The funding per visit has fallen," she says. "We want to take care of patients. That's hampered by the impossibility of keeping ahead of the fiscal pressures in the office. The issue isn't what doctors salaries are . . . it's the threat to their ability to take good care of their patients, which is inherent in the rapid turnover required to meet fiscal obligations."
In fairness, she says, the state's HMOs began facing financial problems a few years ago.
When the survey was conducted last fall, Harvard Pilgrim Health Care was being reorganized. Massachusetts officials put the state's largest HMO in receivership in January after discovering that losses would be double what was projected. The state recently ended its oversight of the HMO's daily operations.
"There was a lot of uncertainty about claims payment," says Eric Linzer, spokesperson at Harvard Pilgrim. "Doctors were concerned about getting full payment. We make no secret that claims weren't going through (quickly)."
Linzer says payment systems at Harvard Pilgrim have improved significantly since the survey was conducted and the HMO reorganized. But he admits, as do other HMO representatives, there is a long way to go.
"We're all trying to move to greater usage of technology for billing and record keeping," Linzer says. "Some of the steps we've initiated . . . will go a long way in addressing some of the problems."
Financial factors in the Massachusetts market have made things difficult, Tufts' Boulter says.
"Physicians are always concerned about the timing of their payment and the adequacy of their payment," he says. "The timing and adequacy were not where they would like it to be."
One positive note, Boulter says, is that the survey showed that four of five doctors say they felt free to make their own medical decisions without interference from HMOs. The 1996 study found similar results.
He says it is interesting that Massachusetts physicians don't regard the plans highly though they're ranked as some of the best in the nation.
"The paradox is that if you look at the national surveys, the health plans in Massachusetts are all in the top 10 or so in the country," Boulter says. "It's an interesting dichotomy."
The fact that the HMOs and the medical society have not only worked together for a solution but on the survey shows that the environment can improve for patients and physicians, he says.
"There's enormous change going on. Change never creates a lot of satisfaction."