HMOs are high on the list of things Americans love to hate.
News coverage is rife with horror stories of HMO patients injured or killed by negligence, while films and TV shows portray managed-care executives as sacrificing quality to boost profits.
Policymakers, too, point to opinion polls indicating that most Americans believe HMOs provide inferior care. It's proof, they argue, that increased managed-care regulation is a must.
But the results of a study released last month suggest the HMO problem may be more one of perception than reality. The nonpartisan Center for Studying Health System Change found that differences in the way people rate their healthcare are attributable more to the type of plan they think they are in than to their actual plan type.
"The results are striking once you realize what they actually suggest," says James Reschovsky, lead author of the study. "Typically, we expect survey results to reflect people's attitudes based on their actual experiences. But our findings strongly suggest that prevailing stereotypes influence how people assess their personal experiences. That is, your perception of what kind of health plan you are in colors your perception of what kind of care you receive and, ultimately, your level of satisfaction."
As part of the study, HSC asked some 20,000 privately insured people what kind of health insurance they had, as well as their feelings about their most recent medical visit, their trust in their doctor and their overall satisfaction with the care they receive. But unlike most surveys, which generally don't confirm the accuracy of responses, the HSC study verified the type of coverage each respondent claimed to have by contacting the individual's insurer.
Surprisingly, almost one in every four people surveyed incorrectly reported whether they were covered by an HMO or not. Eleven percent thought they were not in an HMO but really were, while 13% thought they were in an HMO but really weren't.
Perhaps more sobering, though, is what these discrepancies revealed about the public's views on HMOs.
Consistent with other polls, people who reported that they were covered by an HMO expressed lower levels of satisfaction with their healthcare and trust in their physicians. Specifically, these respondents were more likely to rate the thoroughness of their last doctor's exam as fair to poor and to doubt that their doctor would refer them to a specialist when needed.
Across nearly all 10 measures examined, however, those HMO enrollees who thought they were in another kind of plan--such as a PPO, point-of-service or indemnity plan--gave ratings similar to those who actually were in those other plans. Conversely, those enrolled in other types of plans who thought they were in HMOs responded much more like those who actually were in HMOs.
In fact, when researchers adjusted for those who had incorrectly identified their type of coverage, differences in healthcare ratings between HMO and non-HMO enrollees shrunk and in many cases, disappeared.
"Those who conduct and use surveys assume that respondents will follow a pure line of reasoning such as, `The care I receive is good. Hence I'm satisfied with my healthcare,' " Reschovsky says. "But studies show that when people don't have a strong handle on an issue, they tend to fall back on conventional wisdom. And that usually results in biased reasoning like, `I'm in an HMO. I've heard that HMOs provide worse care than other kinds of plans. Therefore, I'm dissatisfied with my care.' "
For the American Association of Health Plans, which represents some 1,000 HMOs, the study serves as ammunition in its fight against proposed patient-protection legislation intended to place more limits on the nation's health plans.
The findings, says AAHP spokeswoman Susan Pisano, suggest that policymakers should be cautious when drawing conclusions about HMOs from survey data, because they don't tell the full story.
"Much of the healthcare debate in Washington has been predicated on the widespread belief that the quality of care differs from one type of plan to another, and random opinion polls have been used to justify efforts to further regulate managed care," Pisano says. "But (the HSC study) shows that such data may not provide an accurate comparison of care."
Indeed, a number of recent clinical studies indicate that the care HMOs provide isn't nearly as bad as public attitudes suggest.
On Sept. 6, for instance, the National Committee for Quality Assurance, an independent agency that evaluates HMO quality, reported that managed-care plans made several major improvements last year, including increased use of preventive screenings and drugs. In releasing the report, the NCQA stated, "In terms of quality, 1999 was by far the best year in the history of managed care."
Still, consumer advocacy groups aren't ready to concede the issue.
The fact that Americans may play into negative stereotypes of HMOs doesn't erase the fact that the nation's managed-care system is in dire need of improvement, says Ronald Pollack, director of the Families USA Foundation in Washington.
"The issue has never been one of numbers. So whether consumer dissatisfaction is as high or somewhat lower than previously thought in no way invalidates the need to restore balance to the system," Pollack says.
"Besides," he adds, "the study never said there was no truth to the (HMO) stories that people are responding to. In my book, where there's smoke there's fire."