DIAGNOSING MANAGED CARE : GROUP DRAFTING CRITERIA TO GAUGE HEALTH PROVIDERS.

Byline: Deborah Adamson Daily News Staff Writer

If you're basing your choice of health plan on member satisfaction surveys, you're probably confused.

Fact is, health plans galore have come out with highly flattering reports.

For instance, Kaiser Permanente in October publicized its distinction as the 1996 Quality Leader on member satisfaction for 12 out of 14 California metropolitan regions in a survey by the National Research Corp.

Health Systems International, parent of Woodland Hills-based Health Net, said 87 percent of its HMO members are satisfied with the care they receive.

CaliforniaCare, the HMO unit of Wellpoint Health Networks in Woodland Hills, boasts a 76 percent satisfaction level among its members.

With practically every plan claiming to be tops among its members, it's no wonder that consumers find it hard to pick among them.

But help is on the way. Starting next year, the National Committee for Quality Assurance, a nonprofit group that reports on the quality of managed care, will have a standardized national survey on member satisfaction.

The goal is to have an apples-to-apples comparison of different plans. The problem with using different surveys is that it's easy to skew data based on how you conduct it, said NCQA spokesman Barry Scholl.

``It's very easy to manipulate the data or present it in such a way as to make yourself look good,'' he said. ``A health plan could craft any survey to make it say what they wanted to say - like 98 percent consumer satisfaction. This leaves a less than useful comparative survey.''

People tend to be more positive when responding to questions over the phone, for example, than in anonymously answering a questionnaire by mail.

The kind of people contacted by the survey also matters. Not surprisingly, current members tend to have more positive feelings than those who've left.

The need for a standardized description of all plans is especially acute among seniors, who are enrolling in Medicare HMOs in record numbers.

``The burden of figuring out benefit and cost comparisons among HMOs falls exclusively on the beneficiary. That is not right,'' said Sen. Ron Wyden, D-Ore., a member of the Senate Special Committee on Aging.

``We cannot expect beneficiaries to rely solely on television ads when deciding whether or not to join an HMO,'' he added. ``Seniors need truthful, standardized plan descriptions in order to make appropriate choices.''

NCQA's solution is to start conducting member satisfaction surveys using its Health Employer Data and Information Set, or HEDIS.

The NCQA already measures performance by managed care groups on this yardstick, which most HMOs accept.

HEDIS is being used to track 60 categories including immunization rates and percentage of women getting mammographies to gauge quality of care. When NCQA starts to track member satisfaction next year, the number of categories will rise to 75.

Efforts to create a national standard are appreciated by organizations such as the Pacific Business Group on Health, a San Francisco-based coalition of firms whose goal is to improve health care quality and control rising costs.

With one standard methodology for health plans, employers hope to find it easier to compare among them and share this information with their workers.

``It's very necessary,'' said David Hopkins, director of health information improvement. ``Everyone's trying to collect their own data.''

But Kit Costello, president of the California Nurses Association in Sacramento, takes issue with the kind of information collected by HEDIS.

``They fail to measure the bad stories,'' she said, such as patient falls and hospital accidents.

HEDIS does not measure medical outcomes, a more important barometer of care, added Jeanne Finberg, health care policy analyst for Consumers Union in San Francisco, the publisher of Consumer Reports magazine.

``It's important information, but tangential,'' she said.

Dr. Brian Johnston, president of the Los Angeles County Medical Association, agreed. The HEDIS parameters are largely ``irrelevant.''

Checking to see how many pap smears a patient went through won't be much help unless the physician cares enough to look up the laboratory results and make sure the right care is delivered, he said.

One useful tool in finding out how a plan performs is its dis-enrollment rate.

In Los Angeles last year, Foundation Health had the highest percentage of patient departures at 42 percent while Kaiser had the lowest at 4 percent.

The report, prepared by the General Accounting Office for the Senate Special Committee on Aging, included only cancellations within the first three months of enrollment. That way, the data better capture patient departures due to confusion about the plan or enticement by its marketing program.

NCQA says it accredits managed care firms to monitor quality of care.

Scholl said 40 percent of plans score in the highest level - full three-year accreditation. Kaiser Permanente of Southern California and Prudential Health Care Plan of Southern California are some Southland plans with top scores.

One out of 10 plans are denied accreditation.

But Finberg said the accreditation process is undermined by two things: It is voluntary and expensive to implement.

Still, not everyone makes it.

Last year, CaliforniaCare was denied accreditation. CaliforniaCare parent, Wellpoint Health Networks, sued the NCQA, contending that its measurement methods were inadequate.

``They were flawed in their methodology,'' said Cynthia Coulter, spokeswoman for Wellpoint, adding that the health maintenance organization is going through the accreditation process again.

The whole point of accreditation is to prove that managed care delivers quality treatment, an assertion that has been the target of much criticism.

Managed care groups say that's because the media unfairly focuses on medical ``horror'' stories instead of the good that they deliver.

In addition, until a national health care reform is implemented, managed care is the answer to the problem of escalating health care costs.

In 1970, health care costs rose an average of 10.6 percent a year from the decade before. By 1975, costs rose by 12.3 percent annually and reached a peak of 13.6 percent in 1980.

But aggressive cost containment has slowed those rates. From 1985 to 1994, the average annual price increases dropped from 11.6 percent to 6.4 percent. That's about when managed care took off.

But cheaper does not mean better, Finberg said.

Some companies might start cutting care to the bone, she said.

What's more, for-profit managed care companies take millions out of health care revenues to beef up salaries of top executives, Finberg said. That money should be poured back into patient care.

But executives in any industry have a right to be compensated well if they perform well, managed care executives said at a recent industry gathering.

Ron Williams, president of Wellpoint's Blue Cross of California Businesses, added that salaries of managed care executives are not out of line.

``It is no more or less than in any other industry,'' he said.

Finberg argued that it's all right for Bill Gates of Microsoft to take home a huge salary, but doing the same thing in the health care industry is different.

Health care ``is so fundamentally necessary for everyone,'' Finberg said.

Before managed care became a national fixture, health care providers often err on the side of caution in treating patients, Costello said.

To cut costs, nurses today ``send patients home with complex instructions,'' she said. ``You hope that nothing bad happens.''

But throwing money at health care won't necessarily help either, said Dr. Arthur Southam, president and chief executive of Health Net.

``I think that paying a lot for something does not guarantee quality,'' he said.

The challenge is to provide the right balance between cost and care.

``We all want affordable premiums and we all want broad choices,'' Southam said.

CAPTION(S):

2 Charts

Chart: (1--Color) RISING COSTS

(2) GETTING OUT

Los Angeles HMO's total disenrollment rates, 1995

Gregg Miller/ Daily News