PRIVATE GROUPS TO HELP EXAMINE HMO PLANS.

Byline: Jane E. Allen Associated Press 

A national group that accredits hospitals and a subsidiary of the California Medical Association will evaluate up to 32 health maintenance plans for the state of California, officials said Monday.

The state Department of Corporations granted a joint contract to assist in the gathering of information on how the HMOs are serving more than 16 million Californians.

The findings will be used to check the licensed HMOs' compliance with the state law governing managed health care, known as Knox-Keene regulations.

``In the extreme case, it can lead to revocation of licensure,'' Chief Deputy Commissioner Brian Thompson said in an interview. However, he said the department's goal was to encourage compliance.

Department staff will use the information to develop mandated surveys of each health plan. The HMOs will be given time to correct deficiencies.

In a teleconference, Dr. Dennis O'Leary, president of the Joint Commission, said this was the ``first time the state of California has turned to external private-sector organizations to evaluate the quality of its health plans.''

Asked why the state was turning to the private sector for help, Thompson told the Associated Press: ``The whole process of managed care has really grown recently. What was good and what was effective 10 years ago is not effective in 1996. We have done considerable evaluation of our responsibilities under the Knox-Keene Act - what we should do and what we haven't done.''

The use of two independent groups ``helps us to provide a better end product for California enrollees.''

The 45-year-old, nonprofit Joint Commission on Accreditation of Healthcare Organizations, based in Oakbrook Terrace, Ill., evaluates 15,000 hospitals and other health care facilities nationwide.

The California Medical Association's nonprofit Institute for Medical Quality was established in January to respond to concerns about the effects of competition and for-profit systems on medical care.

Under the contract, which became effective last week, the two organizations will evaluate 13 plans by June 30, 1997. Under an option to renew, they will review up to 19 more by June 30, 1999.

Thompson said each survey costs $23,980.

Thompson said state law requires the department to conduct medical surveys of HMOs once every three years. It currently regulates 43 full-service HMOs. Those recently evaluated by department staff won't be subject to the outside evaluations, he said.

Dr. Richard S. Frankenstein, IMQ board chairman, said the evaluations will address the public concern ``that the quality of their health care might be sacrificed to meet the relentless pressure to cut costs.''

The joint review will include interviews with health plan members and an examination of complaints filed with the state, including those registered on a toll-free complaint line.

The surveyors will look at HMO central offices as well as at least six places where patients are treated, including doctors' offices and surgery centers.

Each evaluation will be conducted by a three-person team that includes a doctor from each organization, plus a nurse or administrator. They'll look at patient access to medical care, as well as approval and denial of treatment and overall satisfaction with care.

In response to criticism that the Joint Commission is too close to the managed care industry to make objective evaluations, O'Leary said: ``We do draw upon expertise in the managed care field to develop our standards as we draw on expertise in all fields. There is no evidence whatsoever that we are dominated or controlled by, or even significantly influenced by HMOs or any other provider type.''

Frankenstein defended the decision not to make surprise visits, citing the disruption to patients.

``A surprise visit would not be warranted or add that much more,'' he said.

Jill Silverman, president and chief executive officer of IMQ, said California hospitals won't be reviewed by the joint evaluation team. They're licensed separately through the state Department of Health Services.