The Way I See It

Let's demand full disclosure by HMOs

Patients who are wooed by slick sales pitches need more facts, less hype. This doctor should know­he's been on the receiving end.

By Joel A. Moskowitz, MD

When poor health forced me to retire from medicine, my wife and I relocated to an area where we knew none of the doctors. We soon discovered that health plans here invite seniors to breakfast seminars to help them choose their Medicare coverage. We've now attended six coffee-klatch attempts to "cover our lives." These events, which have the feel of fraternity and sorority rush, are appallingly blatant sales presentations. In no way do they offer an unbiased analysis of Medicare options.

Arlene and I had expected to hear the answers to such questions as "Who will my physician be?" "How good a doctor is he/she?" "How available are appointments?" "What do I need to know about the hospital the physician uses?" Instead, we heard triumphant comparisons with rivals, such as "Ours is a nonprofit organization. Therefore, we have more money to spend on patients." Or "We offer $100 toward eyeglass frames; the Jolly Wish You Well Caring Group allows just $60." Without telling us anything about the quality of optical products available under those plans, they might as well have been comparing apples and pineapples.

There is some talk about drug formularies at these gatherings, but never a discussion about how the formulary committee determines which drugs are included. Nor do the promoters tell us whether the plan will expect a senior with diminished dexterity or visual impairment to break an 80-mg pill in half to obtain the prescribed 40-mg dose—so that the HMO can save a few bucks. Instead, we hear anecdotal reports on the usefulness and ready availability of acupuncture.

One HMO promoter cheerfully announced at the beginning of the session that her goal was to sign up each attendee by the conclusion of her talk, a pitch reminiscent of time-share presentations. The expectation was that we timid souls would sign up without further contemplation, reflection, or comparison. One presentation touted an affiliation with a hospital that I knew had lost its accreditation and was in jeopardy of losing its Medicare funds.

At another sales session, we were assured that a certain dental procedure would cost 25 percent less when performed by a participating dentist. When I went home and did some comparison shopping among local dental offices, I quickly discovered a range of several hundred percent for the same procedure. Do you think it's a good buy to purchase a car marked down 25 percent when the sticker price is a floating variable? Too often these presentations reminded me of car salesmen who trumpet the size of the trunk, the sound of the radio speakers, or the tread on the tires and say little or nothing about the safety, endurance, and comfort of the vehicle itself.

It is equally appalling that seniors attending these seminars don't ask more-penetrating questions about the quality of care they'll receive. I've sat in audiences where the most urgent concern seemed to be the availability of toenail trimming.

How can we advise our patients to make wise choices? And how can we physicians do the same, once we're on the other side of the stethoscope? Here are some suggestions that might make it easier:

• HMOs should provide a written summary of their organizations in advance of a sales presentation. This document should include the HMO's record in complying with government regulations and quality assurance efforts. The customer is also entitled to know a thing or two about the health plan's financial condition and any past fiscal or legal disputes with the medical staff. If there have been such troubles, how were they resolved? Does the plan currently have similar difficulties in any other state?

What we really need is a national data bank on HMOs, like the one for doctors. It's only fair.

• Since some HMOs make a sales point of their lower expenses, let's have full disclosure of what they pay their administrators, especially their CEOs. If the companies are publicly traded, how have they performed for their investors? Do they "cooperate" with an outside claims review organization? If so, I'd like to know the exact nature of that arrangement and any fiscal advantage gained.

• In this age of electronic information, why not offer prospective subscribers a brief introduction to their choice of physicians? All of the plan's doctors might be included on CD-ROM or a format that's accessible online. For the computer-phobic, the information would be available in print through the HMO's offices.

A video of the doctor, the office, and key staff might be a friendly way to say hello and give the physician a chance to explain his or her special aptitudes and interests. This could include a CV, some personal notes about the doctor, and information on office locations, complete with driving directions.

• Independent data on the ease of scheduling a visit with a doctor should be provided up front. Data should also be available on how easy it is to obtain referrals to specialists or arrange mammograms and other diagnostic tests. Testimonials about specific physicians from appreciative patients would be most worthwhile.

• We need to know what will happen when things go awry. What must a subscriber do if he's dissatisfied with his care? Not once in these "informational" meetings did the dispute resolution process come up. It should have been on the agenda. When a friend of ours suffered complications after a dental procedure, he was sent to a consulting dentist employed by the same plan. This "expert" was not given the past X-rays or history. The plan said it wasn't necessary.

The process by which HMOs and other Medicare providers go prospecting for new members is sick. As a recipient of these overtures, and as a physician, I'd say we need to find a cure.

The author, an internist, is retired and lives in La Jolla, CA.

Editor's Note:There is, in fact, a Medicare Managed Care National Marketing Guide that governs the promotional activities of plans. Beginning this year, plans must disclose whether a formulary or preferred list is used, explain what they are, and indicate how changes to the formulary or list will be made during the year. The guide also describes what's allowed in the way of testimonials and promotional giveaways, and requires plans to provide patients with information in writing—prior to enrollment—on how to file claims appeals or disenroll. For a look at the Medicare Managed Care National Marketing Guide, go to www.hcfa.gov/medicare/OPL120.htm . In addition, the HCFA Medicare Web site has a section called Search and Compare Tools that allows you to search for information on specific health plans in a given area.

Joel Moskowitz. Let's demand full disclosure by HMOs. Medical Economics 2001;10:59.