"Before Your Health Plan Expires, Operate."
"At a Time Like This, There's Only One Benefit You Want From a Health Plan."
"Health Care With More to Give!"
So go the headlines in the ads for health plans as more than a dozen Washington area health insurers and medical plans begin their annual appeals for the hearts, minds, signatures and dollars of nearly a half-million federal workers, retirees and family members.
These are their targets in the annual "open season" -- starting Nov. 9, ending Dec. 11 -- during which people insured via the federal government decide to stay put or switch plans. Many are switching these days, as are thousands of privately employed, who also get an annual choice. For feds and non-feds alike, the choice can be bewildering.
As late as the early '70s, it was not that way. Mostof the employed were covered by Blue Cross-Blue Shield, Aetna, Mutual of Omaha or maybe one of the few group health plans then in existence, like Washington's Group Health Association. The plans took care of most medical needs, and most members found few reasons to complain.
No more. There are many plans, many options and many complaints. There are higher rates -- a shocking 31 percent higher on the average this year for federal employes -- and equally shocking increases for many non-feds. In the federal system, the government pays from a third to two thirds of the premium, depending on the plan and the kind of benefits chosen. But the employe's share still increases. And the bulk of the increases now for federal employes, at least, are for traditional health insurance, with HMOs largely holding the line.
There are also vast differences in benefits among plans. Many severely limit choices of doctors and hospitals. Many private employers are requiring large cash outlays before they, or their health insurer, will start picking up any part of the bills.
The HMOs -- "health maintenance organizations," the slick new name for group health plans -- and their offshoots, the IPAs and PPOs, now cover about a sixth of the American population and are growing fast.
IPAs are "individual practice associations" or "HMOs without walls," HMOs that use private doctors in their own offices instead of staff doctors in the plan's own clinics. PPOs ("preferred provider organizations") are IPA offshoots in which you don't absolutely have to go to one of the plan's "preferred" doctors or hospitals, but you pay substantially more if you go elsewhere. The rules and benefits of all these alphabet soups can differ drastically.
HMOs and their ilk gained substantially in last year's federal open season, increasing their share of the federal work force from 16.1 to 17.9 percent -- a jump of 86,444 enrollees. They could gain still more this year, with many either holding the line or actually trimming back a bit on their rates. In contrast, traditional health insurers have been forced to raise premiums because of increased use, rising health costs and past restraint in the face of HMO competition.
Will this year's HMO restraint prove equally temporary? Hard to say. HMOs try to hold down costs by holding down hospitalization and specialist care. But some have been bleeding red ink, and they, too, may have to raise premiums, add co-payments or discourage use. Signs of Discontent
At least one thing is becoming clear: Many members of HMOs, IPAs and PPOs are finding that all is not as rosy as the pictures of happy members in the plans' ads and brochures.
The Health section has received nearly 500 letters in response to a request for comments on health plans. Compliments outnumber complaints by about six to four so far, but only a few years ago one heard far fewer complaints from HMO members.
The gripes commonly include statements like:
"I don't like their doctors."
"The doctor always rushes me."
"I can never get them on the telephone. Once it took me 40 minutes, first the busy signal, then the phone ringing and ringing, then an answering machine and another long wait."
"They wouldn't let me go to a specialist when I needed one."
"I'd like to go to a gynecologist, but they'll just let me see a family doctor."
"The receptionists treated the patients like cattle."
There are also many readers who have their complaints but also some equally strong compliments for the same health plans.
This is the new reality in health care. These readers have come to realize that just as there is no perfect doctor, there is no perfect health plan.
"You can't join a health plan and not continue to be a consumer," says Andrea Stillman, a top official of M.D.-IPA, largest of the Washington area individual practice plans.
Growth of HMOs
The four area HMOs "with walls," that is, their own clinics -- Group Health, Kaiser, the George Washington University Health Plan and the Columbia Health Plan -- and nine IPAs and PPOs are among some 700 HMOs and HMO hybrids that now serve nearly 30 million Americans. In a few cities, like Minneapolis and St. Paul -- in a part of the country where group medical practice was long established -- they now claim more than half the population.
In the Washington area, where the individual doctor's office has long been the norm, they already cover more than 16 percent of the population.
Everyplace, they are growing. And growing nationally at an annual rate of 25 percent. In a place like the Twin Cities, says Max Fine, health plan consultant, employers, doctors and hospital officials "expect a total fade-out of indemnity insurance" -- like traditional Blue Cross -- within a few years.
In short, many observers are saying, some private, fee-for-each-service medical practice will continue for the more affluent, but, if present trends continue, most doctors will either work for a health plan or -- while remaining in their own private offices -- care for one or several health plans' patients for some pre-set rates.
In the Washington area, the newcomer but national giant Kaiser has more than 166,000 members, topping Group Health's 141,000, and it shows no signs of slowing down, despite its share of members' complaints.
Group Health is in what its new director, Robert Pfotenhauer, calls "a tumultuous period." It had an unsettling doctors' strike last year. It is in the process of selling its large downtown headquarters. But it intends to replace it with new clinics, more convenient to members, and it retains large numbers of loyal members who swear by the plan.
Leading the independent practice plans, M.D.-IPA has 110,000 members. Capital Care, an IPA started by Blue Cross-Blue Shield only last year, already has more than 31,000. And some large Baltimore plans like CareFirst, with some 93,000 members, have started expanding into the Washington market.
Among the traditional health insurers, Blue Cross-Blue Shield still has more than 1 million area members, dwarfing any HMO membership. It is from this pool that HMOs are getting more members.
This is happening despite the fact that -- in the opinion of Dr. Paul Ellwood, the health planner who coined the term "health maintenance organization" and helped launch the HMO movement -- HMOs have "stumbled" by failing to provide uniformly high quality care.
Most past studies have nonetheless found that the care given by HMOs is either equal to or better than the general quality of care in their communities. Private medicine often stumbles too.
Pressure to Save
But now HMO doctors, in clinics or their own offices, and private practice doctors alike are under increasing pressure to cut costs by limiting care to the essential. The definition of the "non-essential" often seems hard on patients: the elderly person who is sent home from the hospital while still weak, the patient who is told he must be treated by his "plan doctor," not the specialist he had been seeing, the parents who are told the plan won't pay for their child's care if they move the child to Children's Hospital without the plan's O.K.
HMOs -- both clinic-style and doctor's office-style -- typically appoint a "gatekeeper" physician for each patient. Usually, this is either a family practitioner or an internist; for children up to 18, a pediatrician; or for women in some plans, but by no means all, a gynecologist. This means your doctor must grant permission for you to see most or sometimes any specialists.
Medical insurers as well as many of the larger employers who "self-insure" for employe health care increasingly rely on another form of what they're calling "managed care." This means, for one thing, that a doctor must get a telephone approval from a central office for any but an emergency hospitalization.
HMOs stress "medical productivity," meaning setting quotas for their physicians, quotas that may give a doctor little leeway in spending more than 10 or 15 minutes per patient.
In many of these plans, doctors may be financially rewarded or penalized according to how little, or how much, the plan has to spend on tests, hospital care and specialist care for their patients. This means a doctor may be tempted to do too little if doing more hits his or her pocket.
Of course, some doctors have always seen the dollar sign as well as the patient through their scopes. And HMOs, at their best, can give a patient with a complicated illness -- an illness requiring many X-rays and tests and the care of more than one doctor -- conscientious, coordinated, often one-stop care by doctors who regularly consult with each other, rather than uncoordinated care by doctors who may communicate poorly if at all.
One of the nearly 500 readers who told us about their experiences with their health plans agonized mainly about her insurance plan's increasing costs.
"So many plans are raising rates and reducing benefits," she said. "It's getting to be just too much. If someone doesn't do something about it, the poor employe is going to go down the drain.
"What can we do?"
Individuals can do only so much. The most intelligent thing they can do today is get all the information they can about as many health plans as they can, and pick the one that will not be perfect but, hopefully, will be the best.