"Thank God for my HMO."

"HMOs will let you die."

In recent weeks, nearly 500 readers have written us letters at both these extremes.

And many places in between.

These came in response to our request for reports on your HMOs, the growing health plans that promise almost all your medical care for a set monthly sum.

Both quotations above are verbatim. We received many like them about almost every HMO (health maintenance organization) and IPA (independent practice association)-type HMO in the Washington area.

Of 460 responses that could be classified, 56 percent were entirely or mainly positive; 36 percent, entirely or mainly negative; 8 percent, part one way, part the other.

This is not a scientific or statistically reliable result. Patients with complaints are probably over-represented.

Just the same, there were a lot of complaints -- more, I believe, than one would have heard about HMOs just a few years ago. And enough to tell us that bad experiences are not rare and seem to be growing.

Yet many readers said their plan delivered all or almost all it promised: freedom in the main from paper work, bills and the fear of back-breaking medical expenses; a choice of doctors; 24-hour urgent or emergency care. :: :: ::

As Ann Parker of Chevy Chase wrote: "My husband has said many times that he has one great regret about Kaiser: that we didn't join years earlier."

But many reported receiving far less, and a third of the mainly positive responses included some sharp complaints.

No different from traditional insurance? Very probably.

The fact that every plan drew both raves and howls shows that, in HMO medicine as in private medicine, there are wide differences in the quality of doctors and of their staffs, and that often there are good and bad results at the hands of the same doctor. There are also patients and patients. Some patients are far more skilled than others at finding and demanding good care. Obviously, more patients need to become skilled.

The overwhelming number of complaints concerned:

Doctors. They are often in a hurry, careless or uncaring; in many plans, they are here today, gone tomorrow, making it hard to find a permanent "primary care doctor," the doctor all these plans urge members to choose.

Appointments. It is often difficult to get non-urgent (and sometimes urgent) appointments, with many waits of weeks or months.

Phone calls. Readers had trouble getting Kaiser and, to a lesser but still large extent, Group Health Association on the phone. Then came many long waits at the clinic or doctor's office.

Seeing specialists. Difficulty often in getting the plan or the primary doctors -- every plan's so-called gatekeepers -- to refer a patient to a specialist or some special care, especially mental or emotional care or long-term physical therapy or rehabilitation.

A lesser but still striking number of complaints involved:

Difficulty in getting the plan to pay -- or pay with any reasonable speed -- for urgent or emergency care outside the plan's usual facilities.

"Surly" receptionists or other non-medical staff. ("Surly" was a recurring word.)

Seeing an auxiliary -- either a nurse practitioner or a physician's assistant -- instead of an MD or before being allowed to see an MD.

In every plan, however, larger numbers of readers praised their doctors. Larger numbers said they got satisfactory specialist care (except for mental care). Larger numbers praised the physicians' assistants, nurse practitioners, nurse-midwives and nurses generally, including the "advice nurses" some plans use to screen phone calls and guide patients.

In all the major plans, many readers, like M.D.-IPA member Terri McGee, said: "We have saved a lot of money on doctor bills."

Here are some of the things we heard about three of the plans whose readers replied in largest numbers, three HMOs with their own staffs in their own centers. Group Health Association

GHA had 57 wholly positive reports, 22 mainly positive, 5 mixed, 8 mainly negative, 27 very negative.

"I'm a 48-year member," said Ted Siley of the District. "I'm 83, my wife soon will be. We owe our long life to GHA's quality of care."

The Sileys were among many loyal longtime participants in member-owned GHA -- this year a 50-year-old pioneer in the prepaid health movement -- who wrote in like vein.

And Sandra Derge of Gaithersburg, a member since 1984, wrote: "I think the advantages of an HMO are great, and I cannot imagine any other kind of care for our family. There is always care available . . . The economic advantages are great, especially for a family with children."

From others: "My doctor gives me plenty of time and answers all the questions I want" . . . "I have had the same doctor for 17 years." And: "Use of PAs {physicians' assistants} for non-critical treatment speeds time. PAs are well-trained, courteous, conscientious and alert to their limitations."

But also:

"There is a seemingly high rate of medical turnover. I've had three doctors in seven years" . . . "I know of one doctor who left GHA because of his pressing schedule. He did not feel he could give the type of care he felt his patients deserved."

And: "Doctors are booked for months in advance" . . . "It took me six weeks to get a routine appointment" . . . "They estimated an opening for a physical examination in three months" . . . "Every time I've had to call GHA, I've been put on hold so long I think my hair grew an inch" . . . "The telephone service has improved in the last year but is still not adequate" . . . "I have found a great many of the clerical personnel either incompetent or surly."

"Things are getting tighter due to financial problems and competition," said G.N. Fridberg of Alexandria. "It takes longer to get referrals, and there are fewer" to non-GHA specialists.

GHA indeed lost money last year and is currently getting something of a shake-up -- hopefully to members' benefit -- from a new chief executive.

George Washington University

GW's plan had 22 wholly positive reports, 17 mainly positive, 4 mixed, 5 mainly negative and 19 very negative.

"The plan has been the family doctor we have never had," said Richard Snyder of Alexandria. "We deal with a single physician who knows us and our bodies. What she thinks we need, we get. The superb talent and facilities of a teaching hospital are plugged in when needed, no fuss, feathers or delay."

"Our expectations for quality health care are quite high," said Nina Gilden Seavey of Takoma Park. "I have never experienced {such} quality health care privately."

And: "Our professionals are of the highest caliber. They are careful, caring and concerned. We all get to see the doctor or nurse practitioner of our choice for all services but emergency. Specialists are readily available when needed."

And: "The nurse practitioners seemed very skilled, compassionate and caring."

But also: "I have had two primary physicians in 2 1/2 years. As an older patient, I would like to be able to feel that my doctor will be around as long as I will" . . . "I cannot reach a doctor without going through a gauntlet of nasty, uncaring and uncooperative supernumeraries" . . . "I complained of agonizing earaches, dizziness and muffled hearing for six months before I was finally referred to a specialist."

And: "They have oversubscribed to the point where it is impossible to get adequate service" . . . "The Team 4 desk to which I was assigned seems to view the arrival of a patient as an unwelcome intrusion in their constant stream of babble."


Kaiser Health Plan had 45 wholly positive reports, 26 mainly positive, 16 mixed, 20 mainly negative, 38 very negative.

"Kaiser has a dedicated staff of caring physicians who have often telephoned during the evening to follow up," said Joyce Benson, Silver Spring. "The first time this occurred, I was amazed. Several times since, other Kaiser doctors have done the same thing."

Also: "In general, I find my wait for a doctor when I have made an appointment is no longer (and most of the time shorter) than when I used to go to a private physician" . . . "The receptionist greets me with 'I hope you're feeling better,' not with 'Do you have insurance?' or 'We require payment in advance.' "

On the "advice nurses" whom Kaiser members first encounter on the phone: "This system throws some people off (my husband is one) at first. They don't feel comfortable unless they can speak to a doctor. However, once one realizes that this is the only economical way the HMO can operate, one accepts it and ultimately one feels freer to call for assistance than if one has to worry about 'disturbing' the doctor" . . . "On a number of occasions, the advice nurse has spotted {medical} significance where I had not and has suggested that I make an appointment with a doctor, thereby stopping a problem" . . . "The advice nurse is worth the cost of the premiums alone."

On the negative side: "It is very hard to get an appointment. If you are sick, Kaiser will work you in today or tomorrow. However, I called July 24 for an appointment for an OB-GYN checkup. The earliest I could get is for Oct. 28. My husband and I also requested appointments for physicals on July 24. We are on a waiting list. I called on Oct. 19 and was told it will probably be late November or early December. Four to five months seems like a pretty long waiting list!"

And several other such stories. Alan Silverstone, Kaiser regional manager, recently wrote one reader of a new scheduling system that should help.

Also: "When I called for an appointment, I have held the line for as long as 43 minutes" . . . "At times -- 10 or 1 or 3 -- I have been put on hold for as much as 50 minutes."

And: "Our major complaint concerns the exceedingly high turnover rate among doctors" . . . "I have had four primary physicians in four years and three GYN physicians, and the children have had approximately four different MDs over the past five years. The MDs have all been good, but they don't stay."

But this member, Heddy Hubbard of Rockville, added: "The wonderful GYN nurse practitioner, thank goodness, is a constant."

Next Week: Is there a way to be a successful HMO member? And a report on an IPA.