Health-Care Plans Get Sickly Score from Workers

A survey of 42,000 Consumer Reports readers about their health maintenance organizations and preferred provider organizations finds a “lukewarm” average reader-satisfaction score of 73 (on a scale of 0 to 100) – lower than the average score for homeowners insurance (84) or car insurance (88).

Plan sponsors should note, however, that all in all, the greatest determinant of members’ overall satisfaction with their plans was choice of doctors available, according to “HMO or PPO,” a report appearing in the October issue of Consumer Reports.

Satisfaction Gaps

Of course, as with any such evaluation, Consumer Reports found a wide variation in satisfaction between those enrolled in plans ranked in the top third, compared with those covered by providers in the bottom third of the plans evaluated. For example, in the top-rated HMOs, just 2-8% of respondents said they had trouble getting care that they and their physicians felt they needed, but in the low-rated group, the volume of complaints rose as high as 18%.

The report acknowledged higher health-care costs – and noted, “managed-care companies have not been shy about keeping their profit margins fat.” The report notes that 11 major managed-care companies posted a 36.6% increase in net income, to $1.95 billion, in the first quarter of 2003 alone, a focus on the bottom line that is translating into higher costs for employers – and higher premiums, co-pays, and deductibles for their workers.

Consumer Reports says that, even setting aside rising costs, some common dissatisfactions among enrollees emerged, such as:

• “Serious” Concerns 12% of the 12,662 survey respondents and their families who suffered serious medical problems in the last year said they had difficulty getting care that they and their doctors believed necessary (only 5% of other respondents had that problem).
• The Doctor is “Out” 22% of HMO members had difficulty seeing doctors (typically because they had to wait a long time for an appointment or couldn’t get plan approval, or because a doctor left the network). In contrast, just 15% of preferred provider organizations (PPO) members reported such a problem.
• Mental “Help” Roughly a quarter of respondents who needed mental-health care reported problems getting the treatment that they and family members needed, a complaint of both HMO and PPO members.
• Bill “Pill” Billing problems remain a major annoyance for PPO members, where, on average, 32% of PPO respondents said they had at least one billing problem, compared with 15% of HMO members.

HMO vs. PPO

The report notes that consumers who select a health maintenance organization (HMO) typically pay lower premiums and have fewer out-of-pocket expenses in exchange for choosing a more restrictive option that dictates a network of providers they must use. Alternatively, with preferred provider organizations (PPOs), there are out-of-pocket expenses that require enrollees to pay part of the bill or co-insurance.

CR noted that the overall satisfaction score among readers was about the same for HMOs and PPOs, although it said that when dealing with conditions such as back pain and arthritis, PPO respondents were more satisfied with their treatment. However, Consumer Reports notes that distinctions between the two have blurred, with many HMOs loosening restrictions to lure consumers away from PPOs (which CR says now command the enrollment of 52% of workers).