Patients Prefer HMOs (And Other Healthcare Surprises)

The following post originally appeared on the TIME Moneyland blog.

Are health insurance plans with big brand names better than smaller insurers that most people have never heard of? “Not usually,” says Nancy Metcalf, senior program editor, at Consumer Reports. Unless, that is, the plan’s name is “Kaiser.”

Among the surprising findings of a new Consumer Reports ranking are:

  • In general, smaller plans outranked the well-known names, and plans offered by non-profit insurers scored better than products sold by for-profit insurers;
  • When it comes to patient satisfaction, Health Maintenance Organizations (HMOs) received higher marks than Preferred Provider Organizations (PPOs) even though HMOs require that patients remain “in network;”
  • Kaiser Permanente, a non-profit that insures some 8.8 million Americans nationwide, stands “head and shoulders” above the other large insurers; and
  • The rankings show wide geographic variation—for example, it’s much easier to find a high quality plan in New England or California than in the South or some parts of the West.

Consumer Reports’ national rankings for some 830 insurance plans are available online, with detailed scores based on research done by the National Committee on Quality Assurance (NCQA), an independent non-profit organization that accredits and measures the quality of health plans. The ratings reveal how well the plans perform when it comes to preventive care and management of chronic conditions (which account for 60 percent of the score); patient satisfaction (25 percent); and whether the plan is accredited by the NCQA (15 percent). On, readers can research plans by state and compare up to five plans simultaneously.

National rankings reveal wide variations in quality—and mixed results for many of the nation’s largest insurers. The industry’s giants, Aetna, Cigna, Humana, Kaiser Permanente, and UnitedHealthcare—together with the 60 mostly state-based Blue Cross Blue Shield Plans—account for three-quarters of the 390 HMOs and PPOs that NCQA ranked. Yet only 17 of their offerings made the list’s top 50—and six of those were Kaiser Permanente plans.

In general, Consumer Reports points out, insurance plans in the South and some parts of the West don’t perform as well in national rankings as insurers in the Northeast, particularly New England: “Eighteen of the 50 top-ranked private plans are in this compact six-state region,” the magazine observes. “Both Aetna and the ‘Blues’ had New England plans ranked in the top 100, while many of the same insurers’ plans in southern and western states ranked near the bottom of the list.”

This may be because some states have fewer resources, poorer patients, less efficient hospitals, more “safety-net” hospitals that are struggling to stay afloat, fewer physicians, and a medical culture where providers are less likely to collaborate to co-ordinate care. Thus, a Kaiser plan in Georgia that ranks 52nd nationally, but first in the state, may well be delivering the best care possible under less than ideal circumstances.

There are limits to what Consumer Reports can tell us about care that an insurer provides because they are usually looking at quality data that measures what researchers call “process.” Did the hospital remember to give the patient the aspirin both when he was admitted and when he was discharged? Did someone give him the Beta-blocker? Did the diabetic patient receive an eye exam?

But in the end, what we really care about is “outcomes.” Did the diabetic lose his eyesight? Did the patient have another heart attack?

Consumer Reports’ Nancy Metcalf acknowledges that the data used looks primarily at process. “In theory, if providers do the right things” on the checklist, “this will lead to better outcomes,” she points out. But research shows that, too often, this is not the case. Indeed, while focusing on “process,” providers can lose sight of other, more important matters—such as listening to and talking to the patient. As reform evolves, I suspect future studies will likely focus on “outcomes” as well.

Maggie Mahar is the healthcare fellow at The Century Foundation and is the editor of HealthBeat, where you can read more of her analysis of the Consumer Reports findings.

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