Open-model plans please more patients

Study ranks staff-model HMOs lowest in plans

Patients are more satisfied with their primary care and more trusting of doctors who are not tied to a single health plan, according to a study of state employees in Massachusetts.

The study was conducted by a team of researchers led by Dana Gelb Safran, ScD, director of the Health Institute of the New England Medical Center in Boston and funded by the U.S. Agency for Healthcare Research and Quality.

"We found that patients rank their physicians’ performance the highest when doctors remain in their private offices and contract with as many plans as they care to, rather than when the doctor and the plan function as a single entity," she says.

The study compared five models of managed care:

1. managed indemnity insurance;

2. point-of-service plans;

3. IPA/network model HMO;

4. group-model HMO;

5. staff-model HMO.

Participants were 6,000 Massachusetts state employees enrolled in any of 12 health plans available to state workers. Overall, the indemnity insurance system performed most favorably, and staff-model HMOs performed less favorably. Group-model HMOs performed mostly at intermediate levels.

The researchers administered the Primary Care Assessment Survey, a 51-item questionnaire, which asked the patient to rank their physicians’ performance in 10 categories:

1. access to care;

2. duration of relationship;

3. visit-based continuity;

4. physician’s knowledge of the patient;

5. preventative counseling;

6. integration of care;

7. communication;

8. physical examination;

9. interpersonal treatment;

10. trust.

They followed up with interviews with senior health plan executives concerning the results of their study.

Patients in staff-model HMOs rank their physicians the lowest in nine of the 10 categories. The only category in which those plans didn’t score the lowest was in preventive health counseling. Staff-model HMOs employ salaried physicians to treat only their plan members.

Patients gave the highest rankings to their physicians when they were members of a managed indemnity insurance plan, traditional fee-for-service insurance with controls such as pre-authorization. Other forms of open-model plans such as point of service and network-model HMOs also fared well. In fact, in most cases, the rankings of open-model plans varied only negligibly.

"One reason we believe we find these things consistently is that doctors who are in an open model know and recognize that it is their responsibility, and theirs alone, to ensure that they have a patient panel who will support their livelihood," Safran says.

Involvement with all aspects of patient’s visit

Physicians who are in an open-model plan concern themselves with all aspects of the patient experience from making sure patients have access to the quality of the patient encounter, she adds. "When the doctor and the plan are a joined entity, the doctor has limited responsibilities and may come to view it as the plan’s responsibility to make sure they have a patient base."

The study results also suggested that among network model HMOs, some strategies to manage care, such as financial incentives for patient satisfaction and use of clinical practice guidelines, had a positive effect on how patients rated their physicians and the care they receive.

The researchers examined whether the duration of the relationship was affected by employer actions, such as changing plan offerings, or physician actions, such as leaving a plan. However, they found that all the plans except one, the point of service, have been offered for at least seven years; the majority of participants had been enrolled in their plan for at least three years; and the physician turnover has been negligible. This led the researcher to conclude that physician shifting, which occurred most frequently in the staff-model HMO and the group-model HMO, was because of patients’ voluntary actions.

"[This] suggests that patients in these models of care are failing to establish primary care relationships that they consider worth maintaining," the study says.

The results mirror those from a similar study that Safran led 12 years ago when researchers studied three types of plans: indemnity insurance, independent practice association network model HMO, and staff or group HMO.

"Managed care has expanded tremendously in the last 12 years, and there are new forms of the model system that didn’t exist before. Yet, everything we looked at is consistent with what we found in our Medical Outcomes study in 1986-88," Safran says. "As we found before, this study shows that there is not a single form of managed care. There are different models, and they do appear to perform differently."