The new anatomy of health care - includes related articles and glossary of medical terms - Panel Discussion

Chief Executive, The, Jan, 1996 by J.P. Donlon, Barbara Benson

Rosen: But you're not going to close down a hospital, either.

O'Kane: No, I'm simply putting information out into the marketplace that says, "This organization doesn't meet our standards." It's already having an effect in the market. Companies are looking at our information and saying, "I'm not going to offer this plan."

Donlon: Let's ask an HMO.

Lynaugh: The NCQA accreditation process or its equivalent is the price of HMOs' moving into the mainstream. As long as only 10 percent of the population used them, no one cared. Now that it's taking center court, this is going to be the price of traffic in Medicare and Medicaid. We must face that fact.

As for NCQA, it's important to distinguish between what is a realistic hope, and what is almost a pursuit of the Holy Grail. For process issues - immunization records, rates of mammograms, etc. - the NCQA is right on target. But measuring results to a given patient on a given course of treatment is confounded by so many variables.

Donlon: Can we arrive at a standard that's not perfect but good enough for purchasers to say, "That's where I want to put my benefit dollars"?

Go: Properly designed, the accreditation process can give us a binary decision on whether a health plan has or has not met certain criteria. I don't think we'll ever get to a point where we can say, "This company is No. 35 on the list."

Liguori: If it's that simple - either you're on the left side or the right side - why can't consumers just see that and decide for themselves? Why do we need to accredit?

Go: How do you think people make decisions about HMOs today? It's often based on how well HMOs market themselves.

Korman: Absolutely. These plans are not bought. They're sold.

Go: A well-designed accreditation process at least can add an objective measure.

Liguori: But you know if you've bought quality goods. If the plan you purchase doesn't meet your quality standards, you don't stay with the system.

O'Kane: It's not like buying shoes. If you buy a bad health insurance plan, you're stuck with it.

Liguori: You're not stuck with it for life.

O'Kane: It might be for life if you get sick enough.

Rosen:: Are you suggesting that plans hire bad doctors or bad hospitals?

O'Kane: Yes.

Rosen: In other words, the way we monitor our professionals doesn't work?

O'Kane: Right.

Rosen: Are the poor ratings due to administrative error or larger issues such as malpractice?

O'Kane: There is some malpractice and abuse. I'm not suggesting it's that widespread.

Rosen: You sound exactly like the government. Now we have one more bureaucracy that has to govern itself.

Tabak: I'm troubled by NCQA's benchmarking process, because it might reflect only how well a managed-care company markets itself, not how well it provides medical care.

NEW OPTIONS FOR SAVINGS

Donlon: One of the flaws in our healthcare system is that the users are not the ones who pay for it. Jack's firm is a standard-bearer for medical savings accounts, which try to address that problem.

John M. Whelan (Golden Rule Insurance): Several years ago, the typical deductible in an indemnity insurance plan was $250, and the plan had a co-insurance band, which means that the insurer paid 80 percent of the cost after the deductible, and the individual paid 20 percent. Now the typical deductible is about $500.