Department of Health and Human  Services 
OFFICE  OF 
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OEI-06?91-00731  Specillc  details of problem  extent and intensiveness  among HIWls  follow. 
Fedend  Enrollment  Procedures 
Asking beneficiaries  about their health problems during application  was a fairly  widespread 
and intensive problem. 
Being required  to take a physical  examination  before joining  the HMO  was relatively 
infrequent. 
Understanding  of HMOS 
Lack of awareness  of appeal  rights was the most widespread and intensive  problem,  while 
beneficiary  misunderstanding  of other requirements  was cmnmon  but less severe. 
Medical Appointments 
In about two-thirds  of HMOS, beneficiaries  experienced  mcxkwite to minor  dil%culties with 
medical  appointments. 
Service Access 
Perceived  service  access problems  were fairly widespread  and moderately  intensive  for 
disenrollees,  but relatively  infrequent  for enrollees. 
Personal  Treatment 
The most widespread  and intensive  personal  treatment  problems  among  HMOS were the 
failure  of primary  HMO  doctors  to take beneficiary  complaints  seriously  and perceptions  that 
hoMing down the cost of medical  care was more important  than giving the best medical  care 
to their primary  doctors  and/or  their HMO. 
Beneficiaries  Responses  Varied  According  to HMO  Model  Type  and  Profit  Status. 
Beneficiaries  in group  and staff model HMOS were more likely to report  being  required  to 
have a physical  examination  at application,  not being aware of appeal  rights,  and having 
problems  with appointments. 
Beneficiaries  in non-profit  HMOS were more likely to report  being required  to have a 
physical  examination  at application,  not beiig  aware of neediig  a referral  to see a specialist, 
and having problems  with appointments. 
ii  CONCLUSIONS 
Beneficiary-level  data linked with respective HMOS provides additional  insights for 
examining  HMO enrollment  and service acczss problems.  lt  may prove  especially  useful in 
focusing  monitoring  efforts.  Determining  a problems  distribution  cmdd  either  signal the 
need for progmm-wide  monitoring  or for targeting  speciilc HMOs.  A problems  degree  of 
intensity can also be determined.  However,  to best utdiie  this knowledge,  HCFA  should 
establish  acceptable  tolerance  ranges for the,se indkators,  since a prohiem  may be pervasive 
but not critical. 
Additionally,  certain  structural  factors,  e.g.,  non-profit  status and group  and staff models, 
may affect beneficiaries  perceptions  of HMO semice.  Such knowkdge  can help target 
monitoring  efforts  for HMOS with these characteris&s. 
For an HMO-level  analysis,  our experience  suggests HCI?A may want to stratify  by 
Medicare  enrollment  size, as well as for selected structural  characteristics,  e.g.  model type 
and profit  status,  when surveying HMO beneficiaries. 
...
111  TABLE  OF  CONTENTS 
PAGE 
EXECUTIVE  SUMMARY  . . . . . . . . . . . . . . . . ..-.  -..  . . . . . . . . . . . . .  i

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . 1

FINDINGS  . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .  . . . . . . . . . . . . . 4

  Overview  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Federal Emollient  Procedures.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

 
  Understanding  ofHMOs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Medical Appointments  . . . . . . . . . . . . . . . . . . . . . . .. . . .  ...........5

 
  Service Access  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........6

Personal Treatment  . . . . . . . . . . . . . . . . . . ..- -.  .- . . . . . . . . . . . . ..7

 
Model Type andProfitStatus.  . . . . . . . . . . . . . . . .. . . . . .  . . . . . . ...7

 
CONCLUSIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

ENDNOTES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .  10

APPENDICES

A:
 Distribution  and Problem Intensity  . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l 
B:
 StatisticaUy Signiilcant Structural Factors  . . . . . . . . . . . . . . . . . . . . . . . ..B-1 
c:
 Profile ofHMOs  --Structural  Factors  . . . . . . . . . . . . . . . . . . . . . . . . . ..C-1 
D:
 Statistically  SigtilcantDiffemnces  forKeyQuest.ions  . . . . .  . . . . . . . . . . .  D-1  INTRODUCTION

PURPOSE 
To provide  HMO-level  data to identify distribution  and intensity of enrollment  and service 
access problems. 
BACKGROUND 
In a previous  OIG report,  Beneficiary  Persptives  of Medicare  Risk HMOS (OEI-06-91-
00730),  we reported  results from a survey of beneficiaries  enrolled  in Medicare  risk HMOS. 
Using HCFA  databases,  we selected a stmdfkd,  random sample of 4,132  enrollees  and 
disenrollees  from 45 Medicare  risk HMOS.  Since our primary focus was Medicare 
beneficiaries  perceptions,  we collected  information  directly  from them. 1 We surveyed both 
enrollees  and disenrollees  to compare  their responses,  and thus, to gain greater  insight into 
HMO issues.  We did not attempt  to validate their responses thrcmgh ~ecord review  or HMO 
contact. 
Generally,  beneficiary  responses  indicated Medicare  risk HMOS provide  adequate  service 
access for most beneficiaries  who have joined.  The majority of enrollees  and disenrollees 
reported  medical  care  that maintained  or improved their health, timely  appointments  for 
primary  and specialty  care,  good access to Medi~  covered  services  and to hospital, 
specialty  and emergency  care,  and sympathetic personal  tmntment by their HMOS and HMO 
doctors.  In some instances,  however,  enrollees  and disenrollees  differed  markedly  in 
reporting  their HMO  experiences.  When this happened,  we described  the difference  as a 
point of comparison. 
However,  our  survey  results  also indicated  some serious problems  with enrollment 
procedures  and service  access that,  we believed,  required HCFAS attention.  Three  items 
need immediate  exploration:  1) better  informing  of beneficiaries  about their appeal  rights as 
required  by Federal  standards;  2) carefully  examining  service access problems  reported  by 
disabled/ESRD  beneficiaries,  an especially  vulnerable  group; and 3) monitoring  HMOS for 
inappropriate  screening  of beneficiaries  health status at application.  Other service access 
issues meriting  examination  by HCFA  in the near Iiture  concerned  beneficiaries  perceptions 
of problems  with making  routine  appointments,  declining  health caused by HMO care,  and 
HMOS refusal  to provide  certain  services. 
Our intent  has been not to prescribe  spedic  corrective  actions,  but to identify,  based on 
information  from beneficiaries,  areas apparently  needing improvement  and to suggest 
techniques  HCFA  can use to further  monitor  these areas.  In addition,  we wanted to explore 
if linking beneficiary  responses  to their respmtive  HMOS could show whether  or not problem 
areas occurred  program-wide  or were only isolated within speciilc HMOS.  Also,  at the 
HMO-level,  we wanted  to determine  problem  intensity or degree  of severity  among HMOS. 
1
 Construction  of an HMO-level  alu+a.base 
To construct-an  HMO-level  database,  we aggregated  our original  individual-level  dataz to 
link beneficiaries  with their  respective HMOS.  FCNcontinuity and consistency  with our first 
report,  we separated  the HMO-level  data by arcd.lees  and disenrdees.  Also,  since our 
individual-level  data was a disproportionate  sample of enroilees  and disenrollees,  we had to 
account for varying  response  rates per HMO.  Enrollees  we~e distributed  among all 45 
HMOS, but disenrollee  representation  was Iiited.  Four HMOS had less than 20 of 50 
disenrollees  return  their  survey.  Thus,  for disenrollees  on.iy,.these 4 HMOS were dropped 
from further  analysis.  Also,  5 other HMOS had less than 14 diierdlees  in their total 
population  when we sampled.  Nevertheless,  we still included these 5 .HMOS in our analysis 
if 2 conditions  were met.  First,  at least 75% of their disendkzs  mtumed  a usable survey. 
Second,  for those remaining,  at least 75% of their disenmllees  answered  on a question-by-
question basis.  It was not our intent to generalize  our findings to all Medicare  risk HMOS 
but,  rather,  to use our data to detect trends within our own sample, especially  to illustrate  the 
utility of HMO-level  analyses. 
Problem  Distribution  and Intensiiy 
First,  for each question,  we determined  if an HMO had at ieast one beneficiary  report  an 
incidence.  This process-counted  the  number of involved HMOS and established  how widely 
distributed  the -problem was among them.  Second, we calculated  the proportion  of negative 
responses per  question  for all beneficiaries  within eaeh HMO.  Third,  we constructed 
f~uency  ranges  which provided  a common descriptive  fimnework  to compare  problem 
intensity  or degree  of severity  among HMOS.  The ranges included no beneficiaries  (O%) in 
each HMO  reporting  the problem,  1% to 10% of beneficiaries,  11% to 25% of beneficiaries, 
26% to 50% of beneficiaries,  or more than 50% of beneficiaries.  Fourth,  we counted,  per 
question,  how many HMOS fell into each of these mnges.  Tables showing  specillc 
distribution  and degree  of intensity  are categorized  in Appendix  A as health  screening, 
understanding  of HMOS, medical  appointment  problems,  perceived  service access problems, 
and perceived  personal  treatment  problems. 
Dejbulion  of Structural  Factors 
We selected  5 structural  factors  to examine  how beneficiaries  perceptions  may be affected: 
HMO  model type3, profit  status,  contracted  services4, location in multiple  States,  and 
Medicare  enrollment  size.  We used several sources to identify these characteristics.  HMO 
model type was obtained  from the HCFA  monthly report of Me&cam  prepaid  health plans 
for February  1993.  Profit  status,  contract  services,  and location in 1 or multiple  States were 
found in the  1992-1993  Managed  Care Report  section of Business Insurance  (December 
18, 1992).  We alSOUSedthe HCFAS Group Health Plan (GHP) database  as of February  28, 
1993 to obtain  information  on Medi~  enrollment  sizes (See Appendix  C for a profde  of 
HMOS).  To determine  the signifkance  of these structural  factors,  we conducted  various 
statistical  analyses.s 
2  This inspection  was conducted  in accordance  with the Quali~  Smn@ds  for  Inspections 
issued by the Presidents  Council on Integrity and Efficiency. 
 
3  FINDINGS

OVERVIEW 
Our analysis of beneficiary  problems  with Federal  enrollment  puc.edures,  understanding  of 
HMOs,  medical appointments,  service access,  and personal treatment  suggested  two general 
findings: 
Most  Reported  Problems  are Widespread  Among  the  Sampled  N&dkare  Risk  HMOS, 
but  at Varying  Degr- of Intensity. 
Disenrollees  Generally  Experienced  these  Problems  at a Higher  Degree  of Intensity  than 
Enrollees. 
Speciilc details  of problem  extent and intensiveness among ~C?s  follow. 
Federal  Enrollment  Procedures 
Asking  beneficiaries  about their heailh problems  diming application  was a fairly  widespread 
and intensive problem.  (See Appendix  A,  T&k  1.) 
Health  Screening  (37 % of enrollees  and 39% of disenrollees)~ 
In over two-thirds  of the HMOS, between 26% to more than 50%  of both enrollees  and 
	
disenrollees  said they were asked about health problems during  application. 
Being requind  to take a physical  examin&on before joining  the HMO  was relatively 
injk?quent. 
Reuuired  a L)hvsica.1exam  (4% of enrollees  and 2% of disenrollees) 
.	 Enrollees  in a little over one-half  of the HMOS and disenrollees  in slightly more than 
one-third  of the HMOS said a physical  was required  to join.  Usually  such reports  were 
of minor intensity  (<10%). 
 The percentage  of enrollees  and disenrollees  who  responded  negatively  to each issue. 
4
 Understanding  of HMOS 
Lack of awareness  of appeal  rights was the most widespread and intensive problem,  while 
beneficiary  misundemtanding  of other membemhip  requirements was present  but less 
severe.  (Sei?Appendix  A,  Tdle  2.) 
AIIDtXil rkzhts  (26% of enrollees  and 32% of disemwlkzs) 
.	 From  11% to over 50% of beneficiaries  in more than 90% of the HMOS reported  they 
were not aware  they had a right to appeal their HMOS refhsd  to provide  or pay for 
services. 
S-pecialist referm.1  (11% of enrollees  and 15% of disenrollees) 
.	 Not being aware  of needing a primary  doctor referral  to ,see a specialist  was more 
intensive  for disenroilees.  From  11% to 50% in over two-thirds  of the HMOS reported 
a lack of awareness  of this process. 
Abil.itv to back-out  (11% enrollees  and 18% of disenrollees) 
.  More  disenrollees  were not aware of their ability to back-out of. enrollment  after 
application.  Eleven percent  to 50% of disenrollees  in nearly two-thirds  of the HMOS 
reported  this lack of knowledge. 
Lock-in  (4% of enrollees  and 7% of disenrollees) 
.	 Beneficiaries  in over two-thirds  of HMOS reported they were not aware of being 
~stricted  to HMO  doctors  and hospitals.  However,  this situation represents  <10%  of 
beneficiaries  in each HMO. 
Medical  Appointments 
In about two-thirds  of HMOS, beneficiaries  experienced  moderale to minor &ficuilies  with 
medical  appointments.  (See Appendix  A,  Table 3.) 
A-ppointment when verv  sick  (6% of enrollees-and 12% of disenrollees) 
.	 Not being able to get an appointment  within 2 days when very sick was found in two-
thirds of the HMOS.  However,  it was worse for disenrollees,  of which  11% to 50% in 
about half of the HMOS reported  the problem. 
5 Atmointments  with Drirnarv HMO doctors  and specialists.  (Dc@or appointment,  15% of 
enrollees  and  18 percent  of disenrollee~  specialist appointment,  19% of enrollees  and 24% 
of dkenrollees) 
.	 In at leZst 58% of the HMOS, from  11% to over 50% of benefkia.ries  said they waited 
more than  12 days for a scheduled appointment with their primary  HMO doctor.  For 
scheduled appointments  with a specialist,  disemdkes  indicated longer  waits.  In half of 
the HMOS, from 26% to over half of the disc-a.dkes  repmted  this  situation. 
Wait in doctors  office  (5% of enrollees and  13% of disenrolks) 
.	 More  disenrollees  waited longer than an hour in the office to see their primary  HMO 
doctor.  In about half of the HMOS, fmrn 11% to 50% of disenrollees  reported  waits 
this long. 
Busv tehmhone  lines  (10% of enrollees  and 13% & di,senrollees) 
.	 In more than one-third  of the HMOS, from 11% to 50% of beneficiaries  said 
consistently  busy telephone  lines caused them sometimes to give up scheduling  an 
appointment. 
Service  Access 
Perceived  sernce access problems  were finrfywidksprwd  and modinately  intensive for 
disenrollees,  but relatively  injiequent  for  enrollees.  (See Appen@  A,  Table 4.) 
Sou~ht out-of-clan  medical  care  (7% of enrollees  and 15% of disenrollees) 
. In 68% of the HMOS, from  11% to 50% of disenrollees  said they  sought out-of-plan 
medical  care,  excluding  dental,  routine eye, and emergentiurgent  care. 
Not referred  to a smcialist  (4% of enrollees  and 14% of disenrollees) 
. In 52% of the HMOS, from  11% to 50% of disenrollees  said their doctor  sometimes 
failed to refer them  to a specialist  when needed. 
Failed to sret needed Me&a.re  services  (4% of enrollees  and 12% of disenrollees) 
.	 Ahnost  half of the HMOS had from  11% to 50% of their disenrollees  saying their 
primary  HMO  doctors  failed to provide  needed Me&care  services. 
Health  Status Worsened  (2% of enrollees  and 11% of disenrollees) 
.	 More  disenrollees  reported  a decline  in health  status.  In 40% of the HMOS, from  11% 
to 50% of disenrollees  reported  the medical care they received  from their HMO caused 
their health  to worsen. 
6 Personal  Treatment 
lle  most widespread  and intensive personal  treatment prwblems among  HMOS were the 
ftilure  of primary  HMO doctom to take benejic%wy complaints  seriously  and perceptions 
that prima~doctors  and HMOS sometimes place  too much emphu.sis on hokling down the 
cost of care.  (See Appendix  A,  Tdle  5.) 
Comr)laints not taken  seriously  (12% of enrollees  and 25% of di,serwollees) 
In over 80% of the HMOS, from  11% to mom than  50% of disemrollees,  as compared 


to 11% to 25% of enrollees  in over half of the 14MOS, reported  their complaints  were 
not taken  seriously  by their primary  HMO doctor. 
Doctor  holdinp down the cost of medical care  (7%of enroilees  and 25%  of disenrollees) 
.	 In over  80% of the HMOS, from  11% to more than 50% of disrmrollees,  as compared 
to 11% to 25%  of enrollees  in more than a third of the HMOS, thought  holding down 
the cost of care  was most important  to their primary  HMO doctor. 
HMOS holdimz down the cost of medical care  (15% of enrollees  and 35% of disenrollees) 
.	 In over 90%  of the HMOS, from  11% to more than 50  of disenrollees,  as well as 
YO 
11% to 50% of enrollees  in over two-thirds  of the HMOS, indicated  that holding  down 
the cost of medical  care was more important  than giving the best mdlcal  care  to their 
HMos. 
Beneficiaries  Responses  Varied  According  to Model  Type  and  Profit  Status. 
Benefi&uies  in group  and s@#  mo&l  HMOS  were more likely  to repoti  being  required to 
have a physical  at application,  not being aware of appeal rights,  and having difficulties 
with appointments.  (See Appendix  B.) 
~  exam.  Enrollees  in staff model HMOS were  more than 2.5  times 
more likely than enrollees  in other models to say a physical  was required  prior  to 
enrollment. 
Disenrollees  in group  model HMOS were 3 times more likely than disenrollees  in other 
models to say they were required  to take a physical. 
Ameal  rhzhts.  More  disenrollees  in group model HMOS were almost twice as likely to 
say they were not awzue of their appeal rights. 
Appointment  with Drima.ry HMO doctor.  Enrollees  and disenrollees  in a group  model 
were almost 2 to over  3 times more likely than their counterparts  in other  models  to 
indicate  waiting  longer  than  12 days for a scheduled primary  doctor  appointment. 
7  ADDOhbIent  with s~ecialist.  Enrollees  in group models wem more  likely than enrokes  in 
other models to say they waited longer than  12 days for an qpoin~ment  with a specialist. 
For disenrollees,  those in a group model were 2 times more  likely than other disenrollees 
to report  such a wait. 
Atmointment  when verv sick.  Disenrollees  in a group model wem twice  as likely as 
disenrollees  in other models to report  having difilculties  getting an appointment  with  2 
days when very sick. 
Busv telmhone  lines.  13nrollees in a group model were at least twice as likely as enrollees 
in other  models to report  sometimes  giving up making an appointment  because  of 
consistently  busy telephone  lines. 
Benej?ciarres in non-profi  HMOS  were  more likely to rqxm? being required  to have a 
physical  examition  at application,  not being aware of needing a specialist  referral,  and 
having problems  with appointments.  (See Appendti  B,  Table 2.) 
Reuuired  a llhvskd.  Disenrollees  in non-profit HMOS wem at kast  twice as likely as 
disenrollees  in for-profit  HMOS to say they were required  a physical  examination  for 
application. 
Understandimz of HMOS.  Both enrollees  and disenrcdlees in non-profit  HMOS were over 
1.5 times  more likely than beneficiaries  in for-profit HMOSto say they were not aware  of 
the need for a specialist  referral. 
Enrollees  in non-profit  HMOS were almost 2 times more likely as enrollees  in for-profit 
HMOS to say they were not aware they could back-out  of enrollment. 
Appointment  with Drirnarv HMO doctor.  Both enrollees  and disenrollees  in non-profit 
HMOS were almost  twice as likely as those in for-profit  HMOS to say they usually waited 
more than  12 days for a scheduled appointment  with their primary  HMO doctor. 
Armointment  with a specialist.  Both enrolkes  and disenrollees  in non-profit  HMOs  were 
over  1.5 times  more  likely as beneficiaries  in for-profit  HMOS to say they waited  more 
than  12 days for a specialist  appointment. 
Busv tekmhone  lines.  Enrollees  in non-profit  HMOS were at least 2 times  more likely as 
enrollees  in for-profit  HMOS to say they sometimes gave up on making  an appointment 
because  of busy  telephones  lines. 
8
 CONCLUSIONS
We found th~t using beneficiary-level  data linked back to the HMO provides  additional 
insights for examining  HMO enrollment  and service access issues.  This type of information 
may prove  especially  useful in focusing monitoring efforts.  For example,  most of the 
problem  areas  we found were distributed  throughout  the sampled HMOS and were not just 
isolated incidence.  This pervasiveness  could signal the need for program-wide  monitoring 
efforts.  Additionally,  this level of data could be used to pinpoint  speciilc  problematic  HMOS 
and indicate  when corrective  actions should be initiated. 
HMO-level  analysis  can also show a problems  degree of in$ensity.  For  example,  for our 
sampled HMOS, we would focus program-wide  attention on screening  for health  status at 
application,  not making beneficiaries  aware of their appeal rights,  and  not taking  complaints 
seriously.  Also,  for disenrollees  only,  we would focus program-wide  attention  on service 
access problems.  However,  to best utilize knowledge of problem  intensity,  we suggest 
HCFA  establish  acceptable  tolerance  ranges for these indicators,  since a problem  may be 
pervasive  but still not be seen as critical. 
Additionally,  our analysis  suggests that certain  structural factors  also impact beneficiaries 
perceptions  of HMO  service.  For example,  of the structural  factors we examined,  group and 
staff model,. as well as non-profit  status,  made a. signifkant  difference  in. how beneficiaries 
experienced  certain  problems.  This type of knowledge could help target  monitoring  efforts 
for HMOS with these characteristics. 
For an HMO-level  analysis,  our experience  suggests HCFA may want to stra@  by 
Medicare  enrdrnent  size,  as well as for selected structural  characteristics,  e.g.  model type 
and profit  status,  when surveying HMO beneficiaries. 
Additional  Office  of Inspector  General  Work 
Using our beneficiary  survey data,  we also plan to produce  a report exploring  the value and 
use of disenrollment  rates as an HMO performance  indicator,  including  an analysis  of the 
most significant  reasons  for beneficiary  disenrolhnents. 
9
 ENDNOTES

1.  We did not contact HMOS or their  staffs,  nor did we attempt to assess the quality  or 
propriety  of-medical  care  rendered  by the HMOS to these beneficiaries.  Additionally,  we did 
not specillcally  ask beneficiaries  about their  satisfaction with the HMOS, as the concept  of 
satisfaction  is less objective  than,  and sometimes  independent  of, the issues of membership  in 
a Medicare  risk HMO. 
2. We selected a stratifkl  random  sample from HCFAS Group Health  Plan  (GHP) data 
base.  First,  we sampled 45 HMOS from the 87 HMOS under a risk contract  with HCFA  as 
of February  1993.  Beginning  with the GHP data,  we counted the number  of enrollments 
occurring  within calendar  years  1991 and  1992.  For this cohort,  we then calculated  the 
proportion  of disenrollments  within the following  12 months.  Based on this disenrollment 
rate,  we divided the 87 risk HMOS into three  stmta of 29 HMOS each.  Within  each strata, 
we selected  15 HMOS by simple random  sampling.  Second,  from each sampled HMO,  we 
randomly  selected  50 Medicare  beneficiaries  who were enrolled  as of February  28,  1993  and 
50 who  had disenrolled  between  November  1992  and February  1993 inclusive.  When  the 
total number per HMO  for either group  was less than 50,  we  selected  them all.  Using 
HCFAs  Enrollment  Data Base,  we excluded,  from the sampling universe,  beneficiaries  who 
had died or who appeared  as current  enrollees,  but had actually  disenrolled  since the last 
update to the GHP fde.  This process  resulted  in 2,217  enrollees  and  1,915 disenrollees  for a 
total of 4,132  beneficiaries.  A total of 2,882  surveys were deemed usable,  yielding  an 
unweighed  return  rate of 70% overall,  77% for enrollees  ~=  1,705) and 61% for 
disenrollees  (N= 1, 177). 
3.  HMO  model  types  are divided  into three categories.  Group models  contract with 
independent,  multispeciaity  physician  groups.  Individual  practice  associations  (IPAs) contract 
with independent  physicians  or small,  single specialty physician  groups  who also maintain 
private practices  co-jointly  with their HMO contract.  Staff models directly  employ  salaried 
physicians  to serve patients. 
4. Contract  services  refers  to whether  or not an HMO formalizes  an agreement  with another 
established  HMO  to provide  services. 
5.	 We categorized  Medicare  enrollment  size as:  1) very small,  with a total enrollment  of 
less than  1000; 2) small or medium,  with a total enrollment  between  1000 and  15,000;  3) 
large,  enrollment  between  16,000 and 31,000;  and 4) very large,  greater  than 31,000. 
6.  TO test signifkant  differences  for each structural  factor per question,  as well as between 
enrollees  and disenrollees  responses  per question,  we used one or mom of the following 
programs  from  SPSS for Windows  (SPSS, Inc.  1993):  1) MBANS which calculates  a 
standard analysis  of variance  table;  2) Independent-Samples  T TEST  which computes 
Students t; and 3) CHAID  (Chi-square  Automatic  Interaction  Detection)  which finds 
statistically  signifkant  subgroups. 
10  7.	 Using Federal  regulations,  we measured  beneficiaries  enrollment  experience  with health 
screenings  and understanding  of HMO membership.  Strictly speaking,  HMOS should have 
no negative  experiences  reported  in these areas.  Possibly,  smne HMCISconduct health 
assessment  interviews  shortly after enrollment  and some benefkiar-y responses  may refer to 
such assess~nts.  If so, our data may be somewhat inflated. 
11  APPENDIX  A

 
PROBLEMDISTRIBUTIONANDWTENWIT 
TABLE1. HealthSemen@ 
DistributionAmong  HMO& 
r 
1%to 10%of  11%to 2s%of  26%@50%of  >50%of 
be-es  O%of Beneficiary  Bendicisries  BedkiarA  Bedicldes  Beneficiaries 
Responding 
in... 4  in... 4  m... J  k.. . J  in... & 
b  Were asked  at application  about  heallh problems,  exchuiiag  kidney fhdurw  and  hospice  care. 
Enrdlea  37 %  2 HMos  12 HMOS!K  19 HMos  12 HMos 
(N=418)  (4%)  07%)  (42%)  (27%) 
I 
Dlseslrdlees 39%  1 Hh40  8 Hlms  M IiMos  14 HMos 
(N=276)  (3%)  (21 %)  @!J%)  (36%) 
b  Were required Zto hlamve  a phdysical oexamainatio n  before joining  the HMO. 
I 
Enrollees 4%  20 HMos  4 HMos  1 Hh40 
(N=57)  (44%)  (44%]  (9%)  Q%) 
Disenmllees 2 %  i4 HMO  14 HMos  lHh40-
(-N=20)  (62%)  (36%)  (2%) 
I 
*Note:  N= 45 HMOS  for enrollees;  N  varies  for dkenrollees  (see Methodology  section,  page 2 of this report). 
Also,  percentages  may not equal  100 % due to rounding. 
A-1
 TABLE2.  Understa.mihwof HMOs 
Distrmutiorl  Among  XMOS* 
1% to 10% of  ll%m25t6Qf  26%U*50% of  >50%  of 
Beneficieri&  O% of Beneficiaries  Beneficiies  Bae4auies  Beneficiaries 
Responding 
m... J  In4...  ill... J  k  . &  in... 4 
b  Did G  know  they had a right to appeal  an HMOS refwd  to provti  or poy for  setvices. 
Enrohes  26 %  1 HMo 
(N=381)  (2%) 
Disenroilees 32%  1 HMo  2 HMos 
(N=250)  (3%)  (5%) 
z  1  iaziiC 
b  Did ~t  know  they needed  a referrtd jbm  thekgnimary  HMO doc.tar #u see a specidi.rt. 
Eocollees 11%  3 HMos  22 H&me  M Hhms  2 XMos 
1 
(N=176)  (7%)  {49%)  (40%)  [4%) 
Dlsenrollees 15%  4 HMos  9 HMos  22 HMOS  4 HMos  1 HMo 
(?J=151)  (lo%)  (23%)  (5s%)  {)0%)  (2%) 
b  D&i @  know  they  could change  their minds  about  enrolilng  in #JteHMO i@er  they appltid  (3ack-
Out). 
Enrollees 11%  2 HMos  21 HMos  20 HMffs  i HMo  1 HMo 
(N= 133)  (4%)  (47%)  (44%)  0%)  (2%) 
Disenrollees 18%  4 HMos  9 HMos  13 HMrh  12 HMos 
(N=135)  (11 %)  (24%)  C34%)  <31%) 
  Dhi ~  know  they  could only use HMt2desigrurted  a%ctors ad  hoqikdr  (lock-ti). 
Enrollees 4%  15 HMos  ?7 Hhms  3 Hh40s 
(N=63)  (33 %)  (60%)  (7%) 
Disenrollees 7 %  11 HMos  19 HMos  9 HMos  1 HMo 
(N=68)  (28%)  (47%)  (23%)  (2%) 
*NOW  N= 45 HMOSforenrollees;N variex  for digenrdees  (see Methodology  section,  page  2 of this report). 
Also,  percentages  my  not equal  100% due to rounding. 
A-2
 TABLE3.  Medical@@n?ment Problems 
Distribution AmoruzHMCk* 
1%to 10% of  11%tn 2s%of  26%MS50% of  >50%  of
Beneficieriek- 0% of Beneficiaries  Beneficiaries  Lkaam&S  BflMriasies  Beneficiaries 
Reqnding  in... 4  in... &  irk... 4  it)-.  4  in... J 
b  When  very sick,  was @  able to get a doctors  appointsnent  withiu 3 to 2 dkys. 
Enrollees 6%  17 HMos  19 HMos  6 HMOS  3 Hbfos
4
(N=63)  (38%)  (42%)  (13%)  (7%) 
Disenrdlees  12%  10 Hh40s  8 WOS  i4 HMa  4 HMos 
(N=60)  (28%)  (22%)  @9%)  ($1%) 
b  For schedlded  appointments  with primary  H,VO &.I.0.rs,  ZSU@  waited more  than  12 &ys. 
Enrollees 15%  4 HMos  15 HMos  N HMOs  7 HMos  1 Hh40% 
(N=225)  (9%)  (33%)  (40$6)  (16%)  (2%) 
1 
Disenrolkes  18%  5 HMos  8 WOS  i7 mm  7 HMos  5% 
(N=149)  (13%)  (20%)  @4%}  (18%)  (N=2  HMos) 
b  For scheduled  appointments  with specialists,  WU@  wdted  mare than  E  dhys. 
Enrollees 19%  1 HMo  11 HMos  22 HMos  9 Hhlos  2 HMos 
(N=222)  (2%)  Q4%)  (49%)  (20%)  (4%) 
I 
Dkencollees 24%  1 HMo  6 Hh/K)s  9 mms  19 Im.Kls  2 HMos 
(N=153)  (3%)  (16%)  (24%)  (51 %)  (5%) 
b  Usually  waited  1 hour  or more  in the ojj%e  to see prinuuy  HMO  doctor, 
Enrollees 5%  11 Hh40s  27Hrvmll  7 HMos 
(N=80)  (24%)  (60%)  (16%) 
DkenroUees 13%  8 Htvlos  10 HMos  13 HMos  5 Hh40s  1 Hh40 
(N=108)  Q2%)  (27%)  (35%)  (14%)  (2%) 
b  Conshtently  busy telephone  Ities  someties  hindered  benes  nratig  appointments. 
Enrollees10%  13 HMos  16 HA@  10 HA40s  6 i+M@ 
(N=85)  (29%)  (36%)  (22%)  (13%) 
Disenrdkes  13%  12 mms  10HMos  8 WOS  6 HMOS 
(N=62)  (33%)  (28%)  (22%)  (17%) 
[ 
*Note:  N =45  HMOSfor enrollees;  N varies  for dksmrollees  (see ~  section,  page  2 of this report). 
Also,  percentages  may not equal  100% due to rounding. 
A-3
 TABLE4.  ServiceAccess 
Distribution Among HMOS* 
1%to 10% of  11%to 25%of  26% to 50% of  >50%  of 
Bene&iaries  0% of Beneficiaries  Benetlciaries  Benefkiarks  -ties  Benefkiies 
Responding  in... J  in... &  ill... J  k...  4  in... & 
b  Thought  needed  to seek out-of-plan  care,  excluding  dental,  rautzhe  eye, mwi emergentlurgent care. 
Enrollees 7%  2 HMos  34 IiMos  9 HMos 
(N=I08)  (4%)  (76%)  (20%) 
Diseorollem 15%  3 HMos  10 HMos  24 HMOS  3 HMos 
(N=120)  (7%)  (25%)  (60%)  (8%) 
b  Primary  HMO  doctor  sometimes  failed  to refer to a spec&uist whsn  needed. 
Enrollees 4%  11 HMos  30 HMos  4 HMos 
(N=66)  (24%)  (6?%)  (9%) 
Dlsenrollees 14%  8 ~Ch  11 HMos  16 HMOS  5 Hh40s 
(N=115)  (20%)  (28%)  (40%)  (12%) 
b W  HMO doctor someties failed  to provide  needed  Medh.re  services. 
Enrollees 4%  13 HMos  31 HMos  1 HMo 
(N=60)  (29%)  @9%)  (2%) 
Disemdees  12%  5 HMos  16 IiMOS  16 EIMOS  3 HMos 
(N=105)  (12%)  [40%)  (40%)  (8%) 
b  Medical  care received  through  the HMO  caused  beneficiaries  health  to imorove. 
Enrollees 53%  19 H.Mos  26 Mck 
(N=772)  (42%)  (58%) 
Disenrollea  39%  1 HMo  3 HMos  28 HMas  7 HMos 
@=296)  (3%)  (8%)  (72%}  (17%) 
b  Medical care received  through  the HMO  caused  bene~iades  heailh  to stav about  the same. 
Eorollees45 %  1 HMo  31 H&KJs  13 Hhlos 
(N=649)  (2%)  (69%]  (29%) 
Dlsenrouecs 50 %  3 HMos  17 HMos  19 HMos 
(N=383)  (7%)  (44%)  [  (49%) 
b  Medical  care  received  through  the HMO  caused  beneficiaries  health  to worsen. 
Enrollees 2%  .24HW  :  20 HMos  1 HIuo 
(N=32)  (53%)  (44%)  (2%) 
Dissnrollees 11%  13 kbms  ~  10 Hh40s  12 HMos  4 HMos 
(N=86)  ,.(33%)  (26%)  (31%)  (lo%) 
I 
*iVote: N= 45 HMOS for enrollees;  N varies  for disertrollees  (see  Methodology  section,  page 2 of this report). 
Also,  percentages  may not equal  100% due to rounding. 
A-4
 TABLE 5.  Pemcmal Treatment 
Distribution Among HMCW 
1%to 10% of 
Beneficisriei  0% of Baseficties 
Rqmuting 
m... 4 
m~y  ~~ 
b  Primaty  HMO  doctor  sometimes  failed  to take berzejicimys  ?zeailh compkdnts  seriously. 
Enrollees 12%  22 HMos  23 HMos 
(N= 175)  (49%)  (51 %) 
Disenrollees 25 %  2 HMos  4 HMOs  14 ?rMOs  19 HMos  1 HMo 
(N=219)  (5%)  (lo%)  (35%)  {4.3%)  (2%) 
  Most  important  to primary  HMO  doctor  was ~ving Ike best medical  care possible. 
Enrollees 86%  45 HMos 
(N=1197)  (100%) 
Dkenrolkes  73 %  5 HMos  34 HMos 
(N=471)  {!396)  (87%) 
b  Most  importanl  to primary  HMO  doctor  was holding  down the wst  of care. 
Enrollees 7%  4 HMos  25 HMos  16 HMOS 
(N=120)  (9%)  (56%)  (35%) 
Disenrdees  25 %  2 HMos  5 HMos  16 HMOS  13 HMos  3 HMos 
(N=162)  (5%)  (13%)  (41%)  J33 %)  (8%) 
b  Most  important  to the ~  was givtig  the best medical  care possible. 
Enrollees74%  45 HMos 
(N=1036)  (100%) 
Dkenmlks  57 %  2 HMos  12 HMos  25 HMOS 
(N=387)  (5%)  (31%)  (64%) 
I 
b  Most  important  to the ~  was holding  down  the cost of care. 
Enrollees 15%  13 Hhlos  27 Iiktf3s  5 HMos 
(FI=213)  Q9%)  (60%)  (11 %) 
Dlsencollees 35 %  2 HMos  10 HMos  20 HMos  7 HMos 
(N=230)  (5%)  @6%)  (51 %)  (18%) 
*lVote:N=45  HMOS for  enrollees;  N varies  for diaenrolleea  (see  Methodolo~  section,  page 2 of this report). 
Also,  percentages  may not equal  100 % due to rounding. 
A-5
 APPENDIX  B 
SIGNIFICANT  STRUCTURAL FACTORS 
TABLE  1: ModelTypes- significantDflerellcesin lMeanResponses* 
Enrollees  Dkenrollees 
Benetlciary Responses  ~A88  Group  StatT  ~AW  Group  Staff 
HEhLTH  SCREENING 
Physical  exam  was required 
before joining.  3%  4%  11%  2%  6%  2% 
UNDERSTANDING  OF HMOS 
Did @  know  they had the right 
to appeal an HMOs  refusal  to 
urovidel~.a y.  for services.  29%  45%  24%
AwtmmfEm 
For scheduled  appointment  with 
primary HMO  doctors,  usually 
waited  more  than 12 days.  9%  33%  18%  11%  39%  15% 
For scheduled  appointments  with 
specialists,  usually  waited  more 
than 12 days.  14%  31%  23%  21%  42%  21% 
When very  sick,  was ~  able to 
get a doctors  appointment  within 
1 to 2 &ys.  10%  21%  9% 
Consistently  busy telephone  lines 
sometimes  hindered  benes 
making appointments.  7%  19%  11% 
8No&:  My  s~tisti~lY  sidfi~t  &ffemnces  at p < .(M are shown.  pemen~ges  me omdd 
xk~divid~  ~tice  Association 
B-1
 TABLE 2: Profit Status - !Yqgnifmt  DitTerences in .Meau kiiOIISeS* 
Mean Emolkm  Mean Dkenrolke 
Resplxtse  Response 
For- Noa- For- Non-
Benefick-y  Responses  E%dH  Profit  Profit 
EiVROLLUEiVTPROCEDURES 
Were required to have a physical before joining the  2%  5% 
HMo. 
 
lhVDERST~DLVG OF HMOS 
Did ~t  know, from the beginning, they must be referred 
to a specialist by their primary HMO doctors. 
9%  i-}%  14%  22% 
Dld ~t  know they could change their minds shout 
enrolling atler they applied. 
Kl%  !8% 
For scheduled appointments with primary HMO doctors, 
usually waited more than 12 deya. 
16%  27%  14%  30% 
For scheduled appointments with specialists, usually 
waited more fhan 12 days. 
13%  23% 
Consistently busy telephone liies sometimes hindered 
benes 
making appointments.  8%  17%  8%  20% 
*iVote: Only  statistically  significant  differences  at p <.05  level  are shown.  Percentages  are rounded. 
B-2
 APPENDIX  C

PROFILE OF HMOS - WRUCTURAL  FACTORS 
ENROLLEES  DISENROLLEES 
in 45 HMOs  in 41 HMOs* 
. 
MODEL TYPE 
  lpA  30 HMos  27 HNIOs 
Group  9 Wos  9 HMOS 
 
.  staff  6 HMos  5 HMOS 
FOR-PROFIT/NON-PROFIT 
.  For-Profit  34 HMos  30 HMOS 
. Non-profit  11HMOS  11HMOS 
! 
ENROLLMENTSIZE 
  VerySmall(< lK)  6 HMOa  5 HMOS 
.  Small to Me&um  (1K - 15K)  28 HMOS  26 HMOS 
  Iarge  (16K  - 31K)  6 HMOS  5 HMOS 
.  Very  Large  ( >3 lK)  5 HMOS  5 HMOS 
I 
COMPETITIVE/NON-
COMPETITIVE  AREA 
  Competitive  36 HMOS  32 HMOS 
.  Non-Competitive  9 HMos  9 HMOS 
CONTRACTED/NOT 
CONTRACTED  SERVICES 
  Contracted  14 HMos  14 HMOS 
.  Not Contracted  31 HMos  27 HMOS 
LOCATION 
. 1 state  14 HMOS  14 HMOS 
  Multiple  States  31 HMOS  27 HMOS 
*Note:  See Methociolo gy section,  page 2 of this report. 
c-1  APPENDIX  D

Key Questions:  Significant DMTerencesbetween EnmWes and D~enrollees* 
Enrollees  Dkenrollees 
Mean  Mean 
#of EIMos  Response  # of HMOS**  Response 
UiWERST~DiNG  OF HMOS 
Did g@ know  they could  change  their minds 
about enrolling  in the HMO  after 
application.  45  12%  38  18% 
Were @  aware  they needed  a referral from 
their primary HMO  doctor  to see a 
specialist.  45  11%  40  16% 
 
Were~t  aware  they could  only use HMO-
designated  doctors  and hospitals.  45  4%  40  7% 
Did ~t  know  they had a right to appeal an 
HMOs  refusal  to provide  or pay for 
services.  45  26%  38  32% 
MEDICti  APPUAWMENZS 
When very  sick,  was ~t  able to get a 
doctors  appointment  within  1 to 2 days. 
45  7%  36  12% 
Usually  waited  1 hour or more in the office 
to see u. rirnary HMO  doctor.  45  5%  37  14% 
SMWK!E  ACCESS 
Primary HMO  doctor  sometimes  failed  to 
provide  needed  Me&are  services. 
45  4%  40  12% 
Primary HMO  doctor  sometimes  failed  to 
refer to a specialist  when  needed. 
45  4%  40  12% 
Sought  out-of-plan  care,  excluding  dental, 
routine eye,  and emergentl  urgent care. 
45  7%  40  14% 
D-1
 Key Questions:  Significant Differences between Enrollees amd Dkenrollees* 
Enrollees  Disenrollees 
Mewx  Mean 
#of HMO%  Rtqxnlw  # of HMOS**  Response 
Me&cal  care  received  through  the HMO 
caused  beneficiaries  health to im~rove.  45  W%  39  40% 
Medical  care received  through  the HMO 
caused  beneficiaries  health  to wo.r sen 45  2%  39  11%
. 
PERSONAL  XUZ4TMENT 
Primary  HMO  doctor  sometimes  failed to 
take beneficiarys  health complaints 
seriously.  45  12%  40  24% 
Most  important  to primary HMO  doctor  was 
giving  the best rnedcal  care possible.  45  $6%  39  71% 
Most  important  to primary HMO  doctor was 
holding  down  cost  of care.  45  9%  39  27% 
Most  important  to the ~  was giving  the 
best rnedcal  care mssible.  45  74%  39  57% 
Most  important  to the ~  was holding 
down  cost  of care.  45  15%  39  37% 
*Note:  OrdY questionsstadsti~ significant  at ps .05  (two-tailed)  are shown.  PwcmWw me rounded. 
**S= Methodolo  ~  section,  page 2 of this report. 
D-2