Department of Health and Human Services 

OFFICE OF 

‘INSPECTOR GENERAL 

MEDICARE RISK ~~(h: 

BENEFICIARY ENROLLMENT AND 

SERVICE ACCESS PROBLEMS 

$W7C* 

+@ “%+ *+4 

$ JUNE GIBI/S BROWN 

% Inspectoq General . 5 

%**

%a4CL	

AP12q.41995 

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 problem’s distribution cmdd either signal the 

need for progmm-wide monitoring or for targeting speciilc HMOs. A problem’s 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:


B:


c:


D:


Distribution and Problem Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l 

StatisticaUy Signiilcant Structural Factors . . . . . . . . . . . . . . . . . . . . . . . ..B-1 

Profile ofHMOs --Structural Factors . . . . . . . . . . . . . . . . . . . . . . . . . ..C-1 

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 HCFA’S 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-byquestion 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 HCFA’S 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 President’s 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 HMO’S 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 twothirds 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 doctor’s 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 sern”ce access problems were fin”rfywidksprwd 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 YO of disenrollees, as well as 

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 examiti”on 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 problem’s 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 HCFA’S 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 

HCFA’s 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 

Student’s 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%) I (42%) (27%) 

Dlseslrdlees 39% 1 Hh40 8 Hlms M I’iMos 14 HMos 

(N=276) (3%) (21 %) @!J%) (36%) 

b Were required to have a physical examination before joining the HMO. 

20 HMos 

(N=57) (44%) (44%] (9%) Q%) 

Disenmllees 2 % i4 HMO 14 HMos lHh40-

(-N=20) (62%) (36%) (2%) I 

Enrollees 4% I Zlmdoa 4 HMos 1 Hh40 

*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

“4

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 In... ill... J k . & in... 4 

b Did G know they had a right to appeal an HMO’S 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 Hh’ms 2 XMos 

(N=176) (7%) {49%) (40%) 1 [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 (3ackOut). 

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 HMOSfor enrollees;‘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 doctor’s appointsnent withiu 3 to 2 dkys. 

Enrollees 6% 17 HMos 19 HMos 6 HMOS 3 Hb’fos 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) 1 (16%) (2%) 

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 Hh’los 2 HMos 

(N=222) (2%) Q4%) (49%) I (20%) (4%) 

Dkencollees 24% 1 HMo 6 Hh/K)s 9 mms 19 I’m.’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 2’7Hrvmll 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 bene’s 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&u’ist 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 Hh’los 

(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) I ,.(33%) (26%) (31%) (lo%) 

*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 berzejicimy’s ?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%) I (64%) 

b Most important to the ~ was holding down the cost of care. 

Enrollees 15% 13 Hh’los 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 HMO’s refusal to 

urovidel~ay. . 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 doctor’s appointment within 

1 to 2 &ys. 10% 21% 9% 

Consistently busy telephone lines 

sometimes hindered bene’s 

making appointments. 7% 19% 11% 

8No&: My s~tisti~lY sidfi~t &ffemnces at p < .(M are shown. pemen~ges me ‘omdd” 

x’k~divid~ ~tice Association 

B-1

TABLE 2: Profit Status - !Yqgnifmt DitTerences in .Meau kiiOIISeS* 

Mean Emolkm Mean Dkenrolke 

Resplxtse Response 

For- Noa- For- NonBenefick-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 

bene’s 

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 

MODEL TYPE 

� lpA 

� Group 

. staff 

FOR-PROFIT/NON-PROFIT 

. For-Profit 

. Non-profit 

ENROLLMENTSIZE 

� VerySmall(< lK) 

. Small to Me&um (1K - 15K) 

ENROLLEES DISENROLLEES 

in 45 HMOs in 41 HMOs* —. 

30 HMos 27 HNIOs 

9 Wos 9 HMOS 

6 HMos 5 HMOS 

34 HMos 30 HMOS 

11HMOS ! 11HMOS 

6 HMOa 5 HMOS 

28 HMOS 26 HMOS 

6 HMOS 5 HMOS 

5 HMOS 5 HMOS 

I 

36 HMOS 32 HMOS 

9 HMos 9 HMOS 

14 HMos 14 HMOS 

31 HMos 27 HMOS 

14 HMOS 14 HMOS 

31 HMOS 27 HMOS 

� Iarge (16K - 31K) 

. Very Large ( >3 lK) 

COMPETITIVE/NONCOMPETITIVE AREA 

� Competitive 

. Non-Competitive 

CONTRACTED/NOT 

CONTRACTED SERVICES 

� Contracted 

. Not Contracted 

LOCATION 

. 1 state � Multiple States 

*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 HMOdesignated doctors and hospitals. 45 4% 40 7% 

Did ~t know they had a right to appeal an 

HMO’s refusal to provide or pay for 

services. 45 26% 38 32% 

MEDICti APPUAW’MENZS 

When very sick, was ~t able to get a 

doctor’s appointment within 1 to 2 days. 

45 7% 36 12% 

Usually waited 1 hour or more in the office 

to see urirnary . 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 worsen

—. 45 2% .— 39 11%

PERSONAL XUZ4TMENT 

Primary HMO doctor sometimes failed to 

take beneficiary’s 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