WASHINGTON, D.C., July 19, 1995—At a time when managed care is bringing rapid and profound changes to the U.S. health care system, a new survey finds that Americans are feeling some negative side effects. Working Americans surveyed in Boston, Los Angeles, and Miami report greater dissatisfaction with managed health care than with traditional fee-for-service insurance, and the dissatisfaction is more than twice as great among those whose only choice in health insurance was managed care.
The new, in-depth population-based survey reported today in the public policy journal Health Affairs also reveals surprising instability in health insurance coverage. Nearly one-third of respondents had changed health plans involuntarily within the previous three years.
"This survey takes the pulse of workers about their health coverage and finds symptoms of distress with the accelerated shift to managed care," said Karen Davis, Commonwealth Fund president and lead author of the Health Affairs report. "Stopping to take a close look at managed care plans reveals that, while these plans get slightly higher ratings for cost and paperwork requirements, there is a pattern of dissatisfaction with choice and quality of doctors, access to specialty and emergency care, and waiting time for appointments. Managed care enrollees rate these aspects of care from two to five times more negatively than fee-for-service members. As more and more Americans join managed care plans, comparative satisfaction and quality information from enrollees will be important in assessing their ability to access quality health care."
The survey was sponsored by The Commonwealth Fund, a national philanthropy engaged in health and social policy issues, and conducted by Louis Harris and Associates, Inc. More than 3,000 adults between the ages of 18 and 64 were interviewed: all respondents had employment-based health insurance and the option of enrolling in managed care, and most respondents also had the option of selecting fee-for-service insurance.
FINDINGS
Managed care enrollees are less satisfied with their health plans than those in fee-for-service
Overall, managed care enrollees were more likely to rate their plan as fair or poor (21%) than fee-for-service users (14%), particularly for quality of health care services and access to services, including specialty care and emergency care.
Managed care enrollees were also much less satisfied than fee-for-service members with their plans' ease of changing doctors, choice of doctors, and quality of doctors. They were also more likely than fee-for-service members to rate their regular doctor or nurse as fair or poor in terms of really caring about them and their health, spending enough time with them, and being accessible by phone or in person.
Managed care enrollees were also more inclined to assign negative ratings to waiting time for a routine appointment, waiting time in the office, and convenience of their provider's location.
The ability to choose a health care plan is key to satisfaction
Three out of 10 managed care users reported they had no option of a fee-for-service plan. Nearly one-third (32%) of these enrollees with no choice gave fair or poor ratings to their plans. Of those in managed care who had a choice of a fee-for-service plan, only 16 percent rated their plan negatively.
"Managed care can work, but as this survey shows, it is not enough by itself," said Edward N. Brandt, Jr., M.D., head of the Center for Health Policy at Oklahoma University and assistant secretary for Health, Department of Health and Human Services from 1981-85. "Results show serious dissatisfaction among almost one-third of managed care enrollees who did not have the choice of fee-for-service coverage. When they had a choice, there was little difference in levels of dissatisfaction between managed care and fee-for-service members. Mandatory managed care is evidently not an easy medicine to swallow, and physician choice is an important consideration."
Employee health care coverage changes frequently
One out of three working adults surveyed said they had to switch health plans within the previous three years, primarily because they changed or lost their jobs or because of a plan change required by the employer or union that sponsored their health insurance.
For 41 percent of these managed care enrollees, changing plans also meant changing doctors. In contrast, only 12 percent of fee-for-service users had to change doctors when they changed plans.
"There is a danger that care may be compromised as people are shuffled from one insurance plan to another," said James J. Mongan, M.D., executive director of the Truman Medical Center in Kansas City, Missouri, and associate director of the White House domestic policy staff from 1979-81. "Under managed care, changing your job or health plan more often means losing your doctor. We need to find ways to protect continuity of care for people."
Results also showed that satisfaction is directly linked to length of time in a health plan, and that instability of coverage is greatest among managed care plan enrollees. Members of managed care and of fee-for-service plans who belonged to their plans for 10 years or more were much less likely to rate their plans negatively (11% and 12%) than those who had belonged to their plans for less than three years (24% and 17%). More than one-half of managed care enrollees (53%) had been in their current plan for less than three years, compared with 37 percent of those in fee-for-service plans.
Low income enrollees give lower ratings to managed care plans
Of the survey respondents, more low income working adults were in managed care plans than fee-for-service plans. Managed care plans received low marks from members in households with annual earnings of $15,000 or less, with almost one-third (32%) rating their plans overall as either fair or poor. This is more than twice the negative ratings that low income adults gave to fee-for-service plans (13%). Low income managed care enrollees also were more likely to be dissatisfied with specific aspects of access, quality, and physician care.
The promises of managed care are only partially realized
Managed care organizations have the potential to provide vital, affordable, preventive care, with the promise of lower costs and less paperwork. Survey results find that, while more fee-for-service members (30%) were dissatisfied with out-of-pocket costs, one out of four managed care enrollees (25%) were also dissatisfied. Paperwork requirements, rated as fair or poor by 20 percent of fee-for-service respondents, also received negative ratings from 16 percent of managed care enrollees.
Similar percentages of respondents in managed care (17%) and fee-for-service plans (19%) reported not having a regular source of care, postponing needed care in the prior year (11% v. 9%), not getting preventive services such as Pap smears (25% v. 24%), mammograms (31% v. 31%), blood pressure readings (14% v. 12%), or prostate cancer screenings (46% v. 48%).
"This survey points to the need to build consumer protection into managed care," said Gail Shearer, director of Health Policy Analysis for the Washington office of Consumers Union, the non-profit publisher of Consumer Reports magazine. "Consumers need the freedom to go outside of managed care networks at a fair price, and they need assurance that medical appropriateness, not bottom-line profitability, determines treatment decisions."
Parents in fee-for-service plans are more satisfied than those in managed care plans with their children's care
Managed care enrollees were more likely (45%) than those in fee-for-service plans (39%) to have children under the age of 18. Parents in fee-for-service plans were more likely than those in managed care to be very satisfied with the doctor's overall attitude and behavior toward their child (86% v. 77%), the quality of care received (86% v. 76%), access to emergency care (81% v. 71%), and access to needed diagnostic tests (79% v. 66%).
Satisfaction varies by city and by type of plan
Managed care enrollees were somewhat more likely than fee-for-service members to assign negative ratings to their health plans. Managed care enrollees in Miami (24%), Los Angeles (20%), and Boston (18%) rated their plans fair or poor, compared with 14 percent of fee-for-service members in each of the three cities.
On a variety of measures, managed care members in Miami and Los Angeles were much more likely than those in Boston to rate their plans as fair or poor for choice of doctors (27% in Miami, 29% in Los Angeles, and 19% in Boston), for quality of doctors (22% in Miami, 19% in Los Angeles, and 10% in Boston), and for coverage of preventive care (22% in Miami, 19% in Los Angeles, and 14% in Boston).
Survey results also show rating differences between those enrolled in different types of managed care plans. Dissatisfaction were greater with Preferred Provider Organizations (PPOs) than with Health Maintenance Organizations (HMOs) for out-of-pocket costs (34% v. 21%), for coverage of preventive services (26% v. 16%), and for amount of paperwork (21% v. 13%).
However, dissatisfaction was lower with PPOs than with HMOs for waiting time for routine appointments (21% v. 31%) and for ease of changing doctors (21% v. 27%).
Demographics
Managed care enrollees interviewed were younger, less educated, and less affluent, and they were more likely to be of African American or Hispanic heritage, female, and to work in smaller firms than fee-for-service members. Most managed care enrollees (53%) were under age 40, compared with 43 percent of fee-for-service members in this age group. Twenty-eight percent of managed care enrollees had a high school education or less, compared with 21 percent of fee-for-service members.
Managed care plans had more low income enrollees (9%) with annual household earnings of $15,000 or less than fee-for-service plans (5%). Eleven percent of managed care plan enrollees were African American and 17 percent were Hispanic, compared with 8 percent of African American and 12 percent of Hispanic members in fee-for-service plans. Fifty-five percent of managed care enrollees were women, compared with 51 percent of fee-for-service members. Forty-five percent of managed care enrollees worked in firms with fewer than 500 employees, compared with 37 percent of fee-for-service plan members.
SUMMING UP
"Managed care is clearly becoming a dominant force in American health care. Plan choice, with an affordable, fee-for-service option, may be a critical safety valve," Ms. Davis said. "Top quality health coverage demands a competitive market with affordable alternatives."
Methodology
The Commonwealth Fund survey was carried out by Louis Harris and Associates, Inc., with 25-minute telephone interviews of a random sample of 3,348 adults, between the ages of 18 and 64, who had employment-based insurance. Respondents were screened to yield a final sample that was equally divided between fee-for-service members and managed care enrollees, with fee-for-service respondents included only if they had the option of joining a managed care plan. All respondents were asked to rate aspects of their health insurance plan as excellent, good, fair, or poor and to indicate why, if applicable, they chose to be in a managed care plan. Boston, Los Angeles, and Miami, the three cities used in the random, population-based survey, were chosen because each has a relatively high penetration of managed care organizations, and different histories and patterns of industry growth. The survey was conducted between January 12 and March 27, 1994, and has a sampling error of plus-or-minus 3 percent.
