Players in the Marketplace

June 25, 1997
Oakland, California





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Program Summary

By Julianna S. Gonen, PhD

The Jacobs Institute of Womens Health and the Pacific Institute for Womens Health held the second in their co-hosted California Leadership Seminar series on June 25th in Oakland. The program, "Players in the Marketplace," was presented in conjunction with the Womens Health Collaborative, a statewide coalition of grantees of the James Irvine Foundation whose mission is to improve the status of womens health in California.

Helen Rodriguez-Trias, MD, Co-Director of the Pacific Institute, noted that womens health is dependent on social, political and economic factors. She enjoined meeting attendees to bring womens health concerns to the public hearings of the Governors Task Force on Health Care Improvement, of which she is a member, as "womens voices have not been heard loudly thus far." Martha Romans of the Jacobs Institute added that during this time of "evolution and revolution" in health care delivery it is critical that the new system not replicate the problems of the past. She observed that the first seminar in this series, held in April, had focused on consumer concerns with managed care, and that today we would shift that focus to the various organizational players in the managed care marketplace. Sarah Samuels, DrPH, of the Pacific Institute then introduced the panelists, who represented academia, the purchaser community, and three large managed care organizations.

Women and Preventive Care

Helen H. Schauffler, PhD, MSPH, Associate Professor of Health Policy at the University of California at Berkeley presented data collected as part of the Health Insurance Policy Program, which is funded by the California Wellness Foundation and conducted by the University of California at Berkeley School of Public Health and the UCLA Center for Health Policy Research.1. Data is to be collected annually over the next five years through five different surveys in order to help inform the policy process in California around health insurance. The data presented by Dr. Schauffler, which she reanalyzed by gender for this seminar, were from the 1996 California Behavioral Risk Factor Survey and the 1996 University of California at Berkeley Survey of California Health Plans. Some of these findings are being used to legislate regulation of fee-for-service (FFS) and preferred provider organization (PPO) plans, which previously had not been regulated, and Dr. Schauffler expressed some concern that this might have the effect of reducing what had been a very high response rate to the health plan and health insurance underwriter survey.

Data were presented on coverage of certain services by health plans best-selling product. While managed care is generally believed to outperform traditional indemnity insurance in the area of preventive care, Dr. Schaufflers findings revealed that one form of managed care, the looser PPO arrangements, actually fared worse than indemnity on many screening services important to women. Health maintenance organization (HMO) and point-of-service (POS) options were more likely to cover comprehensive clinical preventive services and offer comprehensive health promotion programs to their members, and their premiums also tend to be lower, which indicates greater overall value to women from HMO and POS options. Dr. Schauffler then showed that approximately one quarter of women aged 50-64 in California with either employer-based insurance or Medicare had not received a mammogram in the past two years; this figure climbed to 40% for women without insurance. The rates for clinical breast exams were even lower; just under 70% of insured women (private or Medicare) had received an exam, while only 20% of women without insurance had had the exam. Data on the receipt of pap smears by women 18 and over were somewhat more encouraging; over 90% of those covered through private and employer-based insurance had receive a pap smear, compared with 83% of women in Medicare, 88% of Medi-Cal women, and 68% of uninsured women. Dr. Schauffler then presented similar data but broken down by type of insurance - HMO, PPO, and fee-for-service. HMOs significantly outperformed PPO and FFS options on women 50-64 receiving mammograms, HMOs and PPOs both outperformed FFS on clinical breast exams and pap smears, but there were no significant differences among the plan types on women receiving check-ups within the past year or the past two years.

U.S. Deputy Assistant Secretary for Womens Health, Dr. Susan Blumenthal, has said that "changing her health related behaviors should be a womans chief health concern," and also that 50% of the top killers of women are behavioral and lifestyle related. Dr. Schauffler examined the data to determine the extent to which the health care system and managed care plans were encouraging healthy behaviors. Looking at data across purchaser types, as well as at the uninsured, she showed that only 45-60% of women reported having received preventive counseling by a health care provider at any point in the past three years. Clearly, she said, incentives must be changed to encourage preventive counseling by health care providers. Data were presented on specific counseling services - diet, exercise, smoking, HIV/STDs, and gun safety - and the rates for all insurance sources were 40% or below. For many of these services she found that in fact the public health safety net was doing a better job than all types of private insurance, both managed care and indemnity, in providing needed counseling services, as the percentages for uninsured women and women on Medi-Cal were among the highest.

Breaking down the data on receipt of these services by type of insurance - HMO, PPO, or FFS - no significant differences were found, and all were very low. Interestingly, most women in California have had a check-up or periodic health exam in the last two years; the rates are from 94-98% for private insurance and Medicare and Medi-Cal. This suggests a large number of missed opportunities for health care providers to do preventive counseling. Dr. Schauffler then looked at the types of health promotion programs offered by health plans, comparing HMOs to PPO/indemnity plans. HMOs were much more likely to offer such programs overall; 90% of HMOs offered prenatal nutrition programs and 80% offered smoking cessation. But the percentages of HMOs offering exercise, adult immunization, and dietary fat intake programs were 60% and under. The range for the PPO/indemnity category across these types of programs ranged from 20 to 53%. For other programs such as blood pressure, substance abuse, STD prevention, HIV-AIDS prevention, the percentages for both categories of plans were even lower, but HMOs again fared better. Only 43% of HMOs and 7% of PPO/indemnity plans offered mental health promotion programs. Overall, 77% of HMOs were found to offer a moderate to comprehensive level of health promotion activities, compared with 40% of PPO/indemnity plans.

Offering health promotion plans is of course of no value if women do not use the programs, and Dr. Schaufflers data revealed that actual participation rates by women are extremely low. Only 1-3% of women reported having participated in a health promotion program of a health plan; this includes private insurance sources as well as Medicare and Medi-Cal. Rates were slightly higher, although still under 10%, for programs offered at the work site or through the community. No real differences are found when breaking this data down by type of health plan.

Dr. Schauffler concluded by observing that compared to PPO and indemnity plans, HMO and POS plans in California are much more likely to cover comprehensive clinical preventive services for women, offer comprehensive health promotion programs to their members and to the community, and to have relationships with community health agencies. Even in the best-selling plans in the state, however, many benefits that are integral to ensuring womens health are not routinely covered, including mental health services, substance abuse services, pharmaceuticals, and family planning and birth control services. Women in HMOs and PPOs are more likely to receive recommended clinical preventive services than those in indemnity plans; those in indemnity plans are less likely to receive pap smears and clinical breast exams. Counseling women about health behaviors is one of the most important things health plans can do to ensure the health of women in California, but the proportion of women who receive any counseling ranges from 45-60%. Health plans in California need to increase accountability for and incentives to providers to increase preventive counseling rates for women.

The major risk factors responsible for the leading causes of death and the future of womens health are not being adequately addressed in either managed care or indemnity plans. Despite the fact that HMOs offer more health promotion programs, utilization rates are low regardless of plan type. Women in Medi-Cal with the most risk factors have the lowest participation rates in health promotion activities, while women with employer-based insurance who are the healthiest have the highest participation rates. This presents a classic example of reverse targeting of health promotion programs for women; those who need them most are least likely to receive them. Health plans in California do the best job in providing preventive screening for breast and cervical cancer, but a much poorer job in preventing heart disease and other leading causes of death in women through efforts to change lifestyle behavior. Preventive health efforts in MCOs need to start focusing more on preventing heart disease in women, detecting it earlier, and treating heart disease in women as much if not more than prevention, early detection, and treatment of cancer. The medical care system needs to better support women in their efforts to change their health behaviors in addition to providing them with clinical preventive care. And managed care plans must do a much better job in counseling women about their health behaviors, particularly with regard to substance abuse, domestic violence, diet and exercise. We know a great deal about womens health care needs, but this knowledge has not been translated into health plan practices and the practices of health care providers. Dr. Schauffler closed by noting concern about uninsured women in California, who are much less likely to receive routine care and who are more likely to have unhealthy behaviors and poorer health status. Lack of insurance is the primary barrier to these women receiving needed care, and we should work to find ways to increase their access to comprehensive health care programs.

Health Care Purchasers

Catherine Brown, a consultant to the Pacific Business Group on Health (PBGH), discussed the health care purchasing strategies used by PBGHs 33 private and public members. To be eligible for PBGH membership, a company must have at least 2,000 employees eligible for health benefits. The coalition was formed to drive down premiums for its members by harnessing the clout of their market share; PBGH members combined spend $3 billion annually on health care. PBGH pursues its twin goals of quality/satisfaction improvement and cost reduction through negotiating both premiums and the reporting of performance data by health plans. The coalition attempts to "leverage quality" by working cooperatively with the various stakeholders - providers, health plans, consumers, and employers. Plans that participate in the PBGH quality initiative agree to put 2% of the premiums paid by PBGH members at risk for performance measurement against pre-determined target rates negotiated by the plans and purchasers together. The initiative uses some of the HEDIS measures of the National Committee for Quality Assurance, such as mammography rate, pap smear rate, and childhood immunization rate, but is looking to move "beyond HEDIS" to more outcomes-based measures. PBGH is also working with health plans on a standard plan benefit design, including services such as mental health and infertility benefits, and on preventive care guidelines. Ms. Brown noted that there is now a trend to reintegrate mental health benefits back into the basic health plan instead of carving them out, and employers are increasingly interested in moving toward parity with medical benefits.

The Health Plan Perspective

Kaiser Permanente.  The research and purchaser perspectives were followed by a panel of three health plan representatives. Rhoda Nussbaum, MD, in her first official public speaking role as Kaiser Permanentes new Womens Health Leader, noted that Kaiser currently serves one third of the population of Northern California. Kaiser Permanente pioneered access to health education, health maintenance, and preventive care. To further develop their efforts in womens health, Kaisers Northern California region convened a task force in 1996 which was co-chaired by Dr. Nussbaum. The task force identified several ongoing areas of emphasis in womens health delivery, including obstetrics and perinatal health, breast cancer, menopause, adolescence, and research. Dr. Nussbaum described several of the programs in place in each of these areas. She noted that Kaisers rate of initiation of prenatal care in the 1st trimester is 92%, and that their mammography screening rate for women 50-65 is 74%, above the Healthy People 2000 goal of 60%. Kaiser also has many initiatives underway in womens health research, including research on new pap smear technologies, low dose oral contraceptives and cardiovascular disease, and colon cancer screening, and the plan is participating in the NIH-sponsored Womens Health Initiative. The work of Kaisers task force led to the creation of the permanent Womens Health Leader position and an agenda focused on new models of care delivery, convenience for the consumer, partnership and trust, and an aggressive research agenda.

CIGNA HealthCare.  Rosaline Vasquez, MD, Associate Medical Director for CIGNA HealthCare, described the advantages of the independent practice association, or IPA, configuration, as this HMO model allows the health plan to offer enrollees a variety of providers, settings and locations; she also noted that CIGNAs network includes academic health centers. Dr. Vasquez went on to describe womens health initiatives in several areas, including: preventive health (mammogram coverage whenever recommended by a physician, a Healthy Babies program); specific therapies such as autologous bone marrow transplants for breast cancer; access to specialists such as ob/gyns; and new programs such as a 24-hour health information line. Dr. Vasquez added that public policy mandates are not the way to ensure quality health care and instead "drive up costs, which we all pay." Like Kaiser, CIGNA has many clinical studies ongoing.

PacifiCare.  Gordon Norman, MD, Regional Medical Director for PacifiCare, noted that Dr. Schaufflers data presented an interesting and "sobering" picture and said that no payers have successfully privatized public health. He contrasted the old fee-for-service system, characterized by "supply management," with the newer emphases on demand and care management, areas that have been historically untapped. And while managed care initially focused primarily on cutting costs, it is now moving to affect the other component of the value equation - quality. He defined managed cares mission as "only the appropriate care, but all the appropriate care, at the appropriate time, in the appropriate setting, by the appropriate provider, for the appropriate cost."

Dr. Norman outlined four general areas of womens concern with managed care: access, reproductive benefits, communication and empowerment, and quality improvement. He then described several program put in place by PacifiCare to address each of these areas, including a well-woman benefit and Express Referral program (access), female and male infertility diagnosis and treatment and the Healthy Pregnancy program (reproductive benefits), training, brochures, self-efficacy aids and risk assessments (communication), and strategic provider alliances and provider profiling (quality improvement). He noted that the purchaser community is "hungry" for information in the provider profiles. Some specific quality improvement targets have been diabetes, cardiovascular disease, depression, and maternal and child health.

Open Discussion

Seminar attendees used the open discussion period following the speaker presentations to query the panelists on a number of issues, including contraceptive coverage, the ability of community clinics to contract with managed care networks, and implementation and monitoring of clinical guidelines. An overall theme which has emerged during both seminars is the need of consumers for assistance learning the ways of the new world of managed care. This assistance is needed in the form of consumer-friendly information, patient navigators and ombudsmen programs. For while managed care is often billed as an integrated and seamless system of care, consumer experiences are indicating that they are having to become fairly sophisticated managers themselves of these new managed care systems and their accompanying rules and procedures.

 Lessons Learned

HMO and point-of-service (POS) options are more likely to cover comprehensive clinical preventive services and offer comprehensive health promotion programs to their members, and their premiums also tend to be lower, which indicates greater overall value to women from HMO and POS options over PPO and indemnity plans.

Incentives must be changed to encourage preventive counseling by health care providers.

The public health safety net is doing a better job than all types of private insurance, both managed care and indemnity, in providing certain preventive counseling services, including diet, exercise, smoking, HIV/STDs, and gun safety.

Most women are receiving regular check-ups and exams, yet are not receiving preventive counseling, indicating a large number of missed opportunities by health care providers.

Even in the best-selling health plans in the state, many benefits that are integral to ensuring womens health are not covered, including mental health services, substance abuse services, pharmaceuticals, and family planning and birth control services.

There is now a trend to reintegrate mental health benefits back into the basic health plan instead of carving them out, and employers are increasingly interested in moving toward parity with medical benefits.

Quality can be leveraged by working cooperatively with the various stakeholders - providers, health plans, consumers, and employers.

The purchaser community is increasing its demands for information from health plans.

MCOs are in effect requiring women to be sophisticated managers of their own care when they are ill, and consumers are increasingly frustrated. This is a particular problem in the Medi-Cal program. Many consumers see a need for an ombudsman program and greater patient advocacy within managed care. Patient navigators would be a helpful start.

MCOs should cover contraceptives better and encourage their utilization by removing co-payments and by instituting privacy protections; family planning should be viewed in the same mode as other preventive services.

Women need better information that is consumer-friendly. At the same time, health plans need to be more cognizant of womens individual needs, and not just the needs of health care purchasers. The flow of information must be two-way.

MCOs should look to contract with community clinics and other traditional providers such as Planned Parenthood which have served as the backbone for the Medi-Cal program.

Managed care may have a potential role in documenting emerging health impacts, such as injuries and health risks sustained on the job.

There is a difference between a health plan covering a service and actively offering it; this likely has an impact on utilization.


1. See Schauffler HH, Brown ER, Rice T. The State of Health Insurance in California, 1996. UCLA Center for Health Policy Research. January 1997.