Differences in the kinds of problems consumers report in staff/group health maintenance organizations, independent practice association/network health maintenance organizations, and preferred provider organizations in California.

BACKGROUND

Little is known about the extent to which consumers have specific problems with their managed care organizations (MCOs) or whether these problems differ by type of MCO.

OBJECTIVE

To estimate the prevalence at which consumers in managed care report specific problems and to assess whether rates in preferred provider organizations (PPOs), independent practice association (IPA)/network health maintenance organizations (HMOs), and staff/group HMOs differ.

DESIGN

Random probability sample of insured adults weighted to reflect the underlying population in California. A computer-assisted telephone interview survey was conducted in September 1997. Logistic regression models estimate the adjusted odds of reporting each problem in the last year in IPA/network HMOs versus PPOs, IPA/network HMOs versus staff/group HMOs, and staff/group HMOs versus PPOs.

SUBJECTS

One thousand two hundred one insured adults who had resided in California for > or = 12 months.

MEASURES

Prevalence of 11 consumer problems in MCOs.

RESULTS

Forty-two percent of adult Californians in managed care in our sample reported > or = 1 problem with their MCO in the last year. Adjusted odds that adults in IPA/ network or staff/group HMOs reported delays in getting needed care, not receiving the most appropriate or needed care, and being forced to change doctors were higher than for adults in PPOs. Adjusted odds that adults in IPA/network HMOs reported difficulty getting a referral to a specialist and difficulty selecting a doctor or hospital were higher than for adults in PPOs and staff/group HMOs. Adjusted odds that adults in staff/ group HMOs reported misunderstandings over benefits and coverage; important benefits not covered; and problems with claims, billing, or payments were lower than for adults in PPOs and IPA/network HMOs. Adjusted odds that consumers in HMOs in our sample reported any problem with their health plan was higher for those in IPA/network HMOs compared with staff/group HMOs. No differences were seen by MCO type in the rates at which consumers reported being denied care or treatment, forced to change medications, or language and communication barriers.

CONCLUSIONS

Rates at which consumers report problems with managed care and the kinds of problems they report differ significantly across different types of MCOs. These findings have important implications for federal and state policy for consumer protections in managed care.