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Surveys: Wrangling With HMOs

If your experience with HMOs has been frustrating, you're not alone, reports CBS News Correspondent Dan Raviv.

According to the results of two new surveys announced Wednesday, consumers and doctors both report widespread trouble getting needed care from HMOs. Nearly nine in 10 doctors and one in four consumers complained they had difficulties getting needed services.

In addition to that survey, the Kaiser Family Foundation also released a survey of doctors and nurses. It documented frustration, but also found doctors regularly intervening to fight for care they believed to be necessary and usually succeeding.

"This level of conflict and administrative haggling between doctors and plans can't be good for our health care system or for patients who are often caught in the middle," said Drew Altman, president of the foundation, which conducted the poll with the Harvard School of Public Health.

The Kaiser surveyed 1,053 doctors and 768 nurses by mail between February and June. Both groups were randomly chosen.

It found 87 percent of doctors said their patients had experienced some type of denial of coverage over the last two years. The following numbers reflect the percentage of doctors who reported having trouble getting coverage for various reasons:

  • 79 percent had difficulty getting approval for a drug they wanted to prescribe.
  • 69 percent for a diagnostic test.
  • 60 percent for a hospital stay.
  • 52 percent for a referral to a specialist.
  • 38 percent for mental health or substance abuse referrals.

Depending on the type of care denied, one-third to two-thirds of doctors believed it resulted in a serious decline in health. Denials of mental health were most likely to be serious, followed by referrals to specialists; denials of drugs and hospital stays were least likely to be seen as serious.

Similarly, about half of nurses said they had seen a decision by a health plan that resulted in a decline in a patient's health in the last two years.

Two in three doctors said they sometimes or often make contact with a health plan on behalf of patients to fight for treatments they think are necessary. Out of that group, 42 percent said the issue was resolved in favor of the patient and 22 percent said there was a compromise.

In addition, about three in 10 doctors and nurses say they sometimes or often exaggerate the severity of a patient's condition to get them needed care.

The annual survey by the National Committee on Quality Assurance, meanwhile, evaluated 523 health plans offered by 247 insurance companies.

Of those, 410 plans serving nearly 70 million Americans allowed their data to be publicly released -- a big jump from last year, when many companies feared negative publicity and insisted on secrecy.

Overall, there was little change on measurements such as immunizations, advising smokers to quit, screening for breast and cervical cancer and giving early prenatacare.

The report also looked at consumer satisfaction and found 26.5 percent had trouble getting needed care, including difficulty seeing a doctor they liked and getting referrals to specialists. Patients gave higher overall marks to the office staff and doctors and nurses than to the health plans.

Nearly half the people said they had a problem with paperwork, understanding written materials or getting help from a customer service line.

The report also found continued enormous disparities among health plans across the country. In the best plans, more than 80 percent of diabetics -- at risk for blindness -- got eye exams; in the worst, it was below 10 percent.

Health plans in New England were again the top performers and those in the South Central region did the worst.

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