HOW TO CHOOSE WISELY

Into most American lives a managed-care plan will someday come--along with voluminous and bewildering packets of information supposedly designed to let the patients know what sort of health care they can expect. But how to choose? Some organizations, and even some popular magazines, have attempted to rank the HMOs, but their various methods of scoring are at cross-purposes--and may have little to do with the quality of care. For starters, some HMOs have simply declined to participate in these surveys or submit to the accreditation process established by the nonprofit National Committee for Quality Assurance. Moreover, a recent Massachusetts study found that high member "satisfaction" rates reflect good customer relations, not necessarily good medicine.

So far, the most useful vehicle for ranking plans is HEDIS, a set of criteria for evaluating an HMO that lists more than 100 points of comparison, ranging from "childhood immunization" to "ambulatory follow-up for major affective disorder." But HEDIS, with its emphasis on preventive care, is easy to manipulate. When cholesterol tests became a key criterion, HMOs scrambled to offer the tests--often with no follow-up on the patients' results. Most experts agree that it is much more useful for a patient to know the breast-cancer survival rate in a given plan than to know whether it offers free mammograms.

Alas, recovery and survival rates, known in the trade as "outcome studies," are the one objective measure of health-care organizations not available to consumers, and they won't be for several years. The plans have not been eager to compile these data. But now some of the biggest consumers of health care--groups like the American Association of Retired Persons and General Motors--are pressuring managed-care companies to participate in independent outcome studies coordinated by the nonprofit Foundation for Accountability, in Portland, Oregon. Watchdog groups have encouraged the industry to adopt uniform standards for what a plan must disclose to consumers until those data are available. In December the American Association of Health Plans began instructing its members to provide, on request, clear information about:

--How participating physicians are paid.

--How treatment decisions are reviewed.

--The basis for specific treatment decisions.

--Whether a specific drug is covered.

--How plans determine whether a treatment is designated "experimental."

In addition, patient advocates say, a consumer should ask any prospective health-care provider:

--What is the "medical-loss ratio" (the amount that the provider actually spends on medical care)?

--Are there "gag clauses" that keep a doctor from recommending treatment or criticizing the plan?

--Does the HMO have a "no cause" clause allowing it to fire a physician at will?

--What percentage of claims has the plan turned down or denied?

--What is the percentage of emergency-room denials?

--What are the appeals procedures if a claim is turned down?

--What is the satisfaction rate among chronically ill patients?

--Is the HMO registered with the AAHP, and is it accredited with the NCQA?