Correspondence
Not-for-Profit Health Plans
N Engl J Med 1996; 335:438-439August 8, 1996
- Article
To the Editor:
In reply to the Sounding Board article by Nudelman and Andrews (April 18 issue),1 I would point out, first, that to remain competitive in the current market environment, for-profit health plans must provide access to high-quality medical care. Employers, the main purchasers of health care services, are not only expecting but also demanding tangible evidence of the value of their health care dollars, and health-plan enrollees will vote with their feet by selecting plans that provide access to high-quality medical services. The notion that for-profit health plans are not concerned with quality is at best naive.
Second, for-profit plans have made and will continue to make important contributions to the public's understanding in the area of applied health services and outcomes research, ranging from diffusion of new medical techniques2 to the “downstaging” of breast cancer3 and increased compliance with guidelines for the prevention of diabetes.4
Third, documented studies have indicated that there is no correlation between the profit status of a health plan and levels of preventive care services. In 1994, for example, 21 for-profit and nonprofit health plans across the country participated in the Report Card Pilot Project of the National Committee for Quality Assurance5 and published their performance profiles on preventive care services. Some nonprofit health plans consistently scored below the grand mean, whereas some for-profit health plans consistently scored above it. With regard to the breast-cancer screening program the authors mention in their article, the mammography rate for the Group Health Cooperative of Puget Sound in this national audited project indeed exceeded the goal of 60 percent set by Healthy People 20006 but fell below the grand mean of the overall group and below the rates for some for-profit health plans.
Finally, even if one were to accept the argument that the return on investment from nonprofit health plans goes back into the communities that they serve, the data the authors provide in their editorial do not support their argument. They claim that 70 percent of patients over the age of 65 at the Group Health Cooperative are immunized against influenza, as compared with 20 to 40 percent of people in the community they serve as a whole. In this particular case, apparently the community has not benefited by the presence of a nonprofit health plan and its investment in social capital.
Market-based health care and managed competition are the forces behind the improvement in quality of service and medical care in this country, not tax exemptions or government mandates.
6 ReferencesAntonio P. Legorreta, M.D., M.P.H.
Health Net, Woodland Hills, CA 913671
Nudelman PM ,Andrews LM . The “value added“ of not-for-profit health plans. N Engl J Med 1996;334:1057-1059
Full Text | Web of Science | Medline2
Legorreta AP ,Silber JH ,Costantino GN ,Kobylinski RW ,Zatz SL . Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA 1993;270:1429-1432
CrossRef | Web of Science | Medline3
Solin LJ ,Schultz DJ ,Legorreta AP ,Goodman RL . Downstaging of breast carcinomas associated with mammographic screening. Breast Dis 1995;8:45-564
Brooks RJ ,Legorreta AP ,Silver AL ,Fabius RJ ,Krakovitz J . Implementing guidelines for eye care of diabetic patients: results from an HMO intervention study. Am J Manag Care 1996;2:365-3695
Report Card Pilot Project. Washington, D.C.: National Committee for Quality Assurance, 1995.
6
Public Health Service. Healthy People 2000: national health promotion and disease prevention objectives: full report, with commentary. Washington, D.C.: Government Printing Office, 1991. (DHHS publication no. (PHS) 91-50212.)
To the Editor:
The planet on which Nudelman and Andrews live sounds like a very attractive place, but here on planet earth, where I have been practicing medicine in exclusively not-for-profit hospitals for nearly 30 years, I have yet to see the idealistic attitudes and behavior they describe in their not-for-profit world. The hospitals, regardless of what they or anyone else says, are all busily preoccupied with the problems of survival in a competitive world, and the pennies are pinched and the bottom line is defended just as aggressively as in for-profit hospitals.
Nudelman and Andrews loftily suggest that their health plan has discovered how to approach, and presumably to ameliorate, problems that have eluded the rest of us, such as teenagers smoking and people stabbing each other. If so, they are to be congratulated, and they should share their secrets. The not-for-profit hospitals with which I am familiar do not, and cannot, tilt with those windmills and others that Nudelman and Andrews mention, and I doubt that they should. Certainly someone should be looking for ways to prevent teenage smoking, and to prevent, rather than simply sew up, knife wounds, but I question whether health plans or hospitals, not-for-profit or otherwise, are in a position to take responsibility for these problems.
Robert H. Harris, Jr., M.D.
1717 North E St., Pensacola, FL 32501To the Editor:
. . . Whereas Nudelman and Andrews detail one nonprofit organization's exemplary accountability, community service, and commitment to values and effectively contrast these features with those of a typical for-profit organization, their plan does not represent every nonprofit organization. I have seen nonprofit organizations behave very differently from the Group Health Cooperative of Puget Sound but quite similarly to for-profit plans, with the one exception that the “profit” they generated in their operations was spent internally on excessive executive-management salaries and other inefficiencies that failed to yield direct health care benefits to the people they serve. Regrettably, these pseudo-nonprofits will probably survive for at least a time in the marketplace, since their internal inefficiencies may be counteracted by the economic benefits they derive from the tax structure, unless there is more appropriate regulation, enforcement, or both.
David L. McCartney, M.D.
Texas Tech University Health Sciences Center, Lubbock, TX 79430To the Editor:
Nudelman and Andrews speak only of the present and make no reference to where our American system of health care is headed in the future. Like all new and successful markets, the health care market is moving toward efficiency. In health care, an efficient market will come to mean a healthy market; the plans that will survive will be those that can maintain healthy populations. The niche that nonprofit plans have found in prevention and community service will consequently become a market norm, because all health care organizations will be striving to survive in an efficient market. As this comes to pass, one will find that investor-owned plans will be more successful in accomplishing services that the nonprofit sector considers to be exclusively nonprofit phenomena. Why? Because for-profit plans will have the capital to do it better. . . .
The article also claims that investor-owned plans are accountable exclusively to their shareholders. However, a for-profit institution is accountable to two entities, its shareholders and its stakeholders. For investor-owned health plans, these stakeholders are patients, providers of care, payers, and the communities in which they operate — the exact same people that nonprofit plans answer to. . . .
Melissa Commins, B.S.E.
9761 Sibley Cir., Orlando, FL 32836Editor's note:
The foregoing letters were referred to Drs. Nudelman and Andrews, who declined to reply.
