Book Review

The Insider's Guide to HMOs: How to navigate the managed-care system and get the health care you deserve

N Engl J Med 1998; 338:398February 5, 1998

Article

The Insider's Guide to HMOs: How to navigate the managed-care system and get the health care you deserve
By Alan J. Steinberg. 231 pp. New York, Plume Books, 1997. $12.95. ISBN: 0-452-27691-8

With employers, advocacy groups, and publications of every stripe disseminating their own ratings of health maintenance organizations (HMOs) and advice for picking the best one, it was inevitable that doctors would soon contribute to the growing stack of how-to literature on the subject. Dr. Alan Steinberg, a member of the Access Medical Group in Marina del Rey, California, jumps into this genre with insider's tips, points to ponder, points to remember, a “safety” scale for rating health care plans, and even a method for evaluating doctors.

But like so many advice books, this one promises more than it delivers. What useful information there is comes wrapped around a sales pitch for returning control of health care to medical groups like Dr. Steinberg's and for medical savings accounts, which some physicians hope will free them from the constraints of managed care.

No one has yet devised a foolproof way to tell HMO recruits that Plan A will take better care of them than Plan B when they get sick, and Dr. Steinberg's safety scale for rating HMOs doesn't come close to elucidating that one piece of truly useful information. Apparently, a “safer” plan is one that offers the potential for unlimited services. The scale allocates more points to plans that are run by doctors, that directly employ primary care physicians, that pay all doctors fees without a bonus, that avoid using nurse practitioners to diagnose and treat patients, and that are not allowed to terminate physicians without “good reason.” In other words, the scale rewards plans that are akin to the fee-for-service model whose defects brought about managed care in the first place.

Dr. Steinberg offers many tips throughout the book. Some are shopworn — for example, “Check the financial rating of each HMO . . . to make sure you are not on a sinking ship.” Some are naive, such as the recommendation to interview doctors' nurses and see what they'll tell you about their bosses. Other tips, such as those for choosing doctors, are somewhat more useful: Do they squirm when you ask questions about payment? Do they have experience handling medical problems such as yours?

Dr. Steinberg might have been better off sticking to tips on picking a doctor and monitoring his or her body language, because when he ventures into the nuts and bolts of health insurance he is out of his league, dishing up misinformation that may actually hinder readers making complicated decisions. To take one example, he states that a Medigap policy pays “at least 80 percent of the $736 for the first hospital day [the deductible]” and at least 80 percent of the hospital coinsurance for days 60 to 90. In fact, all supplements must pay 100 percent of the hospital coinsurance, and all, except the most basic Plan A, pay 100 percent of the hospital deductible.

Dr. Steinberg doesn't seem to like HMOs, especially capitated plans, and although he tries to lay out the pros and cons of fee-for-service and managed care, he overstates the flaws in the latter to the point that he is barely believable. For instance, he says, “Doctors who are paid by Medicare on [a fee-for-service] basis have a financial incentive to keep you alive, but the same cannot be said for Medicare HMO doctors. . . . You may be worth more to your HMO doctor dead than alive” — an overstatement that would surely surprise millions of beneficiaries who are happy with their plans. Another example: “It is a fact that many HMOs do not want to be associated with hospitals with a sterling reputation for fear of attracting a disproportionate number of patients who may need to be hospitalized at some point.” That statement cries out for proof. Which plans? Which hospitals? Specifics, if Dr. Steinberg has them, might have provided worthwhile information.

But it is Dr. Steinberg's pitch for medical savings accounts, woven into his text and made explicit at the end by Dr. Ronald Bronow in an afterword, that is the most troubling. Medical savings accounts spell potential disaster for unlucky consumers who get sick, save too little in their accounts, and opt for too big a deductible that results in an unaffordable expense. Medical savings accounts should be discussed, but in a fair way, noting their downsides and giving warnings as well. This book urges consumers to buy them without explaining the risks. It is hard to recommend a how-to book that omits such vital advice.

Trudy Lieberman
, Yonkers, NY 10703