The Health
Maintenance Organization Delivery System A National Study of Attitudes of HMO Project Directors on HMO Issues DOMAN LUM, PhD, ThD
The results of a national survey of health maintenance organization project directors' attitudes on HMO delivery issues are presented and discussed.
Introduction Within the last 3 years, prepaid group health care has received national prominence. In his 1971 health message to the 92nd Congress,1 President Richard M. Nixon made the reorganization of health delivery services a focal point of his health program. He proposed a health maintenance organization (HMO) system which would offer comprehensive services purchased annually at a prepayment rate from a medical group through capitation contracts. Rather than massive federal regulations, investment, and planning, Nixon envisioned economic and professional incentives with an emphasis on self-regulation based on a competitive market and on the preventive maintenance of health. Consumers would be able to chose between conventional health insurance and health maintenance contracts from a variety of competing organizations. The HMO program would generate a variety of organizational arrangements with physicians, involvement of private corporations for capital resources, government grants and loans for planning, construction, and initial operations, a competitive market to control costs and improve distribution, and minimal government interference in internal organization. Dr. Lum is Associate Professor in the School of Social Work, California State University, Sacramento, California 95819. At the time of this study he was with the School of Applied Social Studies, Case Western Reserve University, Cleveland, Ohio. This article was submitted for publication in June, 1973, and revised July, 1975. 1192 AJPH NOVEMBER, 1975, Vol. 65, No. 11
During 1971 and 1972, the Administration began to fund feasibility studies and gear up for the HMO delivery system. The Department of Health, Education, and Welfare (DHEW) established the Health Maintenance Organization Services within the Health Services and Mental Health Administration. Through general legislative authority to stimulate experimental health care delivery mechanisms, approximately $10 million was distributed for 86 HMO planning and development grants and 24 technical support activity grants and contracts. Funds were obtained from research and experimentation allocations of comprehensive health services, regional medical programs, and health services research and development. DHEW has curtailed the awarding of grants and is awaiting enactment of specific HMO legislation. However, technical assistance and consultation to HMO planning groups are available.
Purpose of the Study The purpose of this research is to conduct an exploratory study on the attitudes of health maintenance organization project directors regarding HMO delivery issues. Specifically, we refer to the 86 HMO planning and development institutional grantees funded by DHEW. Hopefully, the results of this preliminary study may lead to the formulation of problems for more precise investigation or the development of hypotheses.
Background of the Study Major health delivery issues have emerged from an extensive discussion of the HMO system. Among them are: Prepayment Mechanism
Prepayment has been promoted as an alternative to the traditional fee-for-service mechanism which is utilized by the majority of physicians and criticized for promoting overutilization of services, raising medical costs, and providing high reimbursement from medical insurance. Prepaid group practice studies demonstrate a reduction in the number of hospital days, hospital admissions, and hospital surgical cases. 2, 3 Prepayment controls cost of medical care, encouraging physicians to promote cost effectiveness and eliminating the performance of unnecessary services to increase physicians' income. Others contend that prepayment may foster the underutilization of services to keep cost down and profit high. 4 Moreover, factors other than prepayment may have contributed to reduced hospitalization. Klarman contends, for example, that during this time hospital beds were available because of limited supply to the Health Insurance Plan of Greater New York and that the low ratio between beds and population under the Kaiser-Permanente program was a crucial factor that caused lower hospital occupancy among its subscribers.5 Quality of Care Quality of care has been an issue for providers, consumers, and the government. From the providers' viewpoint, the balance between volume business and maintaining quality has been a major problem. However, Kaiser-Permanente research shows that patients average four visits per year and that urban indigent families generally have a pattern of use similar to that of other members.6 7 Physicians are concerned whether HMO quality of care may suffer from high physician-patient ratios, frequent referrals to other specialists, long waiting periods, and the lack of continuity. Critics further contend that an HMO may sacrifice quality for profit motives, whereas supporters argue that consumers could transfer to another HMO for medical care. This presupposes that there would be sufficient funds for an adequate number of HMOs to generate competitive prices and services. Federal Regulation
There has been vigorous debate in HMO legislation over the degree of government regulation. On the one hand, the potential for abuse is significant. Saward and Greenlick claim that the enthusiasm for HMOs may wane when the total constraints and their implications become clear.8 On the other hand, Havighurst advocates a free, competitive market among HMOs. He claims that trade restraints have prevented effective functioning of the health care industry, that competition would result in self-regulation, and that federal antitrust suits could be introduced in case of a
monopoly.9
The Administration initially argued that competition among HMOs, local peer review, and minimal federal monitoring will promote self-regulation among providers. Even if this could be realized, however, existing medical and hospital practices may force the government to formulate strong regulations to control abuse. Underlying this discussion is whether or not the existing health care system controlled by medical societies can change without government intervention. Consumer Participation
Involving consumers in the decision-making process of an HMO and establishing a grievance procedure for consumers are further issues. Medical policy- and decisionmaking are often viewed as areas for physicians. Some have misgivings about consumers on an advisory or policy board, an ombudsman for consumers, or a consumer grievance mechanism. Although there is a need for further study on the effects of consumer participation in a health setting, the Office of Economic Opportunity has conducted research on the interaction between consumers and providers in neighborhood health centers. A study of 160 consumer participants in neighborhood health centers showed that conflict between consumers and providers became intense when a consumer group held only partial power (e.g. advisory roles). There was less conflict when it retained clear dominance. Issues involved citizen participation, the practice of medicine in health centers, administration of the centers, training and employment of residents from the service area, neighborhood residents' utilization of the centers, financial problems, and relationships with outside groups. 1 0 A similar pattern may confront HMOs with consumer participation features. Public and Private Funding It is estimated that it will cost an average of $250,000 to plan an HMO, up to $2.5 million in capital for construction, and a minimum population enrollment of 20,000 for a solvent group health plan."1 The critical start-up period varies from 1 to 3 years and capital resources are necessary to maintain high initial development. Although Kaiser estimates that it takes 2 to 3 years to break even and losses may reach $2 million, at least for the current Kaiser Health Plan earning rate, 3 to 4 months make this up out of income from total health plan operations. 12 However, many HMOs may not have the financial reserves of Kaiser-Permanente. Funding has become a critical issue since the Administration has reserved its position on HMOs. In his 1974 budget message to Congress, Nixon relegated the HMO program to a demonstration basis. 3 In the 93rd Congress, the compromise House bill accordingly cut HMO funds. It offers loans and loan guarantees for initial operation costs
and deletes all previous features. It appropriates $60 million per fiscal year over a 4-year period compared with the $890 million provision of a nearby full-scale Senate bill.14 In the HEALTH MAINTENANCE ORGANIZATIONS 1193
end, the Health Maintenance Organization Act of 1973 allocated $375 million to study the feasibility of prepaid care. Will the private sector be willing to invest the necessary capital to offset lean Congressional appropriations? Physicians' Attitudes
There are some indications of how physicians feel toward prepaid group practice which have bearing on physician recruitment and turnover. Research on group practices reports that physicians involved are satisfied with their arrangements. They feel they have professional support and stimulation from professional colleagues, a regular work schedule, and opportunities for continued education. Furthermore, they believe that group practice reduces medical overhead and the financial risk of starting up a practice. 15 Surveys of physicians inside and outside prepaid group arrangements lack adequate research methodology and require more intensive scientific design. However, there seems to be a preference for private fee-for-service practice. With respect to group practice turnover rates, KaiserPermanente in Northern California reported in 1970 that the annual terminations were 12.3 per cent of employed physicians and 4.8 per cent of partners. Full-time physicians on the average were with the program for 5 years or less and three-fourths joined within the last 10 years.16 At the same time, further research is need to determine whether physicians can be recruited into HMOs and how long they anticipate remaining in this structure. Consumer Recruitment
HMO legislation initially asked for a voluntarily enrolled population to join a prepaid group practice with an annual open enrollment period without discrimination. A balanced membership was ensured through percentage limits set on persons from medically underserved areas. However, the concern is whether an adequate number of consumers can be recruited for an HMO. Critics contend that although Kaiser-Permanente has been in existence for 30 years, it has attracted only 2 million subscribers, primarily middle class workers through their places of employment. It has only recently broadened the enrollment base to lower socioeconomic groups on a limited scale, with uncertainty as to how medical indigents might use services. Likewise, HMO proponents cannot predict whether prepaid group practice on a large scale might affect existing patterns of behavior among consumers who have formed ties with a physician in fee-for-service private practice over the years. People may not reside near an HMO and may also be reluctant to sever the relationship with a particular private family doctor. These issues raise the need for more research in these areas from a health planning viewpoint.
Study Design The specific research question posed by this exploration study is: What are the attitudes of health maintenance 1194 AJPH NOVEMBER, 1975, Vol. 65, No. 11
organization project directors toward HMO delivery issues? A questionnaire was designed with a Likert-type scale to gather data on demographic variables, HMO project variables, and attitudes on delivery issues. A pre-test of the questionnaire was conducted with the health concentration fa-culty of the Case Western Reserve University School of Applied Social Sciences, and the health planning staff of the East Cleveland Human Services Center. Suggested changes regarding phrasing, length, and format of the questionnaire, and other aspects, were made on the instrument. Through the DHEW Health Services and Mental Health Administration, Health Maintenance Organization Service, the January, 1972, Funded HMO Planning and Development Grants and Contracts Directory was used as a reference for the sampling. The 86 planning and development grants and contracts agencies were in 37 states and the District of Columbia, generally funded on a 12-month basis, nonprofit, and sponsored by 10 types of organizations with a variety of proposed plans. It was decided that the sampling would be the 86 HMO project directors in the DHEW directory. After two mailings of the questionnaire, the response rate was 79 per cent (sample number-67) of the total group. However, there were 13 questionnaire returns which could not be used in the study (four were returned with no forwarding address, four indicated the termination of the HMO program, two were consultation firms, two were returned after the data were analyzed, and one was discarded for lack of adequate data). The actual sample number for the study was 54 (63 per cent). A comparison was made between those who responded and those who failed to answer to determine whether there was a biased return. Such factors as geographical location, sponsor type, amount of grant, and description of project revealed no differences when comparisons were made.
Research Findings: Demographic and Project
Variables Characteristics of HMO Project Directors Research data indicated at HMO project directors tended to be males between ages 25 and 45 (69 per cent). Approximately 50 per cent graduated from professional school between 1960 and 1973, while 35 per cent graduated between 1940 and 1959. Their professional credentials reflected a variety of backgrounds: master's degree types of administrators (43 per cent), MD physicians (24 per cent), bachelor's degree types (17 per cent), and an assortment of
other professional doctorates (7.4 per cent). Nearly threefourths of the group had been employed with their present institution less than 5 years. This may indicate that these directors were hired for the specific HMO project, although many of them indicated serving in a dual role with another responsibility. Nearly one-half of them, however, reported 5 or less years of health planning and administration experience, while another 37 per cent were in this field between 6 and 15 years (Table 1).
TABLE 1-Characteristics of HMO Project Directors No.
%
NA*
1 18 19 11 4 1
1.9 33.3 35.2 20.4 7.4 1.9
Sex Male Female NA
39 6 9
72.2 11.1 16.7
6 13 19 8 8
11.1 24.1
35.2 14.8 14.8
Degree MD Other doctorate Master Bachelor NA
13 4 23 9 5
24.1 7.4 42.6 16.7 9.3
Employment with present institution (years) 0-5 6-10 11-15 16-20 31 andover NA
41 2 2 3 1 5
75.9 3.7 3.7 5.6 1.9 9.3
25 11 9 4 1 2 2
46.3 20.4 16.7 7.4 1.9 3.7 3.7
Age Under 25 25-35 36-45 46-55 56-65
Graduation from professional school 1940-1949 1950-1959 1960-1969
1970-1973 NA
Health planning and administration experience
(years) 0-5 6-10 11-15 16-20 26-30 31 andover NA *
NA, no answer.
Characteristics of the HMO Program Ten types of institutions were identified as sponsors of the HMO project. Private hospitals, physician groups, private medical schools, medical care foundations, insurance companies, and private corporations were classified under the general category "private." Public hospitals, consumer groups, public medical schools, and public groups were termed "public" for the purpose of comparison. Findings indicated slightly more private (54 per cent) than public (43 per cent) institutional sponsors as well as a number of multi-agency coalitions or interorganizational arrangements (17 per cent) which were labeled as "combi-
nation." However, in most cases, the majority of projects were ''single" institution sponsorship. Projected medical services for HMOs revealed comprehensive coverage. Approximately 85 to 93 per cent of the projects indicated physician services, inpatient hospital services, outpatient hospital services, out-of-area emergency reimbursements, diagnostic laboratory services, physical medicine and rehabilitative services, preventive health and early disease detection services, and radiological services. Between 72 and 79 per cent reported plans for extended care facilities, home health, vision care, and mental health services. The three least offered services were prescription drugs (67 per cent), dental services (43 per cent), and podiatric services (43 per cent). On the whole, however, the data suggested that HMOs planned to offer a nearby full range of services. HMO legislative proposals have influenced project planning regarding consumer participation, role of physicians, federal regulations, and location of facilities. Concerning consumers, there was strong agreement on consumer participation on policy boards of HMOs (94 per cent). Likewise, consumer grievance procedure (89 per cent), provisions as a nonprofit corporation (85 per cent), and centralized record keeping (85 per cent) demonstrated high consensus. However, with respect to the role of physicians, the data reflected varying organizational configurations to encourage more physician participation rather than regulations against loose arrangement patterns. For example, project directors reported use of physicians outside the HMO staff (74 per cent) and salaried positions of physicians (63 per cent). It is interesting to note that 61 per cent made provisions for federal regulations and monitoring of HMOs. It may suggest that HMO directors recognize that a degree of federal regulation is inevitable and are awaiting the legislative outcome with an anticipation of federal regulations. Yet 39 per cent chose not to answer this item, which may express resistance. The main objective of HMO legislation is to redistribute health manpower and facilities to medically underserved areas for persons who are unable to afford adequate services. However, only 65 per cent made provisions for recruitment of medical indigents. At the same time, most of the HMOs plan to locate in the inner city (50 per cent) or in a rural area (54 per cent). A few indicated both areas or neither. As regards implementation of HMO projects, 63 per cent were still in the feasibility study or follow-up planning phase by April, 1973. Only 28 per cent were in initial or full-scale operations. Whether the majority of institutions with planning grants were awaiting legislation outcome and/or were without necessary funds to generate an HMO on their own initiative is unknown to this researcher. Finally, reactions of physicians affiliated with the sponsoring institution were 68 per cent favorable and 23 per cent unfavorable. This is, however, no indication of how physicians in general feel about HMOs or whether they would be willing to become HMO staff. Rather, it is a HEALTH MAINTENANCE ORGANIZATIONS 1195
preliminary gauge of how physicians of sponsoring institutions initially react to the HMO plan, from the perceptions of the project director (Table 2).
Research Findings: Delivery Issues Scale 1: Prepayment Mechanism HMO directors tended to favor the prepayment mechanism, although they were aware of potential abuse. They agreed that prepayment is an incentive for physicians to promote cost effectiveness (81 per cent) and a deterrent against the performance of unnecessary services (85 per cent). Moreover, they further agreed (72 per cent) that fee-for-service promotes overutilization of services and that prepayment controls medical care costs. However, although 63 per cent disagreed that prepayment fosters underutilization of services, 33 per cent agreed that there were grounds for such criticism (Table 3).
Scale 2: Quality of Care
HMO directors tended to believe that quality of care would be maintained, but moderately agreed on an efficiency increase or a basis for comparing quality among other types of organizations. For example, they strongly agreed that no quality of care would be lost due to high physicianpatient ratios (83 per cent) and that on a competitive basis an HMO would maintain quality of care (94 per cent). There was, however, less agreement that quality of care might suffer due to caseload volume, that is, the higher the caseload, the lower the quality, and even moderate agreement and disagreement over whether an HMO increases quality of care because of efficient operations or whether quality was comparable between HMO and non-HMO providers (Table 4). Scale 3: Degree of Federal Regulation Federal regulations evoked a measure of disagreement, although responses were in the agreement-disagreement range. Most disagreement (61 per cent) was over uniform government regulations for HMO operations and organizations. The implication is for individual expression for each HMO within general boundaries. Mixed reactions prevailed over the potential for abuse without federal regulations, organizational and operational self-determination without government regulations, the adequacy of competition as a self-regulation device, and the threat to shaping organizational patterns for the local situation. Perhaps the need for a balance between general federal guidelines and intraorganizational autonomy on the local level is communicated in these responses (Table 5). Scale 4: Consumer Participation By and large, HMO directors strongly endorsed the role of consumers in HMO policy formation and decision-making (93 per cent). However, some variation occurred among opinions about aspects of consumer participation. For 1196 AJPH NOVEMBER, 1975, Vol. 65. No. 11
TABLE 2-Characteristics of HMO Program
Characteristics Sponsorship Private Public NA Single Combination NA Medical services Physician services Inpatient hospital services Outpatient hospital services Extended care facility services Home health services Vision care services Podiatric services Out-of-area emergency services reimbursement Mental health services Dental services Diagnostic laboratory services Physical medicine and rehabilitative services Preventive health and early disease detection services Prescription drugs Radiological services
Others Administrative features Recruitment mechanisms for medical indigents Location in inner city Location in rural area Centralized record keeping Use of physicians outside HMO staff Provisions as a nonprofit corporation Salaried positions for physicians Provisions for federal regulations and monitoring of HMO Consumer participation on policy board Consumer grievance procedure Others Developmental phase Feasibility study Follow-up planning Construction of facility Initial operations Full-scale operations
Reactions of physicians to HMO project Strongly favorable Moderately favorable Slightly favorable Slightly unfavorable Moderately unfavorable Strongly unfavorable NA
No.
%
29 23 2
53.7 42.6 3.7
43 9 2
79.6 16.7 3.7
50 50 48 39 42 39 23 46 39 23 50 46 48
92.6 92.6 88.9 72.2 77.8 72.2 42.6 85.2 72.2 42.6 92.6 85.2 88.9
36 49 8
66.7 90.7 14.8
35 27 29 46 46 40 34 33
64.8 50.0 53.7 85.2 74.1 85.2 63.0 61.1
51 48 4
94.4 88.9 7.4
12 22
22.2 40.7 7.4 18.5 9.3
4 10 5
7 21 9 4 6 2 5
13.0 38.9 16.7 7.4 11.1 3.7 9.3
example, there was slight to moderate agreement on whether consumer participation would improve HMO func-
TABLE 4-Scale 2: Quality of Care
TABLE 3-Scale 1: Prepayment Mechanism* No.
%
17 14 8 6 5 4
31.5 25.9 14.8 11.1 9.3 7.4
2. Prepayment reverses incentives for physicians and hospitals to perform unnecessary services. 26 AAA 13 AA 7 A 2 D 2 DD 4 DDD
48.1 24.1 13.0 3.7 3.7 7.4
1. Fee-for-service promotes overutilization of services. AAA AA A D DD DDD
3. Prepayment controls cost of medical care. AAA AA A D DD DDD
4. Prepayment fosters the underutilization of services to keep cost down and profit high. DDD DD D A AA AAA
5. Prepayment is an incentive for physicians to promote cost effectiveness. AAA AA A D DD DDD *
No.
%
1. Quality of care suffers in an HMO due to the caseload volume. DDD DD D A AA AAA
25 14 3 7 5 0
46.3 25.9 5.6 13.0 9.3 .0
2. An HMO increases quality of care because of more efficient operations. AAA AA A D DD DDD
9 14 20 6 4 1
16.7 25.9 37.0 11.1 7.4 1.9
24 16 10 2 2 0
44.4 29.6 18.5 3.7 3.7 .0
23 20 8 2 1 0
42.6 37.0 14.8 3.7 1.9 .0
9 18 12 7 5 3
16.7 33.3 22.2 13.0 9.3 5.6
10 20 9 5 6 4
18.5 37.0 16.7 9.3 11.1 7.4
3. An HMO sacrifices quality of care because of high physician-patient ratios.
11 14 9 13 3 2
20.4 25.9 16.7 24.1 5.6 3.7
4. An HMO would maintain quality of with other health plans. AAA AA A D DD DDD
17 20 12 3 2
31.5 37.0 22.2 5.6 3.7 .0
5. Quality of care is comparable between HMO and non-HMO medical providers. AAA AA A
Responses are graded on a continuum, from AAA, DDD, very strongly disagree.
0
very
DDD DD D A AA AAA
D DD DDD
strongly
care to
compete
agree, to
tions and operations. Respondents might have felt that feedback from consumers might ultimately have an impact on organizational efficiency. Again, responses fell primarily between disagreement and slight agreement over whether health policy decision-making is too technical for consumers and should be reserved for medical and health professionals. Moreover, whereas respondents strongly supported a policyand decision-making role for consumer representatives, the assigning of consumers as advisers to the HMO board and as information resources to other consumers showed 70 per cent agreement and 24 per cent disagreement. Finally, more disagreement than agreement prevailed among directors
government regulations on consumer participation and grievance procedure policies. Of course, throughout the study, federal regulations evoked slight disagreement. On the whole, project directors endorsed consumer participation on an HMO policy- and decision-making board and believed that functions and operation might be improved as a result. There was a certain lack of strong
over
agreement over the role of consumer as advisors and information resources, the exclusion of consumers from the board due lack of technical background, and federal policies governing consumer participation and grievance procedures
(Table 6). HEALTH MAINTENANCE ORGANIZATIONS 1197
TABLE 5-Scale 3: Degree of Federal Regulation No. 1. It is important to have uniform government regulations for HMO operations and organizations. AAA AA A D DD DDD
2. Federal regulations will hinder HMOs from setting up organization patterns for the local situation. DDD DD D A AA AAA NA
5 8 8 8 8 17
1 6 15 15 12 3 2
TABLE 6-Scale 4: Consumer Participation No.
%
9.3 14.8 14.8 14.8 14.8 31.5
1. Consumers should have an active role in the policy formation and decision-making board of an HMO. AAA AA A D DD DDD
26 16 8 2 1 1
48.1 29.6 14.8 3.7 1.9 1.9
1.9 11.1 27.8 27.8 22.2 5.6 3.7
2. Consumer participation on an HMO policy- and decision-making board will improve the functions and operations of an HMO. AAA AA A D DD DDD
14 15 20 2 2 1
25.9 27.8 37.0 3.7 3.7 1.9
3. Consumer representatives should function as advisers to an HMO board and as information resources to other consumers. DDD DD
6 4
3 8 16 14 3
11.1 7.4 5.6 14.8 29.6 25.9 5.6
1.9 13.0 31.5 32.2 18.5 11.1 1.9
4. To ensure consumer protection, the government should specify consumer participation and grievance procedure policies in an HMO. AAA AA A D DD DDD
3 7 15 12 7 10
13.0 27.8 22.2 13.0 18.5
5.6 20.4 18.5 24.1 16.7 13.0 1.9
5. Health care policy decision-making is too technical for consumers and should be reserved for medical and health professionals. DDD DD D A AA AAA
15 13 12 7 5 2
27.8 24.1 22.2 13.0 9.3 3.7
%
3. HMOs should determine their own internal organization and operations without government regulations. DDD DD D A AA AAA NA
3 5 12 7 15 10 2
5.6 9.3 22.2 13.0 27.8 18.5 3.7
4. Competition among HMOs and local peer review are sufficient regulation without federal intervention. DDD DD D A AA AAA NA
5. Without federal regulation, the potential for abuse among HMOs is significant. AAA AA A D DD DDD NA
1 7 17 12 10 6 1
3 11 10 13 9 7 1
Scale 5: Public and Private Funding Similar to the response concerning the regulation, divergent attitudes over public and private funding for HMOs are reflected in the responses. Project directors tended to agree and disagree over whether a massive federal funding program is necessary to cope with health delivery problems or whether, without large scale government funding, the HMO system could be implemented in a significant 1198 AJPH NOVEMBER. 1975, Vol. 65, No. 11
D A AA AAA NA
5.6
Similar reaction patterns were seen in the "experimental HMO approach rather than massive appropriation" statement and the "minimum federal and maximum private corporation investment combination" proposal. Varying attitudes over avenues and sources of HMO funding may mean that HMO directors feel uncertainty over funding sources, are reluctant to accept funding with heavy federal regulations, or favor a variety of funding
way.
TABLE 7-Scale 5: Public and Private Funding
TABLE 8-Scale 6: Physicians' Attitudes toward HMO No.
1. Minimum government loans and grants and investment from private corporations are the best combination to establish HMO funding. DDD DD D A AA AAA NA
2. A massive and comprehensive HMO funding program by the federal government is necessary to cope with health delivery problems. AAA AA A D DD DDD
5 6 9 8 17 7 2
10 12 8 9 6 9
%
9.3 11.1 16.7 14.8 31.5 13.0 3.7
18.5 22.2 14.8 16.7 11.1 16.7
3. Rather than massive appropriations, it would be best for the government to fund experimental HMO centers in various parts of the nation. DDD DD D A AA AAA NA
4. Due to the Administration's restrictions on health funds, there should be HMOs financed and owned by private business corporations. DDD DD D A AA AAA NA 5. Without government funding on a large scale, the HMO delivery system cannot be implemented in a significant way. AAA AA A D DD DDD
5 6 9 7 13 13 1
8 6 9 15 7 6 3
9 12 14 7 9 3
9.3 11.1 16.7 13.0 24.1 24.1 1.9
14.8 11.1 16.7 27.8
No. 1. Physicians are reluctant to join an HMO because of high caseload volumes. DDD DD D A AA AAA NA
%
12 21 13 2 2 2 2
22.2 38.9 24.1 3.7 3.7 3.7 3.7
7 11
16 13 7 0
13.0 20.4 29.6 24.1 13.0 .0
15 19 16 2 2 0
27.8 35.2 29.6 3.7 3.7 .0
4. Physicians prefer private fee-for-service practice to HMO prepaid group practice because there are minimal restrictions. DDD DD D A AA AAA NA
4 8 5 14 13 9 1
7.4 14.8 9.3 25.9 24.1 16.7 1.9
5. Physicians will be attracted to HMOs because of efficient organization and operations. AAA AA A D DD DDD
5 15 17 12 4 1
9.3 27.8 31.5 22.2 7.4 1.9
2. Physicians hesitate to join an HMO because of unnecessary patient demands. DDD DD D A AA AAA
3. Based on the experience of existing prepaid group practices, HMOs can recruit sufficient numbers of competent physicians for their staff. AAA AA A D DD DDD
13.0 11.1 5.6
16.7 22.2 25.9 13.0 16.7 5.6
combinations. Yet they seem to acknowledge that federal funding is necessary to implement the HMO system and make an impact on health care delivery problems (Table 7). Scale 6: Physicians' Attitudes toward HMOs There has been concern over whether HMOs can recruit physicians in sufficient numbers and retain professional
staff, and over how physicians feel toward HMOs in general. While respondents acknowledged that private fee-for-service practice allowed for minimal restrictions (66 per cent), they were confident that they could recruit competent staff physicians to man HMO facilities (92 per cent). On several items, strong reactions were evoked on crucial issues. For instance, HMO directors strongly disagreed that high caseload volume deterred physicians from joining an HMO. However, mixed responses occurred over whether physicians might hesitate to join an HMO due to unnecessary patient HEALTH MAINTENANCE ORGANIZATIONS 1199
demands or over the claim that physicians are attracted to the efficiency of an HMO operation (Table 8). Scale 7: Consumer Recruitment
Consumer recruitment evoked a measure of uncertainty among project directors. HMO directors were aware that the public might be unfamiliar with the HMO system, posing recruitment problems for them (63 per cent), and that it has TABLE 9-Scale 7: Consumer Recruitment No.
%
Other Findings
1. An HMO prepaid group practice will attract a sufficient membership level from among consumer populations. AAA AA A D DD DDD
17 18 15 1 2 1
31.5 33.3 27.8 1.9 3.7 1.9
2. Because prepaid group practice has primarily recruited middle-class workers, it is unlikely that it can achieve a balanced membership among lower socioeconomic classes. DDD DD D A AA AAA NA
10 16 13 8 1 3 3
18.5 29.6 24.1 14.8 1.9 5.6 5.6
3. It has not been proven that an HMO prepaid group practice has broad appeal as a health plan to all classes of consumers. DDD DD D A AA AAA
6 6 8 14 14 6
11.1 11.1 14.8 25.9 25.9 11.1
4. There is such a need for health care that there will be sufficient response from consumers to HMO recruitment. AAA AA A D DD DDD
3 19 11 13 5 3
5.6 35.2 20.4 24.1 9.3 5.6
5. Consumer recruitment will be difficult because HMO prepaid group practice is a relatively unknown health care system. DDD DD D A AA AAA
1200 AJPH NOVEMBER, 1975, Vol. 65. No. I 1
not been proven whether an HMO has broad appeal to all classes of consumers (63 per cent). These are forthright answers to uncertain aspects of health planning. Similarly respondents agreed and disagreed over whether such a need for health care would produce a sufficient response from consumers to HMO recruitment. Yet, on the whole, these project directors felt confident that an HMO would attract a sufficient membership from consumer populations (93 per cent), and a balanced membership, particularly from lower socioeconomic classes (72 per cent) (Table 9).
2 9 9 18 13 3
3.7 16.7 16.7
33.3 24.1 5.6
Table 10 revealed the various mean scores of the scales. The means tended toward positive skewness on a range from 5 (strong agreement AAA) to 30 (strong disagreement DDD). Scale 3 (Degree of Federal Regulation) had the highest mean score (18.91) and fell between the slightly agree and slightly disagree (17.5) range. Scale 5 (Public and Private Funding) followed next with a mean score 17.41, while Scale 7 (Consumer Recruitment) was third with a 15.24 mean score. Scale 4 (Consumer Participation) and Scale 6 (Physicians' Attitudes toward HMO) were 14.72 and 14.37, respectively. They tended toward the slightly agree category. Scale 1 (Prepayment) and Scale 2 (Quality of Care) were between the moderately and slightly agree range and favored the former. T-tests were made on: (1) Scale 4 (Consumer Participation) with the variables: consumer participation on policy board and consumer grievance procedure; (2) Scale 7 (Consumer Recruitment) with the variables: inner city and rural area; (3) Scale 1 (Prepayment), Scale 2 (Quality of Care), Scale 3 (Degree of Federal Regulation), Scale 4 (Consumer Participation), Scale 5 (Public and Private Funding), and Scale 6 (Physicians' Attitudes toward HMO) with the variables: HMO project directors with MD and without MD; (4) Scale 1 (Prepayment), Scale 3 (Degree of Federal Regulation), Scale 4 (Consumer Participation), and Scale 5 (Public and Private Funding) with the variables: public and private, single and combination sponsorship; (5) Scale 1 (Prepayment), Scale 2 (Quality of Care), Scale 3 (Degree of Federal Regulation), Scale 4 (Consumer Participation), Scale 5 (Public and Private Funding), and Scale 6 (Physicians' Attitudes toward HMO) with the variables: favorable and unfavorable physicians' reactions toward the TABLE 10-Mean and Standard Deviation Scores of Scales 1 to 7
Scale 1: Prepayment Mechanisms Scale 2: Quality of Care Scale 3: Degree of Federal Regulation Scale 4: Consumer Participation Scale 5: Public and Private Funding Scale 6: Physicians' Attitudes toward HMO Scale 7: Consumer Recruitment
Mean
Standard Deviation
12.37 11.26 18.91 14.72 17.41 14.37 15.24
4.56 3.73 4.99 4.31 5.38 3.47 3.56
HMO project. There was no significant differences, with p < 0.10, which may indicate that the project directors are a self-selecting group and a homogeneous sample (Table 10).
Discussion of Findings Research findings of this exploratory study on HMO projects and attitudes of HMO project directors have uncovered the following areas: * A brief profile of the typical HMO project director: A middle-aged male who graduated from professional school within the last 15 years with a master's degree in administration, was employed by the sponsoring institution within the last 5 years, and had less than 10 years experience in health planning and administration; * General characteristics of the HMO project: Sponsored by a single private or public institution with fairly comprehensive services, consumer participation and grievance procedure policies, loose physician arrangements, and a medically underserved area focus; clearly in the feasibility and planning stages with the support of physicians who are affiliated with the sponsoring institution; * Attitudes of project directors toward HMO delivery issues: On the other hand, HMO project directors tend to disagree with strong federal regulations and public funding and voice moderate uncertainty over consumer recruitment. This may indicate that they are concerned about government intervention in HMO regulations and funding as well as the need for an adequate consumer recruitment network. On the other hand, they tend toward slight agreement on a consumer participation policy and the ability to recruit physicians, and toward slight to moderate agreement on the prepayment mechanism and quality of care issues. This researcher speculates that respondents may feel more comfortable with such intraorganizational aspects. However, federal regulations, public and private funding, and consumer recruitment represent the external environment, and, to an extent, are beyond their immediate control and sphere of influence. Further research is required to ascertain these differences among their attitudes. Furthermore, numerous areas for follow-up research arise from these findings. Among them are: * Investigation of the project directors in terms of their length of time and various settings in health care administration. In this regard, it would be interesting to find out whether the MD directors have been in administrative or clinical positions and what their motivations are for assuming leadership in an HMO project. A more accurate profile of the capacity, background, training, and experience of the current group of project directors may emerge as a result; * Sponsorship of the HMO program in terms of the independent resources which led to single sponsorship as well as the resources exchange between
organizations which formed multi-agency coalitions; * Follow-up on the HMO operations in terms of current development, membership level, and funding expectations as well as a focus on factors which led to the development of viable institutions which are in the initial or full-scale stage; * Mortality rate of HMO projects in terms of the numbers and factors which may have contributed to termination; * Current attitudes of HMO project directors toward private and public funding, government regulations, quality of care, and consumer recruitment as well as alternatives plans for funding due to uncertain Congressional appropriations; * Progress report of operational programs on consumer board members and consumer grievance policies; * A physicians' attitude follow-up study on physicians who have joined HMO staffs compared with other physicians in the same community who are in fee-for-service practice.
Conclusion A national survey of health maintenance organization project directors' attitudes on HMO delivery issues was conducted to gather data about HMO planning development and delivery areas. Questionnaire results revealed characteristics of the HMO project director, sponsoring institution, and developmental stage. Seven HMO issues (Prepayment Mechanism, Quality of Care, Degree of Federal Regulation, Consumer Participation, Public and Private Funding, Physicians' Attitudes toward HMO, and Consumer Recruitment) were identified to measure the attitudes of directors. As a whole, responses were in the positive range. Scale 1 (Prepayment Mechanism) and Scale 2 (Quality of Care) received the lowest mean scores and were in the moderate agreement range. Scale 3 (Degree of Federal Regulation) and Scale 5 (Public and Private Funding) had the highest mean scores and fell between slight agreement and disagreement. Further research has been noted in various administrative features and issue areas of HMO. Most crucial is the outcome of HMO legislation which has a bearing on the policy and program of the HMO delivery system. On the basis of what appears to be a representative sample of directors of DHEW-funded HMO Planning and Development Projects, the study has assessed attitudes on important issues relevant to HMOs and determined areas of greatest agreement and disagreement. ACKNOWLEDGMENTS The author wishes to acknowledge the following persons for their technical consultation and therapeutic support in the preparation of this article: Jon L. Bushnell, PhD, and Gregory M. St. L. O'Brien, PhD, of the University of Wisconsin, Milwaukee, School of Social Work, and Mel Karmen, PhD, and Grace F. Brody, PhD, of Case Western Reserve University, School of Applied Social Sciences. HEALTH MAINTENANCE ORGANIZATIONS 1201
REFERENCES 1. Nixon, R. M. Health Message from the President of the United States Relative to Building a National Health Strategy. House Document No. 92-49. 92nd Congress, 1st Session, Feb., 1971. 2. Densen, P. M., Balamuth, E., and Shapiro, S. Prepaid Medical Care and Hospital Utilization. American Hospital Association, Chicago, 1958. 3. Densen, P. M. Balamuth, E., and Shapiro, S. Prepaid Medical Care and Hospital Utilization in a Dual Choice Situation. Am. J. Public Health 50:1710-1726, 1960. 4. Brown, D. R. Community Health Planning or Who Will Control the Health Care System. Am. J. Public Health 62:1337, 1972. 5. Klarman, H. E. Analysis of the HMO Proposal-Its Assumptions, Implications, and Prospects. In Health Maintenance Organizations: A Reconfiguration of the Health Services System, pp. 27-29. University of Chicago, Chicago, 1971. 6. Weissman, A., and Anderson, R. Characteristics of Health Plan Membership. In The Kaiser-Permanente Medical Care Program, edited by Somers, A. R., pp. 33-43. Commonwealth Fund, New York, 1971. 7. Greenlick, M. R., Freeborn, D. K., Colombo, T. J., Prussin, J. A., and Saward, E. W. Comparing the Use of Medical Care Services by a Medically Indigent and a General Membership
Population in a Comprehensive Prepaid Group Practice Program. Med. Care 10:187-200, 1972. 8. Saward, E. W., and Greenlick, M. R. Health Policy and the HMO. Milbank Mem. Fund Q. 50:147-176, 1972. 9. Havighurst, C. C. Health Maintenance Organizations and the Market for Health Services. Law Contemp. Probl. 35:716-795, 1970. 10. Chenault, W. W., and Brown, D. K. Consumer Participation in Neighborhood Comprehensive Health Care Centers. Human Sciences Research, McLean, VA, 1971. 11. Duval, M. K. Development of HMOs-Concepts and Benefits. Health Serv. Rep. 87:407, 1972. 12. Valiante, J. D. Start-Up Problems of Health Maintenance Organizations. In Health Maintenance Organizations: A Reconfiguration of the Health Services System, pp. 39-48. University of Chicago, Chicago, 1971. 13. Nixon, R. M. Presidential Documents. 9:200, 1973. 14. American Medical News, p. 12. Aug. 13, 1972. 15. Griedson, E., and Rhea, B. Physicians in Large Medical Groups. J. Chronic Dis. 17:827-836. 16. Cook, W. H. Profile of the Permanente Physician. The KaiserPermanente Medical Care Program, edited by Somers, A. R. pp. 97-105. Commonwealth Fund, New York, 1971.
CLINICAL LABORATORY SYMPOSIUM SCHEDULED A symposium on "The Clinical Laboratory as an Aid in Chemotherapy of Infectious Disease" will be held November 20-21, 1975, in Philadelphia. Sponsored by the Eastern Pennsylvania Branch of the American Society for Microbiology and other institutions, the symposium will feature a distinguished panel of specialists concerned with the new and changing aspects of this topic, one of the most important functions of the clinical laboratory today. Laboratory directors, qualified representatives, and interested individuals should register early, since attendance is limited. The symposium will be held at the new Hilton of Philadelphia on the campus of the University of Pennsylvania. For further information, contact Josephine Bartola, Pennsylvania Department of Health, 2100 W. Girard Ave., Philadelphia, PA 19130.
1202 AJPH NOVEMBER, 1975, Vol. 65, No. 11
Maintenance Organization Delivery System A National Study of Attitudes of HMO Project Directors on HMO Issues DOMAN LUM, PhD, ThD
The results of a national survey of health maintenance organization project directors' attitudes on HMO delivery issues are presented and discussed.
Introduction Within the last 3 years, prepaid group health care has received national prominence. In his 1971 health message to the 92nd Congress,1 President Richard M. Nixon made the reorganization of health delivery services a focal point of his health program. He proposed a health maintenance organization (HMO) system which would offer comprehensive services purchased annually at a prepayment rate from a medical group through capitation contracts. Rather than massive federal regulations, investment, and planning, Nixon envisioned economic and professional incentives with an emphasis on self-regulation based on a competitive market and on the preventive maintenance of health. Consumers would be able to chose between conventional health insurance and health maintenance contracts from a variety of competing organizations. The HMO program would generate a variety of organizational arrangements with physicians, involvement of private corporations for capital resources, government grants and loans for planning, construction, and initial operations, a competitive market to control costs and improve distribution, and minimal government interference in internal organization. Dr. Lum is Associate Professor in the School of Social Work, California State University, Sacramento, California 95819. At the time of this study he was with the School of Applied Social Studies, Case Western Reserve University, Cleveland, Ohio. This article was submitted for publication in June, 1973, and revised July, 1975. 1192 AJPH NOVEMBER, 1975, Vol. 65, No. 11
During 1971 and 1972, the Administration began to fund feasibility studies and gear up for the HMO delivery system. The Department of Health, Education, and Welfare (DHEW) established the Health Maintenance Organization Services within the Health Services and Mental Health Administration. Through general legislative authority to stimulate experimental health care delivery mechanisms, approximately $10 million was distributed for 86 HMO planning and development grants and 24 technical support activity grants and contracts. Funds were obtained from research and experimentation allocations of comprehensive health services, regional medical programs, and health services research and development. DHEW has curtailed the awarding of grants and is awaiting enactment of specific HMO legislation. However, technical assistance and consultation to HMO planning groups are available.
Purpose of the Study The purpose of this research is to conduct an exploratory study on the attitudes of health maintenance organization project directors regarding HMO delivery issues. Specifically, we refer to the 86 HMO planning and development institutional grantees funded by DHEW. Hopefully, the results of this preliminary study may lead to the formulation of problems for more precise investigation or the development of hypotheses.
Background of the Study Major health delivery issues have emerged from an extensive discussion of the HMO system. Among them are: Prepayment Mechanism
Prepayment has been promoted as an alternative to the traditional fee-for-service mechanism which is utilized by the majority of physicians and criticized for promoting overutilization of services, raising medical costs, and providing high reimbursement from medical insurance. Prepaid group practice studies demonstrate a reduction in the number of hospital days, hospital admissions, and hospital surgical cases. 2, 3 Prepayment controls cost of medical care, encouraging physicians to promote cost effectiveness and eliminating the performance of unnecessary services to increase physicians' income. Others contend that prepayment may foster the underutilization of services to keep cost down and profit high. 4 Moreover, factors other than prepayment may have contributed to reduced hospitalization. Klarman contends, for example, that during this time hospital beds were available because of limited supply to the Health Insurance Plan of Greater New York and that the low ratio between beds and population under the Kaiser-Permanente program was a crucial factor that caused lower hospital occupancy among its subscribers.5 Quality of Care Quality of care has been an issue for providers, consumers, and the government. From the providers' viewpoint, the balance between volume business and maintaining quality has been a major problem. However, Kaiser-Permanente research shows that patients average four visits per year and that urban indigent families generally have a pattern of use similar to that of other members.6 7 Physicians are concerned whether HMO quality of care may suffer from high physician-patient ratios, frequent referrals to other specialists, long waiting periods, and the lack of continuity. Critics further contend that an HMO may sacrifice quality for profit motives, whereas supporters argue that consumers could transfer to another HMO for medical care. This presupposes that there would be sufficient funds for an adequate number of HMOs to generate competitive prices and services. Federal Regulation
There has been vigorous debate in HMO legislation over the degree of government regulation. On the one hand, the potential for abuse is significant. Saward and Greenlick claim that the enthusiasm for HMOs may wane when the total constraints and their implications become clear.8 On the other hand, Havighurst advocates a free, competitive market among HMOs. He claims that trade restraints have prevented effective functioning of the health care industry, that competition would result in self-regulation, and that federal antitrust suits could be introduced in case of a
monopoly.9
The Administration initially argued that competition among HMOs, local peer review, and minimal federal monitoring will promote self-regulation among providers. Even if this could be realized, however, existing medical and hospital practices may force the government to formulate strong regulations to control abuse. Underlying this discussion is whether or not the existing health care system controlled by medical societies can change without government intervention. Consumer Participation
Involving consumers in the decision-making process of an HMO and establishing a grievance procedure for consumers are further issues. Medical policy- and decisionmaking are often viewed as areas for physicians. Some have misgivings about consumers on an advisory or policy board, an ombudsman for consumers, or a consumer grievance mechanism. Although there is a need for further study on the effects of consumer participation in a health setting, the Office of Economic Opportunity has conducted research on the interaction between consumers and providers in neighborhood health centers. A study of 160 consumer participants in neighborhood health centers showed that conflict between consumers and providers became intense when a consumer group held only partial power (e.g. advisory roles). There was less conflict when it retained clear dominance. Issues involved citizen participation, the practice of medicine in health centers, administration of the centers, training and employment of residents from the service area, neighborhood residents' utilization of the centers, financial problems, and relationships with outside groups. 1 0 A similar pattern may confront HMOs with consumer participation features. Public and Private Funding It is estimated that it will cost an average of $250,000 to plan an HMO, up to $2.5 million in capital for construction, and a minimum population enrollment of 20,000 for a solvent group health plan."1 The critical start-up period varies from 1 to 3 years and capital resources are necessary to maintain high initial development. Although Kaiser estimates that it takes 2 to 3 years to break even and losses may reach $2 million, at least for the current Kaiser Health Plan earning rate, 3 to 4 months make this up out of income from total health plan operations. 12 However, many HMOs may not have the financial reserves of Kaiser-Permanente. Funding has become a critical issue since the Administration has reserved its position on HMOs. In his 1974 budget message to Congress, Nixon relegated the HMO program to a demonstration basis. 3 In the 93rd Congress, the compromise House bill accordingly cut HMO funds. It offers loans and loan guarantees for initial operation costs
and deletes all previous features. It appropriates $60 million per fiscal year over a 4-year period compared with the $890 million provision of a nearby full-scale Senate bill.14 In the HEALTH MAINTENANCE ORGANIZATIONS 1193
end, the Health Maintenance Organization Act of 1973 allocated $375 million to study the feasibility of prepaid care. Will the private sector be willing to invest the necessary capital to offset lean Congressional appropriations? Physicians' Attitudes
There are some indications of how physicians feel toward prepaid group practice which have bearing on physician recruitment and turnover. Research on group practices reports that physicians involved are satisfied with their arrangements. They feel they have professional support and stimulation from professional colleagues, a regular work schedule, and opportunities for continued education. Furthermore, they believe that group practice reduces medical overhead and the financial risk of starting up a practice. 15 Surveys of physicians inside and outside prepaid group arrangements lack adequate research methodology and require more intensive scientific design. However, there seems to be a preference for private fee-for-service practice. With respect to group practice turnover rates, KaiserPermanente in Northern California reported in 1970 that the annual terminations were 12.3 per cent of employed physicians and 4.8 per cent of partners. Full-time physicians on the average were with the program for 5 years or less and three-fourths joined within the last 10 years.16 At the same time, further research is need to determine whether physicians can be recruited into HMOs and how long they anticipate remaining in this structure. Consumer Recruitment
HMO legislation initially asked for a voluntarily enrolled population to join a prepaid group practice with an annual open enrollment period without discrimination. A balanced membership was ensured through percentage limits set on persons from medically underserved areas. However, the concern is whether an adequate number of consumers can be recruited for an HMO. Critics contend that although Kaiser-Permanente has been in existence for 30 years, it has attracted only 2 million subscribers, primarily middle class workers through their places of employment. It has only recently broadened the enrollment base to lower socioeconomic groups on a limited scale, with uncertainty as to how medical indigents might use services. Likewise, HMO proponents cannot predict whether prepaid group practice on a large scale might affect existing patterns of behavior among consumers who have formed ties with a physician in fee-for-service private practice over the years. People may not reside near an HMO and may also be reluctant to sever the relationship with a particular private family doctor. These issues raise the need for more research in these areas from a health planning viewpoint.
Study Design The specific research question posed by this exploration study is: What are the attitudes of health maintenance 1194 AJPH NOVEMBER, 1975, Vol. 65, No. 11
organization project directors toward HMO delivery issues? A questionnaire was designed with a Likert-type scale to gather data on demographic variables, HMO project variables, and attitudes on delivery issues. A pre-test of the questionnaire was conducted with the health concentration fa-culty of the Case Western Reserve University School of Applied Social Sciences, and the health planning staff of the East Cleveland Human Services Center. Suggested changes regarding phrasing, length, and format of the questionnaire, and other aspects, were made on the instrument. Through the DHEW Health Services and Mental Health Administration, Health Maintenance Organization Service, the January, 1972, Funded HMO Planning and Development Grants and Contracts Directory was used as a reference for the sampling. The 86 planning and development grants and contracts agencies were in 37 states and the District of Columbia, generally funded on a 12-month basis, nonprofit, and sponsored by 10 types of organizations with a variety of proposed plans. It was decided that the sampling would be the 86 HMO project directors in the DHEW directory. After two mailings of the questionnaire, the response rate was 79 per cent (sample number-67) of the total group. However, there were 13 questionnaire returns which could not be used in the study (four were returned with no forwarding address, four indicated the termination of the HMO program, two were consultation firms, two were returned after the data were analyzed, and one was discarded for lack of adequate data). The actual sample number for the study was 54 (63 per cent). A comparison was made between those who responded and those who failed to answer to determine whether there was a biased return. Such factors as geographical location, sponsor type, amount of grant, and description of project revealed no differences when comparisons were made.
Research Findings: Demographic and Project
Variables Characteristics of HMO Project Directors Research data indicated at HMO project directors tended to be males between ages 25 and 45 (69 per cent). Approximately 50 per cent graduated from professional school between 1960 and 1973, while 35 per cent graduated between 1940 and 1959. Their professional credentials reflected a variety of backgrounds: master's degree types of administrators (43 per cent), MD physicians (24 per cent), bachelor's degree types (17 per cent), and an assortment of
other professional doctorates (7.4 per cent). Nearly threefourths of the group had been employed with their present institution less than 5 years. This may indicate that these directors were hired for the specific HMO project, although many of them indicated serving in a dual role with another responsibility. Nearly one-half of them, however, reported 5 or less years of health planning and administration experience, while another 37 per cent were in this field between 6 and 15 years (Table 1).
TABLE 1-Characteristics of HMO Project Directors No.
%
NA*
1 18 19 11 4 1
1.9 33.3 35.2 20.4 7.4 1.9
Sex Male Female NA
39 6 9
72.2 11.1 16.7
6 13 19 8 8
11.1 24.1
35.2 14.8 14.8
Degree MD Other doctorate Master Bachelor NA
13 4 23 9 5
24.1 7.4 42.6 16.7 9.3
Employment with present institution (years) 0-5 6-10 11-15 16-20 31 andover NA
41 2 2 3 1 5
75.9 3.7 3.7 5.6 1.9 9.3
25 11 9 4 1 2 2
46.3 20.4 16.7 7.4 1.9 3.7 3.7
Age Under 25 25-35 36-45 46-55 56-65
Graduation from professional school 1940-1949 1950-1959 1960-1969
1970-1973 NA
Health planning and administration experience
(years) 0-5 6-10 11-15 16-20 26-30 31 andover NA *
NA, no answer.
Characteristics of the HMO Program Ten types of institutions were identified as sponsors of the HMO project. Private hospitals, physician groups, private medical schools, medical care foundations, insurance companies, and private corporations were classified under the general category "private." Public hospitals, consumer groups, public medical schools, and public groups were termed "public" for the purpose of comparison. Findings indicated slightly more private (54 per cent) than public (43 per cent) institutional sponsors as well as a number of multi-agency coalitions or interorganizational arrangements (17 per cent) which were labeled as "combi-
nation." However, in most cases, the majority of projects were ''single" institution sponsorship. Projected medical services for HMOs revealed comprehensive coverage. Approximately 85 to 93 per cent of the projects indicated physician services, inpatient hospital services, outpatient hospital services, out-of-area emergency reimbursements, diagnostic laboratory services, physical medicine and rehabilitative services, preventive health and early disease detection services, and radiological services. Between 72 and 79 per cent reported plans for extended care facilities, home health, vision care, and mental health services. The three least offered services were prescription drugs (67 per cent), dental services (43 per cent), and podiatric services (43 per cent). On the whole, however, the data suggested that HMOs planned to offer a nearby full range of services. HMO legislative proposals have influenced project planning regarding consumer participation, role of physicians, federal regulations, and location of facilities. Concerning consumers, there was strong agreement on consumer participation on policy boards of HMOs (94 per cent). Likewise, consumer grievance procedure (89 per cent), provisions as a nonprofit corporation (85 per cent), and centralized record keeping (85 per cent) demonstrated high consensus. However, with respect to the role of physicians, the data reflected varying organizational configurations to encourage more physician participation rather than regulations against loose arrangement patterns. For example, project directors reported use of physicians outside the HMO staff (74 per cent) and salaried positions of physicians (63 per cent). It is interesting to note that 61 per cent made provisions for federal regulations and monitoring of HMOs. It may suggest that HMO directors recognize that a degree of federal regulation is inevitable and are awaiting the legislative outcome with an anticipation of federal regulations. Yet 39 per cent chose not to answer this item, which may express resistance. The main objective of HMO legislation is to redistribute health manpower and facilities to medically underserved areas for persons who are unable to afford adequate services. However, only 65 per cent made provisions for recruitment of medical indigents. At the same time, most of the HMOs plan to locate in the inner city (50 per cent) or in a rural area (54 per cent). A few indicated both areas or neither. As regards implementation of HMO projects, 63 per cent were still in the feasibility study or follow-up planning phase by April, 1973. Only 28 per cent were in initial or full-scale operations. Whether the majority of institutions with planning grants were awaiting legislation outcome and/or were without necessary funds to generate an HMO on their own initiative is unknown to this researcher. Finally, reactions of physicians affiliated with the sponsoring institution were 68 per cent favorable and 23 per cent unfavorable. This is, however, no indication of how physicians in general feel about HMOs or whether they would be willing to become HMO staff. Rather, it is a HEALTH MAINTENANCE ORGANIZATIONS 1195
preliminary gauge of how physicians of sponsoring institutions initially react to the HMO plan, from the perceptions of the project director (Table 2).
Research Findings: Delivery Issues Scale 1: Prepayment Mechanism HMO directors tended to favor the prepayment mechanism, although they were aware of potential abuse. They agreed that prepayment is an incentive for physicians to promote cost effectiveness (81 per cent) and a deterrent against the performance of unnecessary services (85 per cent). Moreover, they further agreed (72 per cent) that fee-for-service promotes overutilization of services and that prepayment controls medical care costs. However, although 63 per cent disagreed that prepayment fosters underutilization of services, 33 per cent agreed that there were grounds for such criticism (Table 3).
Scale 2: Quality of Care
HMO directors tended to believe that quality of care would be maintained, but moderately agreed on an efficiency increase or a basis for comparing quality among other types of organizations. For example, they strongly agreed that no quality of care would be lost due to high physicianpatient ratios (83 per cent) and that on a competitive basis an HMO would maintain quality of care (94 per cent). There was, however, less agreement that quality of care might suffer due to caseload volume, that is, the higher the caseload, the lower the quality, and even moderate agreement and disagreement over whether an HMO increases quality of care because of efficient operations or whether quality was comparable between HMO and non-HMO providers (Table 4). Scale 3: Degree of Federal Regulation Federal regulations evoked a measure of disagreement, although responses were in the agreement-disagreement range. Most disagreement (61 per cent) was over uniform government regulations for HMO operations and organizations. The implication is for individual expression for each HMO within general boundaries. Mixed reactions prevailed over the potential for abuse without federal regulations, organizational and operational self-determination without government regulations, the adequacy of competition as a self-regulation device, and the threat to shaping organizational patterns for the local situation. Perhaps the need for a balance between general federal guidelines and intraorganizational autonomy on the local level is communicated in these responses (Table 5). Scale 4: Consumer Participation By and large, HMO directors strongly endorsed the role of consumers in HMO policy formation and decision-making (93 per cent). However, some variation occurred among opinions about aspects of consumer participation. For 1196 AJPH NOVEMBER, 1975, Vol. 65. No. 11
TABLE 2-Characteristics of HMO Program
Characteristics Sponsorship Private Public NA Single Combination NA Medical services Physician services Inpatient hospital services Outpatient hospital services Extended care facility services Home health services Vision care services Podiatric services Out-of-area emergency services reimbursement Mental health services Dental services Diagnostic laboratory services Physical medicine and rehabilitative services Preventive health and early disease detection services Prescription drugs Radiological services
Others Administrative features Recruitment mechanisms for medical indigents Location in inner city Location in rural area Centralized record keeping Use of physicians outside HMO staff Provisions as a nonprofit corporation Salaried positions for physicians Provisions for federal regulations and monitoring of HMO Consumer participation on policy board Consumer grievance procedure Others Developmental phase Feasibility study Follow-up planning Construction of facility Initial operations Full-scale operations
Reactions of physicians to HMO project Strongly favorable Moderately favorable Slightly favorable Slightly unfavorable Moderately unfavorable Strongly unfavorable NA
No.
%
29 23 2
53.7 42.6 3.7
43 9 2
79.6 16.7 3.7
50 50 48 39 42 39 23 46 39 23 50 46 48
92.6 92.6 88.9 72.2 77.8 72.2 42.6 85.2 72.2 42.6 92.6 85.2 88.9
36 49 8
66.7 90.7 14.8
35 27 29 46 46 40 34 33
64.8 50.0 53.7 85.2 74.1 85.2 63.0 61.1
51 48 4
94.4 88.9 7.4
12 22
22.2 40.7 7.4 18.5 9.3
4 10 5
7 21 9 4 6 2 5
13.0 38.9 16.7 7.4 11.1 3.7 9.3
example, there was slight to moderate agreement on whether consumer participation would improve HMO func-
TABLE 4-Scale 2: Quality of Care
TABLE 3-Scale 1: Prepayment Mechanism* No.
%
17 14 8 6 5 4
31.5 25.9 14.8 11.1 9.3 7.4
2. Prepayment reverses incentives for physicians and hospitals to perform unnecessary services. 26 AAA 13 AA 7 A 2 D 2 DD 4 DDD
48.1 24.1 13.0 3.7 3.7 7.4
1. Fee-for-service promotes overutilization of services. AAA AA A D DD DDD
3. Prepayment controls cost of medical care. AAA AA A D DD DDD
4. Prepayment fosters the underutilization of services to keep cost down and profit high. DDD DD D A AA AAA
5. Prepayment is an incentive for physicians to promote cost effectiveness. AAA AA A D DD DDD *
No.
%
1. Quality of care suffers in an HMO due to the caseload volume. DDD DD D A AA AAA
25 14 3 7 5 0
46.3 25.9 5.6 13.0 9.3 .0
2. An HMO increases quality of care because of more efficient operations. AAA AA A D DD DDD
9 14 20 6 4 1
16.7 25.9 37.0 11.1 7.4 1.9
24 16 10 2 2 0
44.4 29.6 18.5 3.7 3.7 .0
23 20 8 2 1 0
42.6 37.0 14.8 3.7 1.9 .0
9 18 12 7 5 3
16.7 33.3 22.2 13.0 9.3 5.6
10 20 9 5 6 4
18.5 37.0 16.7 9.3 11.1 7.4
3. An HMO sacrifices quality of care because of high physician-patient ratios.
11 14 9 13 3 2
20.4 25.9 16.7 24.1 5.6 3.7
4. An HMO would maintain quality of with other health plans. AAA AA A D DD DDD
17 20 12 3 2
31.5 37.0 22.2 5.6 3.7 .0
5. Quality of care is comparable between HMO and non-HMO medical providers. AAA AA A
Responses are graded on a continuum, from AAA, DDD, very strongly disagree.
0
very
DDD DD D A AA AAA
D DD DDD
strongly
care to
compete
agree, to
tions and operations. Respondents might have felt that feedback from consumers might ultimately have an impact on organizational efficiency. Again, responses fell primarily between disagreement and slight agreement over whether health policy decision-making is too technical for consumers and should be reserved for medical and health professionals. Moreover, whereas respondents strongly supported a policyand decision-making role for consumer representatives, the assigning of consumers as advisers to the HMO board and as information resources to other consumers showed 70 per cent agreement and 24 per cent disagreement. Finally, more disagreement than agreement prevailed among directors
government regulations on consumer participation and grievance procedure policies. Of course, throughout the study, federal regulations evoked slight disagreement. On the whole, project directors endorsed consumer participation on an HMO policy- and decision-making board and believed that functions and operation might be improved as a result. There was a certain lack of strong
over
agreement over the role of consumer as advisors and information resources, the exclusion of consumers from the board due lack of technical background, and federal policies governing consumer participation and grievance procedures
(Table 6). HEALTH MAINTENANCE ORGANIZATIONS 1197
TABLE 5-Scale 3: Degree of Federal Regulation No. 1. It is important to have uniform government regulations for HMO operations and organizations. AAA AA A D DD DDD
2. Federal regulations will hinder HMOs from setting up organization patterns for the local situation. DDD DD D A AA AAA NA
5 8 8 8 8 17
1 6 15 15 12 3 2
TABLE 6-Scale 4: Consumer Participation No.
%
9.3 14.8 14.8 14.8 14.8 31.5
1. Consumers should have an active role in the policy formation and decision-making board of an HMO. AAA AA A D DD DDD
26 16 8 2 1 1
48.1 29.6 14.8 3.7 1.9 1.9
1.9 11.1 27.8 27.8 22.2 5.6 3.7
2. Consumer participation on an HMO policy- and decision-making board will improve the functions and operations of an HMO. AAA AA A D DD DDD
14 15 20 2 2 1
25.9 27.8 37.0 3.7 3.7 1.9
3. Consumer representatives should function as advisers to an HMO board and as information resources to other consumers. DDD DD
6 4
3 8 16 14 3
11.1 7.4 5.6 14.8 29.6 25.9 5.6
1.9 13.0 31.5 32.2 18.5 11.1 1.9
4. To ensure consumer protection, the government should specify consumer participation and grievance procedure policies in an HMO. AAA AA A D DD DDD
3 7 15 12 7 10
13.0 27.8 22.2 13.0 18.5
5.6 20.4 18.5 24.1 16.7 13.0 1.9
5. Health care policy decision-making is too technical for consumers and should be reserved for medical and health professionals. DDD DD D A AA AAA
15 13 12 7 5 2
27.8 24.1 22.2 13.0 9.3 3.7
%
3. HMOs should determine their own internal organization and operations without government regulations. DDD DD D A AA AAA NA
3 5 12 7 15 10 2
5.6 9.3 22.2 13.0 27.8 18.5 3.7
4. Competition among HMOs and local peer review are sufficient regulation without federal intervention. DDD DD D A AA AAA NA
5. Without federal regulation, the potential for abuse among HMOs is significant. AAA AA A D DD DDD NA
1 7 17 12 10 6 1
3 11 10 13 9 7 1
Scale 5: Public and Private Funding Similar to the response concerning the regulation, divergent attitudes over public and private funding for HMOs are reflected in the responses. Project directors tended to agree and disagree over whether a massive federal funding program is necessary to cope with health delivery problems or whether, without large scale government funding, the HMO system could be implemented in a significant 1198 AJPH NOVEMBER. 1975, Vol. 65, No. 11
D A AA AAA NA
5.6
Similar reaction patterns were seen in the "experimental HMO approach rather than massive appropriation" statement and the "minimum federal and maximum private corporation investment combination" proposal. Varying attitudes over avenues and sources of HMO funding may mean that HMO directors feel uncertainty over funding sources, are reluctant to accept funding with heavy federal regulations, or favor a variety of funding
way.
TABLE 7-Scale 5: Public and Private Funding
TABLE 8-Scale 6: Physicians' Attitudes toward HMO No.
1. Minimum government loans and grants and investment from private corporations are the best combination to establish HMO funding. DDD DD D A AA AAA NA
2. A massive and comprehensive HMO funding program by the federal government is necessary to cope with health delivery problems. AAA AA A D DD DDD
5 6 9 8 17 7 2
10 12 8 9 6 9
%
9.3 11.1 16.7 14.8 31.5 13.0 3.7
18.5 22.2 14.8 16.7 11.1 16.7
3. Rather than massive appropriations, it would be best for the government to fund experimental HMO centers in various parts of the nation. DDD DD D A AA AAA NA
4. Due to the Administration's restrictions on health funds, there should be HMOs financed and owned by private business corporations. DDD DD D A AA AAA NA 5. Without government funding on a large scale, the HMO delivery system cannot be implemented in a significant way. AAA AA A D DD DDD
5 6 9 7 13 13 1
8 6 9 15 7 6 3
9 12 14 7 9 3
9.3 11.1 16.7 13.0 24.1 24.1 1.9
14.8 11.1 16.7 27.8
No. 1. Physicians are reluctant to join an HMO because of high caseload volumes. DDD DD D A AA AAA NA
%
12 21 13 2 2 2 2
22.2 38.9 24.1 3.7 3.7 3.7 3.7
7 11
16 13 7 0
13.0 20.4 29.6 24.1 13.0 .0
15 19 16 2 2 0
27.8 35.2 29.6 3.7 3.7 .0
4. Physicians prefer private fee-for-service practice to HMO prepaid group practice because there are minimal restrictions. DDD DD D A AA AAA NA
4 8 5 14 13 9 1
7.4 14.8 9.3 25.9 24.1 16.7 1.9
5. Physicians will be attracted to HMOs because of efficient organization and operations. AAA AA A D DD DDD
5 15 17 12 4 1
9.3 27.8 31.5 22.2 7.4 1.9
2. Physicians hesitate to join an HMO because of unnecessary patient demands. DDD DD D A AA AAA
3. Based on the experience of existing prepaid group practices, HMOs can recruit sufficient numbers of competent physicians for their staff. AAA AA A D DD DDD
13.0 11.1 5.6
16.7 22.2 25.9 13.0 16.7 5.6
combinations. Yet they seem to acknowledge that federal funding is necessary to implement the HMO system and make an impact on health care delivery problems (Table 7). Scale 6: Physicians' Attitudes toward HMOs There has been concern over whether HMOs can recruit physicians in sufficient numbers and retain professional
staff, and over how physicians feel toward HMOs in general. While respondents acknowledged that private fee-for-service practice allowed for minimal restrictions (66 per cent), they were confident that they could recruit competent staff physicians to man HMO facilities (92 per cent). On several items, strong reactions were evoked on crucial issues. For instance, HMO directors strongly disagreed that high caseload volume deterred physicians from joining an HMO. However, mixed responses occurred over whether physicians might hesitate to join an HMO due to unnecessary patient HEALTH MAINTENANCE ORGANIZATIONS 1199
demands or over the claim that physicians are attracted to the efficiency of an HMO operation (Table 8). Scale 7: Consumer Recruitment
Consumer recruitment evoked a measure of uncertainty among project directors. HMO directors were aware that the public might be unfamiliar with the HMO system, posing recruitment problems for them (63 per cent), and that it has TABLE 9-Scale 7: Consumer Recruitment No.
%
Other Findings
1. An HMO prepaid group practice will attract a sufficient membership level from among consumer populations. AAA AA A D DD DDD
17 18 15 1 2 1
31.5 33.3 27.8 1.9 3.7 1.9
2. Because prepaid group practice has primarily recruited middle-class workers, it is unlikely that it can achieve a balanced membership among lower socioeconomic classes. DDD DD D A AA AAA NA
10 16 13 8 1 3 3
18.5 29.6 24.1 14.8 1.9 5.6 5.6
3. It has not been proven that an HMO prepaid group practice has broad appeal as a health plan to all classes of consumers. DDD DD D A AA AAA
6 6 8 14 14 6
11.1 11.1 14.8 25.9 25.9 11.1
4. There is such a need for health care that there will be sufficient response from consumers to HMO recruitment. AAA AA A D DD DDD
3 19 11 13 5 3
5.6 35.2 20.4 24.1 9.3 5.6
5. Consumer recruitment will be difficult because HMO prepaid group practice is a relatively unknown health care system. DDD DD D A AA AAA
1200 AJPH NOVEMBER, 1975, Vol. 65. No. I 1
not been proven whether an HMO has broad appeal to all classes of consumers (63 per cent). These are forthright answers to uncertain aspects of health planning. Similarly respondents agreed and disagreed over whether such a need for health care would produce a sufficient response from consumers to HMO recruitment. Yet, on the whole, these project directors felt confident that an HMO would attract a sufficient membership from consumer populations (93 per cent), and a balanced membership, particularly from lower socioeconomic classes (72 per cent) (Table 9).
2 9 9 18 13 3
3.7 16.7 16.7
33.3 24.1 5.6
Table 10 revealed the various mean scores of the scales. The means tended toward positive skewness on a range from 5 (strong agreement AAA) to 30 (strong disagreement DDD). Scale 3 (Degree of Federal Regulation) had the highest mean score (18.91) and fell between the slightly agree and slightly disagree (17.5) range. Scale 5 (Public and Private Funding) followed next with a mean score 17.41, while Scale 7 (Consumer Recruitment) was third with a 15.24 mean score. Scale 4 (Consumer Participation) and Scale 6 (Physicians' Attitudes toward HMO) were 14.72 and 14.37, respectively. They tended toward the slightly agree category. Scale 1 (Prepayment) and Scale 2 (Quality of Care) were between the moderately and slightly agree range and favored the former. T-tests were made on: (1) Scale 4 (Consumer Participation) with the variables: consumer participation on policy board and consumer grievance procedure; (2) Scale 7 (Consumer Recruitment) with the variables: inner city and rural area; (3) Scale 1 (Prepayment), Scale 2 (Quality of Care), Scale 3 (Degree of Federal Regulation), Scale 4 (Consumer Participation), Scale 5 (Public and Private Funding), and Scale 6 (Physicians' Attitudes toward HMO) with the variables: HMO project directors with MD and without MD; (4) Scale 1 (Prepayment), Scale 3 (Degree of Federal Regulation), Scale 4 (Consumer Participation), and Scale 5 (Public and Private Funding) with the variables: public and private, single and combination sponsorship; (5) Scale 1 (Prepayment), Scale 2 (Quality of Care), Scale 3 (Degree of Federal Regulation), Scale 4 (Consumer Participation), Scale 5 (Public and Private Funding), and Scale 6 (Physicians' Attitudes toward HMO) with the variables: favorable and unfavorable physicians' reactions toward the TABLE 10-Mean and Standard Deviation Scores of Scales 1 to 7
Scale 1: Prepayment Mechanisms Scale 2: Quality of Care Scale 3: Degree of Federal Regulation Scale 4: Consumer Participation Scale 5: Public and Private Funding Scale 6: Physicians' Attitudes toward HMO Scale 7: Consumer Recruitment
Mean
Standard Deviation
12.37 11.26 18.91 14.72 17.41 14.37 15.24
4.56 3.73 4.99 4.31 5.38 3.47 3.56
HMO project. There was no significant differences, with p < 0.10, which may indicate that the project directors are a self-selecting group and a homogeneous sample (Table 10).
Discussion of Findings Research findings of this exploratory study on HMO projects and attitudes of HMO project directors have uncovered the following areas: * A brief profile of the typical HMO project director: A middle-aged male who graduated from professional school within the last 15 years with a master's degree in administration, was employed by the sponsoring institution within the last 5 years, and had less than 10 years experience in health planning and administration; * General characteristics of the HMO project: Sponsored by a single private or public institution with fairly comprehensive services, consumer participation and grievance procedure policies, loose physician arrangements, and a medically underserved area focus; clearly in the feasibility and planning stages with the support of physicians who are affiliated with the sponsoring institution; * Attitudes of project directors toward HMO delivery issues: On the other hand, HMO project directors tend to disagree with strong federal regulations and public funding and voice moderate uncertainty over consumer recruitment. This may indicate that they are concerned about government intervention in HMO regulations and funding as well as the need for an adequate consumer recruitment network. On the other hand, they tend toward slight agreement on a consumer participation policy and the ability to recruit physicians, and toward slight to moderate agreement on the prepayment mechanism and quality of care issues. This researcher speculates that respondents may feel more comfortable with such intraorganizational aspects. However, federal regulations, public and private funding, and consumer recruitment represent the external environment, and, to an extent, are beyond their immediate control and sphere of influence. Further research is required to ascertain these differences among their attitudes. Furthermore, numerous areas for follow-up research arise from these findings. Among them are: * Investigation of the project directors in terms of their length of time and various settings in health care administration. In this regard, it would be interesting to find out whether the MD directors have been in administrative or clinical positions and what their motivations are for assuming leadership in an HMO project. A more accurate profile of the capacity, background, training, and experience of the current group of project directors may emerge as a result; * Sponsorship of the HMO program in terms of the independent resources which led to single sponsorship as well as the resources exchange between
organizations which formed multi-agency coalitions; * Follow-up on the HMO operations in terms of current development, membership level, and funding expectations as well as a focus on factors which led to the development of viable institutions which are in the initial or full-scale stage; * Mortality rate of HMO projects in terms of the numbers and factors which may have contributed to termination; * Current attitudes of HMO project directors toward private and public funding, government regulations, quality of care, and consumer recruitment as well as alternatives plans for funding due to uncertain Congressional appropriations; * Progress report of operational programs on consumer board members and consumer grievance policies; * A physicians' attitude follow-up study on physicians who have joined HMO staffs compared with other physicians in the same community who are in fee-for-service practice.
Conclusion A national survey of health maintenance organization project directors' attitudes on HMO delivery issues was conducted to gather data about HMO planning development and delivery areas. Questionnaire results revealed characteristics of the HMO project director, sponsoring institution, and developmental stage. Seven HMO issues (Prepayment Mechanism, Quality of Care, Degree of Federal Regulation, Consumer Participation, Public and Private Funding, Physicians' Attitudes toward HMO, and Consumer Recruitment) were identified to measure the attitudes of directors. As a whole, responses were in the positive range. Scale 1 (Prepayment Mechanism) and Scale 2 (Quality of Care) received the lowest mean scores and were in the moderate agreement range. Scale 3 (Degree of Federal Regulation) and Scale 5 (Public and Private Funding) had the highest mean scores and fell between slight agreement and disagreement. Further research has been noted in various administrative features and issue areas of HMO. Most crucial is the outcome of HMO legislation which has a bearing on the policy and program of the HMO delivery system. On the basis of what appears to be a representative sample of directors of DHEW-funded HMO Planning and Development Projects, the study has assessed attitudes on important issues relevant to HMOs and determined areas of greatest agreement and disagreement. ACKNOWLEDGMENTS The author wishes to acknowledge the following persons for their technical consultation and therapeutic support in the preparation of this article: Jon L. Bushnell, PhD, and Gregory M. St. L. O'Brien, PhD, of the University of Wisconsin, Milwaukee, School of Social Work, and Mel Karmen, PhD, and Grace F. Brody, PhD, of Case Western Reserve University, School of Applied Social Sciences. HEALTH MAINTENANCE ORGANIZATIONS 1201
REFERENCES 1. Nixon, R. M. Health Message from the President of the United States Relative to Building a National Health Strategy. House Document No. 92-49. 92nd Congress, 1st Session, Feb., 1971. 2. Densen, P. M., Balamuth, E., and Shapiro, S. Prepaid Medical Care and Hospital Utilization. American Hospital Association, Chicago, 1958. 3. Densen, P. M. Balamuth, E., and Shapiro, S. Prepaid Medical Care and Hospital Utilization in a Dual Choice Situation. Am. J. Public Health 50:1710-1726, 1960. 4. Brown, D. R. Community Health Planning or Who Will Control the Health Care System. Am. J. Public Health 62:1337, 1972. 5. Klarman, H. E. Analysis of the HMO Proposal-Its Assumptions, Implications, and Prospects. In Health Maintenance Organizations: A Reconfiguration of the Health Services System, pp. 27-29. University of Chicago, Chicago, 1971. 6. Weissman, A., and Anderson, R. Characteristics of Health Plan Membership. In The Kaiser-Permanente Medical Care Program, edited by Somers, A. R., pp. 33-43. Commonwealth Fund, New York, 1971. 7. Greenlick, M. R., Freeborn, D. K., Colombo, T. J., Prussin, J. A., and Saward, E. W. Comparing the Use of Medical Care Services by a Medically Indigent and a General Membership
Population in a Comprehensive Prepaid Group Practice Program. Med. Care 10:187-200, 1972. 8. Saward, E. W., and Greenlick, M. R. Health Policy and the HMO. Milbank Mem. Fund Q. 50:147-176, 1972. 9. Havighurst, C. C. Health Maintenance Organizations and the Market for Health Services. Law Contemp. Probl. 35:716-795, 1970. 10. Chenault, W. W., and Brown, D. K. Consumer Participation in Neighborhood Comprehensive Health Care Centers. Human Sciences Research, McLean, VA, 1971. 11. Duval, M. K. Development of HMOs-Concepts and Benefits. Health Serv. Rep. 87:407, 1972. 12. Valiante, J. D. Start-Up Problems of Health Maintenance Organizations. In Health Maintenance Organizations: A Reconfiguration of the Health Services System, pp. 39-48. University of Chicago, Chicago, 1971. 13. Nixon, R. M. Presidential Documents. 9:200, 1973. 14. American Medical News, p. 12. Aug. 13, 1972. 15. Griedson, E., and Rhea, B. Physicians in Large Medical Groups. J. Chronic Dis. 17:827-836. 16. Cook, W. H. Profile of the Permanente Physician. The KaiserPermanente Medical Care Program, edited by Somers, A. R. pp. 97-105. Commonwealth Fund, New York, 1971.
CLINICAL LABORATORY SYMPOSIUM SCHEDULED A symposium on "The Clinical Laboratory as an Aid in Chemotherapy of Infectious Disease" will be held November 20-21, 1975, in Philadelphia. Sponsored by the Eastern Pennsylvania Branch of the American Society for Microbiology and other institutions, the symposium will feature a distinguished panel of specialists concerned with the new and changing aspects of this topic, one of the most important functions of the clinical laboratory today. Laboratory directors, qualified representatives, and interested individuals should register early, since attendance is limited. The symposium will be held at the new Hilton of Philadelphia on the campus of the University of Pennsylvania. For further information, contact Josephine Bartola, Pennsylvania Department of Health, 2100 W. Girard Ave., Philadelphia, PA 19130.
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