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Consumers' HMO complaints listed by state agency

The San Diego Union-Tribune

How does your health plan stack up against the rest?

A new report issued by the state agency in charge of regulating health maintenance organizations may offer a glimmer of an answer.

The Department of Managed Health Care has put out its first report on consumer complaints against HMOs. While the rate of complaints against health plans statewide varied widely, in San Diego County there were relatively slim differences among the major companies.

Of the plans operating in the county last year, PacifiCare of California recorded the highest rate of complaints, with 2.52 for every 10,000 members, while Sistemas Medicos Nacionales, a specialty HMO offering coverage to Mexicans working in this country, had a rate of zero.

Among other large health plans operating in San Diego County, Kaiser Foundation had a complaint rate of 1.22 per 10,000 members, Blue Cross of California had 1.29 and Health Net of California had 2.31.

The report looked only at complaints that reached the stage when records had to be reviewed by the department for resolution. It does not include complaints that were resolved informally, sometimes by phone, or the most difficult complaints--those that require a decision by an independent review medical board.

Since Jan. 1, Californians disputing decisions by their health plans have had the right to appeal to such independent boards.

While saying the report is part of the department's continuing efforts to educate the public about the performance of their HMOs, Daniel Zingale, director of the year-old agency, cautioned that it should be viewed in context with other information.

"I would caution that this is a pretty small sample to base a decision on which HMO to choose," he said.

In the fall, the Office of the Patient Advocate is expected to release a more extensive and thorough state HMO report card. In the meantime, Bobby Pena, a spokesman for the California Association of Health Plans, said the complaint report only confirms that HMOs are doing a good job.

"The ranges that most plans are in, 2-3 for every 10,000 (plan enrollees), aren't that bad," Pena said. "It's a good ratio for any industry."

He added that while the report gives data about the number of complaints, it doesn't provide insight into whether the complaints were legitimate.

"We don't know whether the health plan acted appropriately or not," he said.

Indeed, through June, the independent review board made decisions in 224 of the 276 cases it had seen. The board ruled in favor of health plans 63 percent of the time.

However, Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights, said the complaint report doesn't "capture the real-life experience of patients" because it provides data on only one stage of complaint.

Each month, the department receives more than 14,000 complaints, the vast majority of which are resolved over the phone or through another informal process without a formal complaint being filed.

Court said such complaints "can be very serious, but a patient may not use the internal grievance procedure of the plan," which can set into motion the formal complaint.

Statewide, SCAN Health Plan of Los Angeles had the highest complaint rate in the state, with 6.38 complaints for every 10,000 plan members.

But different factors can affect the complaint rate, and department officials said consumers should not interpret a higher rate of complaints necessarily as a reflection of inferior quality.

Court had a slightly different opinion, saying the report "doesn't have much use."

In PacifiCare's case, a higher mix of Medicare patients may have raised its complaint rate because seniors are more willing to voice their unhappiness, said Cheryl Randolph, a spokeswoman for PacifiCare.

The plan is continually trying to improve customer relations and consumer complaint issues, she said, and PacifiCare is in a three-way, conference-call program with the Department of Managed Health Care. With the plan member and the health plan on the line together, a department representative works to resolve problems on the spot. Kaiser is also in the program.

In addition to looking at the overall complaint rate, the report separated the type of complaints into six categories.

The overwhelming majority, 42 percent, centered on denial of claims and/or payments. The second-most common complaints, 18 percent, related to disagreements over coverage and unhappiness about benefits.

Other complaint categories were quality of care, 17 percent; billing and financial, 14 percent; accessibility of care, 6 percent; and attitude/service, 3 percent.

To get a copy of the complaint report, call (888) HMO-2219. It also can be downloaded from the Department of Managed Health Care's Web site, www.dmc.ca.gov.