Section 5 - Portrait of a modern HMO 

     But what about outcomes?

The fact is, nobody in our FTP scenario has any incentive to really want to know about clinical outcomes – except as they may be incidentally useful as a marketing tool.

Gekko, for one, doesn’t have any reason to care about clinical outcomes.  His outcome is measured by his profit.  So as long as he’s making money, his outcome is good – and data on clinical outcomes would only serve to threaten what is now a nice, clean picture.  Unless pushed, he sees no reason to invest his resources in collecting such data.

What about Dr. Smith – the PCP who has to decide whether to refer his patients with heart problems to cardiologists in the more expensive Valley View group or those in the less expensive Cormatic Group?  Wouldn’t he want to know which group has the better clinical results? Certainly he would, on a professional level.  But he doesn’t have the resources to collect data like that himself; he’d need FTP’s help.  And he just hasn’t seen fit to push FTP for the data.  Subconsciously, he realizes that if he had that data, it might give him the wrong answer – the more expensive group might indeed turn out to achieve better results.  That would certainly complicate his referral decisions. 

And what about the cardiologists of the thrifty Cormatic Group?  Do they really want outcomes data? Well, why should they?  They’re already getting the referrals. 

Members of the "profligate" Valley View Group are the only ones who really have a good reason to care about clinical outcomes since, if they turn out to have more favorable outcomes, it might help to exonerate their expensive ways.  But (even if they can even avoid being thrown off FTP’s panel altogether), they have become virtual pariahs, and have no clout at all with Gekko. 

So, while there is plenty of talk about outcomes in the Gekkonian HMO world, when you analyze the mechanics, it is difficult to find anyone slogging away in the trenches who really wants to know about them.

But surely, you might be thinking, somebody wants to know about quality.  What about the patients? What about the employers who are paying the bills? 

Gekko knows about patients. When patients are faced with a choice between an HMO that’s “free” or an indemnity plan that might cost them an extra $50 or $100 a month, he just knows they’re going to pick the HMO. And while they’re picking it, they want to feel good about it. They deeply, sincerely, and desperately want to hear that they’re making a good choice.  They want to hear what a high quality HMO they’re being forced to join. And that’s where quality and marketing come together. To Gekko, quality is marketing.

“It’s like this,” Gekko says one day to his Marketing Director. “When a young man walks into a car dealership with his heart already set on a sleek red convertible, both he and the salesman know what is needed to close the deal.  That young man doesn’t want to hear about that model’s safety record or repair history or its miles per gallon.  What he wants is for the salesman to tell him what a smart choice he’s making.  So the salesman does, and – even though they both know that beige sedan over there would be a safer, more reliable car – the deal is made. And they’re both happy.”

This is why HMOs over the past few years have gotten away from advertising (and implying ready access to) their fancy, state-of-the-art, high-tech services. Instead, they’ve gone all fluffy, emphasizing warmth, concern, and caring, through filtered lenses and soft music.  When you join this HMO, it’s like joining a family.  What a good choice you’ve made.

Okay, you might reply, but what about employers?  Don’t they want to offer high-quality health care to their employees?  Well, sort of.  What most of them really want is to offer adequate health care without losing their shirts on it. 

My eyes were opened on this issue a few years ago when I attended a retreat, sponsored by my hospital, that featured a panel discussion by a group of prominent local employers.  When asked how they go about assuring themselves that the health coverage they buy for their employees provides high-quality care, the captains of industry responded thusly: “We make widgets, we don’t assess health care quality.  We don’t know how, and we don’t want to know how. So we’ve got to be practical about it.  To us, quality means quiet.  As long as we don’t hear more than the average number of complaints from our employees, the health coverage we provide is, by definition, good enough.”

Men and women like Gekko long ago figured out what their paying customers (i.e., the businesses that purchase health insurance for their employees) want.  And because of what his customers want, Gekko can define quality simply as keeping the volume of complaints down to an acceptable level (and, of course, keeping FTP out of the newspaper). Gekko even suspects that a complaint level that became too low that might become a problem - employers might begin to suspect that they were paying too much for their employee's health care if there were no complaints at all.

Now, to be sure, efforts are being made on several fronts to actually measure quality in health care, and some of these efforts are having an impact. But in general these efforts are not coming from Gekkonian-style HMOs, or even from health care providers.

Next: FTP 2000

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