HMOs have historically provided better preventive and screening services than the fee-for-service sector. HMOs are more generous with their coverage of women’s health services than average fee-for-service plans. Routine gynecologic examinations, screening services, and reversible contraceptive services are all included. The best data source for comparing HMO and fee-for-service coverage of women’s health services is the Alan Guttmacher Institute study on private-sector coverage. The Guttmacher data shows a significant difference in coverage for an annual gynecologic exam between HMOs versus fee-for-service plans. Nearly all HMOs cover the exam. However, only 39% and 49% respectively of smaller employers (those with less than 100 employees) contract with fee-for-service plans. the Department of Women's Health for physical examinations.
HMOs covered 95% of large-firm employees for physical examinations in 1994. This compares to 43% who were covered under indemnity plans. HMOs are more likely than others to provide coverage for Papanicolaou and mammography, which are used to screen for possible cancer cells and diagnose any suspected ones. State and federal legislation increasingly mandate these tests. However, in 1993 only 53% of self-insured plans and 49% of indemnity insurances contracted with large employers provided coverage for the Papanicolaou test, while 100% of HMOs had this coverage. Likewise, HMOs all covered mammography. However, only 71% of self-insured plans and 49% of indemnity insurance plans that contract with large employers had coverage for Papanicolaou tests.5 A 1994 survey of HMOs conducted by the Henry J. Kaiser Family Foundation and Group Health Association of America (GHAA), found that almost all HMOs provide mammography coverage. Eighty-six percent of HMOs cover routine mammograms in women over 50. 19% of HMOs that are group models don't cover annual mammograms of women over 50, but they do cover high-risk women at the physician's discretion or as required by law.
There is not much agreement about the optimal time for mammograms in women below 50 years of age. This makes it difficult to conclude whether rates under any payment method are too high or low. Nearly all HMOs cover mammograms for women aged 40-50. HMOs don't cover mammography for women aged between 35 and 40. Instead, they usually only allow one baseline mammogram for women who are at high risk. For women aged 35-39 years, 20% of HMOs in groups cover mammograms every year. All HMOs provide routine Papanicolaou test coverage, but the time a member is allowed to receive them and get reimbursed for them varies. Around 78% cover the Papanicolaou test annually, while 18.5% cover them "as necessary" or less often than annually. The majority of routine Papanicolaou test coverage is provided by PAS, while group models will cover them at the provider's discretion. In 1994, more than 22% of all conventional indemnity plans didn't cover the routine Papanicolaou test.
HMOs are significantly more likely to cover all types of reversible contraception than traditional plans. HMOs, for example, cover intrauterine device inserting at 86%, 46% in point-of-service networks plans, and 25% in conventional insurance plans. HMOs cover diaphragm fittings for 81%, whereas conventional plans covered only 21% in 1994. HMO model types are associated with the provision of reversible contraceptive services. Eighty-six percent of HMOs that cover group models cover Norplant insertion. 75 and 76%, respectively, of PAS and networks, cover this drug. Group models are more likely than other types to cover prescriptions for diaphragm devices (83%), 67% of networks (69% of IPAs), and 71% of staff (67%). According to the Alan Guttmacher survey, 70% of HMOs cover induced abortion. This is comparable to conventional insurance plans. The Group Health Association of America/Henry J. Kaiser Family Foundation Survey of Women's Reproductive Health Benefits (HMOs) responded that 57% of HMOs "cover abortions." Another 15% replied that it depends. An additional 15% only covers abortions if they are medically necessary.
The rest do not include abortions. The reasons for answering "it depends" are state bans on certain types, restrictions to the first trimester of abortions only, variations by the employer, and other factors. Some plans claimed that they were owned or controlled by religious groups, which prohibited them from covering abortion. The ma- *Survey data regarding reproductive health services provided by HMOs were reported by the Group Health Association of America/Henn, J. Kaiser Family Foundation Survey of Women's Reproductive Health Benefit in HMOs. The Kaiser Family Foundation, GHAA, and GHAA collaborated to survey women's health services provided by HMOs. Two separate topics were addressed in the survey: how HMOs treat patients with HIV and how they provide reproductive services. One survey was mailed to all GHAA members. 23 out of 353 GHAA members responded to the survey (66.9%). Chain members were less likely than independent members to complete the questionnaire (55.6% versus 84.6%). While most plans cover abortion in certain circumstances, some restrict abortions to specific situations or are limited by state or other regulations. The HMO model you choose will determine your coverage.
Only 48% of IPAs offer abortion services without restrictions to 75% of staff-model HMOs. Networks and IPAs responded more often that it depends on whether they offer abortions. 4 percent of staff models reported that they offer abortions. This compares with 21% of networks and 18% of IPAs. IPA models were less likely to offer abortions in any circumstance. Nineteen percent (90%) of IPAs don't offer any abortion services. This compares with 10% of networks, 7% for groups, and 4% for staff-model HMOs. IPAs are less likely than staff and group models to contract out abortion services to other organizations. HMOs with staff models contract out abortion services for more than 40%. The IPA model HMOs were less likely to contract with family planning agencies for any type of service, including abortion. Only 15% of PAS had a contract in place with a family planner agency. These HMOs were more likely to have contracts with group models (mainly to provide abortions) than network model HMOs (34% and 25%, respectively).
This paper outlines the facts about women in HMO settings, including their coverage, copayments, and use of services. Comparisons with women not enrolled in HMOs are made whenever possible. HMO members tend to have lower hospital admissions, shorter hospital stays, and the same or more primary physician visits per enrollee. They also use fewer expensive procedures and tests and make more use of preventive services. However, data on the use of services is much less common than data on specific services. This is because users must be measured at the patient level. However, data on coverage and copayment requirements may be obtained from employers, insurers, or health plans. Researchers must survey HMOs or abstract medical records information to obtain data about individual service users.
All of these data collection activities are very expensive and require large samples of patients to yield meaningful results. It is also difficult to obtain use figures for fee-for-service patients, except when a payer has all the claims submitted by a patient population (such as the Medicare databases). This makes it very difficult to compare HMO and fee-for-service rates. There are data available on the national use rates in and out of HMOs. However, quality assessment or outcomes data are scarce. These data require more detailed data collection to determine the relationship between specific practices and their outcomes. Providers and plans will not usually produce such costly and time-consuming statistics unless there is a compelling reason to do so.
However, this does not mean that it is impossible to analyze patterns of care across the managed care continuum (from fee-for-service through staff model HMOs) This analysis is more important as new types of delivery and payment systems emerge. It is important to assess access to and quality of services for particular populations. This question has yet to be answered by sufficient research. The literature has not adequately addressed the question of how HMOs compare to other delivery options for women in different age groups with different sociodemographics or health statuses. HMOs, offer comprehensive benefits and high-quality medical care to their members.
They are well-received by the employer as well as their members. HMO members love the coordination of their care, the absence of claims, and the lower, more predictable copayments. HMOs are reporting more on their care to payers and employers through mechanisms such as the Health Plan Employer Data and Information Set, (HEDIS). These data are used to improve the care they offer. To improve performance, customer satisfaction surveys are being used more frequently. These activities are not limited to the fee-for-service sector. HMOs can continue to improve the care they offer women and others by collecting and analyzing data about care processes and outcomes.
Sources:
https://pubmed.ncbi.nlm.nih.gov/8907848/
https://www.verywellhealth.com/what-is-an-hmo-how-does-it-work-1738661
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