MCPR 1999 - Measuring the Quality of Pennsylvania's HMOs - News Release


Contact: Joe Martin, Communications Director
717-232-6787 or


Harrisburg, PA - June 27, 2001 - A new government report says HMOs in Pennsylvania do a good job in preventing avoidable hospitalizations for "ambulatory sensitive" medical conditions - these are ailments best treated through good preventive care in a primary care setting. One exception: children were hospitalized at a higher than expected rate for ear, nose and throat infections. Measuring Quality in Pennsylvania's Commercial HMOs, released today by the Pennsylvania Health Care Cost Containment Council (PHC4), also reports that for the second consecutive year, Pennsylvania HMO members are more satisfied with their care than HMO members elsewhere, with 85% reporting no problems in receiving the care they felt they needed.

"One of the selling points of HMOs is that they can help patients avoid unnecessary trips to the hospital through better preventive and primary care," stated Marc P. Volavka, Executive Director of PHC4. "For the first time, the Council was able to use its clinical data to test this theory and the analysis suggests, that for the most part, the approach seems to be working."

Not so clear is the HMO track record on surgical procedures. Breast cancer procedure and reconstruction rates varied widely among HMO plans while procedure rates to correct neck and back problems ranged from 6.5 per 10,000 in one plan to 34.2 per 10,000 in another.


There are 75 million chronic backache sufferers in the United States today, with costs to treat the problem ranging from $50 to $100 billion each year. Studies have shown that practice patterns for neck and back surgery vary across doctors and geographic locations. The guidelines for when to perform back surgery, especially spinal fusion, are unclear. Most professional guidelines recommend conservative treatment before surgery, but recommendations for the duration of conservative treatment differ.

"The financial and quality of life impact of neck and back problems on employers and employees is dramatic," said Mr. Volavka. "Professional guidelines appear to lack consensus about the treatment of these problems and the variation in the data may reflect this uncertainty."


Breast cancer is the most frequently diagnosed cancer site among women. According to the Pennsylvania Department of Health, there were 11,906 breast cancer cases diagnosed in 1998 in Pennsylvania. According to PHC4 data, a total of 8,277 breast cancer procedures (lumpectomy and mastectomy) were performed for Pennsylvania women under the age of 65 in 1999.

"For the first time in Council history, we were able to study one of the most significant health issues affecting women," said Mr. Volavka. "Our report shows wide variation across HMOs in breast cancer procedure rates, type of procedure performed, and whether it was done in an ambulatory or inpatient hospital setting. For example inpatient reconstruction rates following a mastectomy were significantly higher for women belonging to HMOs in the eastern part of the state than for those throughout the rest of Pennsylvania."


More than 500,000 Pennsylvanians have been diagnosed with diabetes, and several hundred thousand more may also be suffering from the disease, but have yet to be diagnosed. In addition, the American Diabetes Association estimates the direct medical cost of diabetes to be $44 billion nationally, with an additional $54 billion attributable to disability, work loss and premature mortality.

"While some hospitalizations for diabetes are expected, appropriate preventive care can minimize hospital admissions, especially for short-term complications of the disease," said Mr. Volavka. "These are admissions we should be working to avoid, yet the wide variation in rates and preventive care measures such as eye exams suggest an uneven approach to disease management."

An HMO is a prepaid health plan that requires members to use participating doctors and hospitals in return for lower premiums and fees, and to get referrals from primary care physicians before seeing specialists. Point of service plans, also included in the report, are similar to HMOs but give members some coverage for services outside the network of preferred providers.

Not included in the report are Medicare HMOs, which serve older and disabled people and Medical Assistance HMOs that serve low-income individuals.

The PHC4 report includes:

  1. Patient outcome information about the rates of hospitalization, hospital readmissions, length of stay and complications for select medical categories: Ear, Nose and Throat Infections, Gastrointestinal Infections, Kidney/Urinary Tract Infections, Hypertension, Chronic Obstructive Pulmonary Disease, Diabetes, as well as procedures for breast cancer and neck and back problems;
  2. HEDIS measures such as Advice to Quit Smoking, Mammography Rates and Mental Health indicators. HEDIS stands for Health Plan Employers Data and Information Set and was developed by the National Committee for Quality Assurance (NCQA);
  3. The degree to which Pennsylvania HMO members are satisfied with the services provided and coordinated by their HMO, as measured by the Consumer Assessment of Health Plans Survey (CAHPS), also an NCQA product;
  4. Each participating HMO's NCQA accreditation status;
  5. Financial and other descriptive information about HMO networks.

"The participating HMOs are to be congratulated for their involvement in this project," said Mr. Volavka. "Through their voluntary efforts, these companies are helping to report meaningful performance data about health care in Pennsylvania and to heighten public awareness about the role of managed care in our health care delivery system."

Copies of Measuring the Quality of Pennsylvania's Commercial HMOs are free and can be ordered by calling the Council at 717-232-6787 or downloaded from the Council's website at

The Pennsylvania Health Care Cost Containment Council is an independent state agency that provides the public with information that can be used to improve the quality and restrain the cost of health care in Pennsylvania.