Health Care Perceptions and Experiences

Originally published as Issue Brief No. 30 by the Center for Studying Health System Change (HSC), September 2000. HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Health Care Perceptions and Experiences: It's Not Whether You Are in an HMO, It's Whether You Think You Are

Survey data consistently showed that most Americans held unfavorable views of health maintenance organizations (HMOs), even among HMO members who were satisfied with their own care. This Issue Brief explored how preconceptions about HMOs colored the way people rated their health care. According to findings from the Center for Studying Health System Change, differences in health care ratings between privately insured HMO and non-HMO enrollees were partly attributable to what type of plan people believed they had, rather than the type of plan that actually covered them. These findings carried important implications for efforts to regulate managed care, suggesting that attitudinal surveys alone gave a somewhat distorted and overly negative picture of care in HMOs, exaggerating the differences in how people assessed the care they received.

Rating HMO Care

The managed care backlash was a powerful force shaping health care policy at the time. Policy makers responded to widely cited surveys indicating that, while most people in either an HMO or another plan type were satisfied with their care, a majority believed managed care reduced quality. Most people therefore favored some form of managed care regulation. But while surveys captured how people felt, they might not accurately indicate the relative quality of care under different types of insurance. A pervasive conventional wisdom that HMOs delivered inferior care could lead respondents to give answers that reinforced this belief, regardless of their actual experiences. Beyond personal experience, negative impressions of HMOs could stem from reports by family and friends, comments from health care providers who were themselves dissatisfied with managed care, and largely negative media coverage driven by anecdotes -- the so-called HMO horror stories.

Experiences or Perceptions?

To investigate how external factors shaped people's assessments, HSC researchers exploited the fact that nearly one in four privately insured people did not correctly know whether they were enrolled in an HMO. Using linked data from the Community Tracking Study Household Survey and the Insurance Followback Survey, researchers compared what consumers reported about their plan type with what insurers confirmed. Among those who misidentified their plan, roughly equal numbers were actually in HMOs and non-HMO plans.

The analysis sorted respondents into four groups: those who correctly identified themselves as HMO members, those who thought they were in an HMO but were not, those who thought they were in a non-HMO but were actually in an HMO, and those who correctly identified as non-HMO members. If people's survey responses reflected their actual care experiences, ratings should have aligned with actual plan type. But if preconceptions about HMOs colored responses, ratings should have tracked with perceived plan type instead.

Across several measures -- satisfaction with care, ratings of the thoroughness of the last doctor's visit, and trust in whether doctors would refer patients to specialists when needed -- expressions of dissatisfaction corresponded most closely with whether people thought they were in an HMO, not whether they actually were. Once perceived plan type was accounted for, there was little difference in dissatisfaction between actual HMO and non-HMO enrollees. The data strongly suggested that a conventional wisdom about inferior HMO care was influencing how people responded to surveys, independent of their real experiences.

Additional Bias from Misreporting

Since many people did not accurately know their plan type, researchers who compared health care assessments based on self-reported HMO status obtained results that were even more biased than comparisons based on insurer-confirmed plan type. For each measure HSC examined, HMOs were viewed relatively more favorably when insurer-reported plan type was used to categorize respondents. For most measures, HMO enrollees still provided slightly lower ratings, but the differences were substantially smaller. On one measure -- whether doctors might prescribe unnecessary tests and procedures -- HMO enrollees actually expressed greater trust when categorized by insurer-confirmed plan type, while no statistically significant difference appeared when self-reported plan type was used.

Implications for Policy Makers

For some consumers, stereotypical views of HMOs interacted with their perception of the type of plan they had, coloring how they assessed their care. The findings implied that some of the negative assessments of HMO care reflected biases rather than genuine differences in the quality of services received. Policy makers relying heavily on attitudinal surveys to shape managed care regulation needed to recognize this distortion. By using more objective data sources -- such as insurer-confirmed plan enrollment rather than consumer self-reports -- researchers and regulators could obtain a more accurate picture of how plan type actually affected health care quality and patient experience.

Sources and Further Reading

HSC Community Tracking Study Household Survey, 1996-1997. | HSC Insurance Followback Survey, 1996-1997. | Reschovsky, James D., and J. Lee Hargraves, Issue Brief No. 30, Center for Studying Health System Change, September 2000.