SAMPLE OF SUBCOMMITTEE QUESTIONNAIRE

QUESTIONS--HEALTH MAINTENANCE ORGANIZATIONS

1. HEALTH MAINTENANCE ORGANIZATIONS

GENERAL CHARACTERISTICS

A. Please define the term Health Maintenance Organization.
B. What is the appropriate size of an HMO? How many phy-
sicians and other paramedical personnel should it have to
assure economic success?

C. What geographic area should it serve?

D. What should the physician-patient ratio be?

E. What should be the ratio of hospital beds to enrollees?
F. What are the average planning costs?

G. What are the average start-up costs?

H. What are the time requirements for planning and start-up?
I. What provisions should be made for monitoring and infor-
mation systems in setting up an HMO What should be the
requirements, for example, regarding compatible medical
information systems among the components of an HMO, and
between HMOs? What requirements concerning the gathering
of utilization and demographic data, to assist management
and planning, should be imposed?

J. What should be the range of services offered by an HMO?
K. What is meant by preventive services in an H'10 and what
measures should be taken to assure they are provided?
L. How can quality care be assured in HMOS?

2. FUNDING OF HEALTH MAINTENANCE ORGANIZATIONS
A. Is there a place for profit-making HMOs?

(1) If so, how can under-utilization of services be
prevented, and how can high quality be assured?
(2) What types of qualifications should professionals
participating in Os be required to have -- what
requirements for continuing education should be
established?

B. In providing for capital costs, what do you see as being
the relative advantages and disadvantages of grants versus
guaranteed loans versus subsidized loans? What is the
appropriate mix among these three for profit-making HMOs?
For non-profit HMOs?

C. Through which mechanisms do you believe HMO enrollees
who are not now covered by health insurance would be able
to participate in HMOs? Would everyone be able to belong
to an HMO under existing circumstances?

D. How can the operating costs in HMOs be off-set? What
guarantees currently exist that HMOs, once initiated, will
be able to continue operation?

E. Are co-payments and deductibles or "service charges"

desirable in HMOS?

3. RISK SHARING IN HMOS

A. Should federally subsidized or sponsored Health Maintenance
Organizations be required to community rate?

B. How can the problems of inequity generated by experience
rating be avoided? What will keep HMOs from "skimming"
the low-risk members of the population?

4. HMOS IN RURAL AREAS AND URBAN GHETTOS

A. How can rural areas and urban ghettos be served by
HMOS?

B. How can HMOs be attracted to such areas?

C. How can problems of communication and transportation
be dealt with in rural areas?

D. In a rural area, how can one assure a high enough popu-
lation density or a large enough population base to
justify the establishment of an HMO?

E. In a ghetto, how can HMOs exclusively for the poor be avoided?

5. ARRANGEMENTS FOR THE PROVISION OF SERVICES

A. Is it appropriate for an HMO to simply be an umbrella which subcontracts the actual provision of various types of services to other individuals or organizations or should it be required to provide its own services directly?

B. If an HMO owns its own laboratories, hospitals, etc., what should be the basis for determining appropriate capitation levels? How can adequate cost accounting surveillance be provided?

6. REGIONAL PLANNING

A. What should be the role of area-wide planning agencies in determining where HMOs are to be established?

B. What should be the role of the Regional Medical Programs in establishing HMOs?

7. MEDICAL RESEARCH AND EDUCATION IN HMOs.

A. Should interns and residents participate in providing
services?

B. Should medical schools own and operate HMOs?
C. It has often been said that the involvement of medical
students, interns and residents increases the costs of
providing services. In your opinion, what is the most
appropriate way to defray these costs? Should costs
of education and/or research be included in the capi-
tation rate?

D. Should HMOs be located near some kind of academic
center?

E. Should they be linked, in the case of rural areas, to
area health education centers?

8. WHAT EFFORTS WOULD YOU CONSIDER TO BE REASONABLE IN ENROLLING MEMBERS OF A POPULATION GROUP INTO AN HMO? HOW MUCH "OUTREACH" ACTIVITY SHOULD HOS HAVE?

9. POLICY MAKING

A. How can one assure adequate consumer representation in an HMO? How would you define the term 'consumer" in

this context?

B. What is the appropriate balance between professional
and consumer contributions to policy making?

C. What should be the role of physicians and other pro-
fessionals in the ownership of HMOs ?

1. HEALTH MAINTENANCE ORGANIZATIONS

GENERAL CHARACTERISTICS

Questions and Responses

1.A. Please define the term Health Maintenance Organization?

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 1

Response. The attached table provides the H.R. 1 definition of an HMO, together with comparisons of differences between H.R. 1, S. 1182 (The HMO Assistance Act), and S. 1623 (The National Health Insurance Standards, and Title II, Family Health Insurance Plan). The definitions are identical except for the following differences:

a. Population coverage: H.R. 1 speaks to Medicare beneficiaries and requires at least half of enrollees to be under age 65; S. 1623, FHIP, speaks to coverage of eligible families and requires that at least half of enrollees be neither FHIP nor Medicaid eligible; and S. 1182 and S. 1623, NHISA are generic definitions which do not have specific mention of poulation groups.

b. Benefits and services covered: H.R. 1 requires HMO's to provide or arrange for Parts A and B services of Medicare; S. 1623, FHIP, requires coverage of FHIP services and S. 1623, NHISA, requires coverage of at least NHISA services, S. 1182 has a broad generic definition of services to be covered, but mentions of the minimum of physician services, hospital care, emergency care, and preventive medical services.

c. Minimum size: The two titles of S. 1623 require a minimum of 10,000 enrollees, with a waiver permitted at the discretion of the Secretary, whereas H.R. 1 and S. 1182 do not speak to minimum size.

The differences in HMO definition in the various bills are not inconsistent. They arise because of the nature of the HMO which combines capacity to deliver health services with the capacity to finance benefit packages. In general, an HMO is an organization which assumes responsibility for the health care of a defined population. This is not unlike the responsibility of a private physician to care for his patients. An HMO should have the basic capacity to provide such services directly or arrange for such services to be obtained from other providers. This is the kind of generic service package envisioned in the basic HMO Assistance Act (S. 1182), which would require a capacity to provide or arrange for any health services needed, but as a minimum would require the HMO to provide directly, or have effective arrangements for the provision of and payment for physicians care, hospital care, emergency care, and preventive services.

On the other hand, the H.R. 1 and S. 1623 legislation speak to the capacity of the HMO to provide directly or to arrange and pay for specific benefit packages for special population groups which enroll with them. An HMO may well have several different kinds of benefit packages for different population groups if it enrolls Medicare, Medicaid, FHIP, and private patients. Most HMO's now operating serve different groups with different packages: for example, the high and low option benefit packages available to the Federal employees.

1Introductory statement accompanying the responses of the Dept. of HEW appears as Appendix II, p. 185.

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