Does Your Hmo Stack Up?

AT FIRST WE COULD IGNORE THEM. THEN we noticed a neighbor joining one. Finally, a fat, forbidding package from the benefits department landed on our desk. Now we know the truth: HMOs rule. The revolution that has already shunted 53.3 million people from Marcus Welby style medicine into the Wal-Mart model of health care will convert an additional 50 million by the turn of the century. If you haven't already been asked to leave your cushy indemnity plan, you will be--soon.

Good luck. Chances are you won't be ready. Why? Because the hundreds of HMOs swashbuckling across the country are indistinguishable from one another--yet you're going to have to choose one. Of course, they're not really identical. But even a savvy shopper would have trouble knowing a good HMO from a bad one. There's no central source of information on HMOs and no authoritative rankings. The industry can't even agree on a definition of quality. "People have almost no ability to compare health plans," says David Lawrence, Kaiser Permanente's CEO.

Why the information vacuum? Though the industry is old, most of the country's 593 HMOs are still in their infancy. Measuring planwide quality is still more an art than a science, too. Despite those challenges, NEWSWEEK thought it would be worth investigating HMO quality and singling out the exceptional plans. The result: ratings of more than 40 of the country's largest HMOs.

The first step was to consult David Lansky, president of the Foundation for Accountability, an influential nonprofit group in Portland, Ore., that helps consumers and corporations make health-care decisions. Together we designed a survey to gather information directly from the HMOs. Of the 75 plans surveyed, 43, covering 24 million members, responded. While that's a good response, it shows how uncomfortable comparison shopping makes HMOs. It also reflects HMOs' low opinion of today's rating tools. That's why United HealthCare, which operates more than 40 plans, with 14 million enrollees, wouldn't participate. "Everyone in the industry is finding problems with these quality measures. They're not appropriate for comparing plans," says Lee Newcomer, United's chief medical officer. Humana answered only part of the survey because it, too, believes that the measures can be misunderstood.

While evaluating HMOs is still an inexact exercise, these ratings provide a good start. At the very least, they allow consumers to differentiate between an HMO that's great at answering the phone from one that's doing a great job of detecting breast cancer. Even if you don't find your HMO on the list, you--or your employer--can use these criteria to evaluate your plan.

Why don't consumers already know this stuff? Because HMOs sort of snuck up on us. They were invented in the 1930s to give doctors an incentive to keep their members healthy. But we don't know much about judging them because HMOs didn't take off until the 1980s, when employers began relying on them to slash costs. Now HMOs and their cousins, preferred provider organizations (PPOs) and point-of-service plans (POS)-are scrambling to dominate markets so that they can wring more costs out of doctors and hospitals. "What's scary is that there's no system in place to detect harm to people while the shakeout is occurring," says Lansky.

But don't be too alarmed. HMOs, for the most part, are willing to be held accountable. That was impossible under your old indemnity plan, when the insurance company paid the bills no matter which doctor you used. Who knew if your doctor was performing too many Caesarean sections?

As you scan the table on page 60, keep two things in mind. First, the ratings are a snapshot of HMO quality, not a permanent grade. Over the coming months HMOs will be reporting their 1995 quality results, which may reflect significant changes. A key way to track those will be through Quality Compass, a database that will be published in August by the National Committee for Quality Assurance, a Washington, D.C., group that accredits HMOs. Also: even low-scoring plans are to be commended for putting their reputation on the line.

NEWSWEEK's highest-scoring HMOs were Harvard Community Health Plan, Fallon Community Health Plan, Kaiser Foundation Health Plan of Colorado and Kaiser Foundation Health Plan-Northern California region. All have close, collaborative relationships with their doctors and a long-established mechanism for keeping people healthier. Low-scoring plans had more distant relationships with doctors, which made them less able to influence the kind of care given to their members. Here are the six criteria NEWSWEEK used to rate all the HMOs:

At the very least, your health plan should pass certain objective standards. While there's no universally revered stamp of approval, accreditation by the NCQA comes close. To get it, a plan is judged on 50 different characteristics, like how well it checks out doctors' credentials. Of the 222 plans in the country that have been reviewed by the NCQA, only 37 percent won full accreditation. An additional 39 percent got partial accreditation, 11 percent received provisional accreditation and 12 percent were denied accreditation, including Aetna Health Plan of California and California Care. Who wouldn't prefer a fully accredited plan? The higher a plan's accreditation status, the more points it received. Points were also given to HMOs planning to seek accreditation.

It was also important to know if a plan published the results of a set of measures called HEDIS, for Health Plan Employer Data and Information Set. HEDIS was developed in 1989 by corporations like Xerox and GE, which wanted to compare plans. Any plan that seriously seeks better quality should be making that information public. Most on our list do.

There were two other measures that were nobrainers: HMOs should be affiliated with hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations and employ a high percentage of doctors who have been "board certified." That means they've had extra training and passed a rigorous exam. Kaiser Foundation of the Mid-Atlantic States had the highest percentage of board-certified doctors, at 95 percent, while FHP Health Care, Ariz., had the lowest, at 67. Also HMOs that tie doctors' compensation to meeting quality and satisfaction targets received extra points.

Most HMOs try to figure out how contented their members are. But for the results to be believable, an HMO has to hire an independent firm to conduct the satisfaction survey, use a standardized set of questions and release the results to the public. HMOs that followed all of those steps received higher scores than plans that didn't. Points were also awarded to plans that will shift to the NCQA's standardized survey this year. That signals an HMO's willingness to have its members' satisfaction levels compared with its competitors'--a huge service. Successful HMOs should also keep their doctors happy. Who wants to go to an unhappy one? So HMOs that asked doctors about their satisfaction with the plan got credit.

Would it surprise you that most HMOs couldn't tell you exactly how healthy or unhealthy their members are? Or how many enrollees smoke, abuse alcohol or engage in unsafe sex? Only one plan merited a four-star rating in this category, which was weighted twice as heavily as the previous two: HMO Blue of Massachusetts. It hasn't been known for delivering exceptional quality. But it turns out our ratings have pinpointed an important development: the HMO is dramatically overhauling its quality programs. "It's one of the best turnarounds I've seen," says consultant Sue Sheffler.

The best plans use hard-nosed measures called "outcomes." Outcomes show the ugly side of health care: how many diabetics had to undergo an amputation; how many women died of breast cancer. HMOs haven't been eager to embrace these measures, largely because an HMO with a high number of diabetic enrollees is bound to look bad next to a plan with very few.

Still, most folks would prefer to belong to an HMO that's sharp enough to be measuring such bottom-line results. That's why points were awarded to HMOs that could reveal their death rate from coronary artery-bypass graft surgeries. This mortality rate is the single best-studied outcome yardstick-one you'd undoubtedly want to ask about if your family had a history of heart disease. But only seven of the 43 plans could report the crude 30-day rate.

One of the easiest ways to keep people healthy is to avoid sickness or detect it early. This principle is so well established that any plan that scored poorly here is probably in the early stages of upgrading its care. Plans were judged on their rates of vaccination, mammography, cervical-cancer screening and diabetic retinal exams because they're such effective tools and because so many HMOs can report on them.

Here three measurements counted. The first tells you how many women received prenatal care during the first trimester of their pregnancy. Top scorers such as Harris Methodist Health Plan have healthier babies and less risky deliveries as a result. The second: the percentage of pregnancies that result in Caesarean sections. The best HMOs are working to lower their C-section rate because so many of the surgeries are unnecessary and expose women to extra danger. The national rate today is 22 percent, but it was just 11 percent in 1971. Only four plans, including HMO-Oregon, could boast rates under 14 percent. The last measurement: the percentage of women who had a normal delivery after a previous C-section. Plans that could simply report it were given points. Why? It wasn't long ago that the medical profession believed that women who had one C-section couldn't have a normal delivery later. Plans that pay attention to this so-called VBAC rate are more likely to go to extra lengths to reduce risk in childbirth.

Satisfaction is slippery to interpret. So instead of relying on each plan's survey results, as originally planned, we used the data collected by three independent sources: CareData, a New York information company; the Center for the Study of Services, which publishes a Guide to Health Insurance Plans for Federal Employees, and a Fortune 500 company that has been a leader in evaluating HMOs on behalf of its employees. One caveat here: a high satisfaction rate doesn't necessarily mean the plan offers topnotch care. It may simply be a sign of excellent customer service. In a recent study of 17 HMOs by the Massachusetts Healthcare Purchaser Group, the plans ranked highest for quality were not the ones that won the highest satisfaction scores.

Every state cautioned against using complaints as a barometer of HMO quality. They cited a variety of reasons: grievances against self-insured plans aren't included; complaints may be coming from doctors and hospitals instead of consumers; and despite its gigantic HMO population, California hasn't yet published the data. So complaints aren't factored into our ratings, although they are broken out. We first calculated the number of complaints per 10,000 members, to adjust for different HMO sizes. Then we compared that complaint ratio with the average for all HMOs in the state. Only 10 of our group had higher than average complaints.

There's little reason to expect that evaluating HMOs will be a snap any time soon. As more consumer-advocate groups and corporations wrestle with the issue, disagreement about the definition will get louder. But it's important to keep trying. The best HMOs will want to provide even more data, because it helps their cause. Others will follow suit to stay competitive. And for consumers, picking an HMO will no longer be like throwing darts.

These ratings are the result of a survey designed by NEWSWEEK and the Foundation for Accountability, a nonprofit group based in Portland, Ore., to assess the quality of care offered by HMOs. The first group of categories, graded in the "Overall Quality Monitoring" column, tells you how willing an HMO is to measure and report its own effectiveness. The second, scored under "Overall Quality Results," tells you whether the HMO is keeping people healthy.

Fallon Community Health Plan, Mass. Number of members * 180 Complaint ratio low Meets industry standards excellent Measures satisfaction excellent Tracks members'health good Overall monitoring very good Prevention and screening excellent Maternity care very good Satisfied customers[a] excellent Overall quality results excellent Overall score excellent Comments Top prenatal and prevention scores, very complete disease monitoring. Harvard Community Health Plan, Mass. Number of members * 591 Complaint ratio high Meets industry standards excellent Measures satisfaction excellent Tracks members'health very good Overall monitoring excellent Prevention and screening excellent Maternity care excellent Satisfied customers[a] good Overall quality results excellent Overall score excellent Comments Among the most sophisticated trackers of health and disease. Kaiser Foundation Health Plan Inc. --Northern Calif. Region Number of members * 2,218 Complaint ratio n/a Meets industry standards very good Measures satisfaction excellent Tracks members'health very good Overall monitoring very good Prevention and screening excellent Maternity care very good Satisfied customers[a] excellent Overall quality results excellent Overall score excellent Comments Accreditation planned; excellent health, disease tracking. Kaiser Foundation Health Plan of Colorado Number of members * 308 Complaint ratio low Meets industry standards very good Measures satisfaction very good Tracks members'health very good Overall monitoring very good Prevention and screening excellent Maternity care very good Satisfied customers[a] excellent Overall quality results excellent Overall score excellent Comments Terrific prenatal care; holds itself accountable for members' health. CIGNA HealthCare of Arizona, Inc. Number of members * 150 Complaint ratio high Meets industry standards excellent Measures satisfaction very good Tracks members'health very good Overall monitoring very good Prevention and screening excellent Maternity care good Satisfied customers[a] good Overall quality results very good Overall score very good Comments Among the best at measuring disease and treatment results. Community Health Plan, N.Y. Number of members * 302 Complaint ratio low Meets industry standards excellent Measures satisfaction excellent Tracks members'health good Overall monitoring very good Prevention and screening good Maternity care excellent Satisfied customers[a] good Overall quality results very good Overall score very good Comments Very good prenatal record and C-section rate; too few vaccinations. FHP of Colorado, Inc. Number of members * 349 Complaint ratio high Meets industry standards very good Measures satisfaction excellent Tracks members'health good Overall monitoring very good Prevention and screening very good Maternity care very good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Works hard at assessing member and doctor satisfaction. Group Health Cooperative of Puget Sound, Wash. Number of members * 634 Complaint ratio low Meets industry standards excellent Measures satisfaction very good Tracks members'health very good Overall monitoring very good Prevention and screening very good Maternity care excellent Satisfied customers[a] very good Overall quality results very good Overall score very good Comments One of the best at monitoring health, risk behaviors and disease outcomes. HealthAmerica Pennsylvania, Inc., Central Pa. Number of members * 204 Complaint ratio average Meets industry standards very good Measures satisfaction excellent Tracks members'health satisfactory Overall monitoring good Prevention and screening very good Maternity care very good Satisfied customers[a] very good Overall quality results very good Overall score very good Comments Good at prenatal care and C-sections, but not at assessing health risks. HealthAmerica Pennsylvania, Inc., Pittsburgh, Pa. Number of members * 270 Complaint ratio high Meets industry standards very good Measures satisfaction excellent Tracks members'health good Overall monitoring very good Prevention and screening good Maternity care good Satisfied customers[a] good Overall quality results good Overall score very good Comments Can report death rate for heart surgery; too few mammographies. Health Net, Calif. Number of members * 1,351 Complaint ratio n/a Meets industry standards very good Measures satisfaction very good Tracks members'health very good Overall monitoring very good Prevention and screening very good Maternity care satisfactory Satisfied customers[a] very good Overall quality results good Overall score very good Comments Excellent asthma, breast-cancer, diabetes tracking; weak on prenatal care. HMO Blue, Mass. Number of members * 850 Complaint ratio low Meets industry standards very good Measures satisfaction very good Tracks members'health excellent Overall monitoring excellent Prevention and screening excellent Maternity care satisfactory Satisfied customers[a] good Overall quality results good Overall score very good Comments Not accredited yet, but good at monitoring health and disease. HMO Pennsylvania--U.S. Healthcare Number of members * 807 Complaint ratio high Meets industry standards excellent Measures satisfaction very good Tracks members'health very good Overall monitoring very good Prevention and screening very good Maternity care satisfactory Satisfied customers[a] very good Overall quality results very good Overall score very good Comments Strong breast-cancer and heart -failure-management programs. Independent Health, N.Y. Number of members * 414 Complaint ratio low Meets industry standards satisfactory Measures satisfaction very good Tracks members'health very good Overall monitoring good Prevention and screening very good Maternity care good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Accreditation denied but reapplying; good measurement of health levels. Kaiser Foundation Health Plan, Inc., Hawaii Number of members * 187 Complaint ratio n/a Meets industry standards very good Measures satisfaction very good Tracks members'health good Overall monitoring very good Prevention and screening very good Maternity care excellent Satisfied customers[a] very good Overall quality results excellent Overall score very good Comments Some of the happiest members; excellent vaccination and C-section rates. Kaiser Foundation Health Plan, Inc., Southern Calif. Region Number of members * 2,200 Complaint ratio n/a Meets industry standards excellent Measures satisfaction very good Tracks members'health very good Overall monitoring very good Prevention and screening good Maternity care very good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Can report key heart-surgery rate; great at tracking members' health. Kaiser Foundation Health Plan of Georgia, Inc. Number of members * 201 Complaint ratio low Meets industry standards excellent Measures satisfaction satisfactory Tracks members'health good Overall monitoring good Prevention and screening very good Maternity care excellent Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Excellent maternity care; doesn't check on doctors' satisfaction. Kaiser Foundation Health Plan of Ohio Number of members * 188 Complaint ratio high Meets industry standards excellent Measures satisfaction very good Tracks members'health good Overall monitoring very good Prevention and screening excellent Maternity care satisfactory Satisfied customers[a] very good Overall quality results very good Overall score very good Comments Great prevention effort, lots of certified docs; too many C-sections. Kaiser Foundation Health Plan of the Mid-Atlantic States, Md. Number of members * 369 Complaint ratio low Meets industry standards excellent Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening very good Maternity care very good Satisfied customers[a] very good Overall quality results very good Overall score very good Comments Second highest percentage of certified docs; doesn't track outcomes. Kaiser Foundation Health Plan of the Northwest, Ore. Number of members * 391 Complaint ratio low Meets industry standards very good Measures satisfaction very good Tracks members'health good Overall monitoring good Prevention and screening very good Maternity care very good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Very satisfied members; solid maternity care; fair health tracking MVP Health Plan, N.Y. Number of members * 525 Complaint ratio low Meets industry standards very good Measures satisfaction excellent Tracks members'health satisfactory Overall monitoring very good Prevention and screening very good Maternity care good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Loyal members; no risk-behavior tracking and too few diabetic eye exams. NYLCare Health Plans of the Mid-Atlantic States, Md. Number of members * 364 Complaint ratio average Meets industry standards excellent Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening very good Maternity care good Satisfied customers[a] good Overall quality results very good Overall score very good Comments Can report key maternity numbers; disease tracking starts this year. Oxford Health Plans, N.Y. Number of members * 1,002 Complaint ratio low Meets industry standards very good Measures satisfaction very good Tracks members'health good Overall monitoring good Prevention and screening good Maternity care good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Too many C-sections; very satisfied customers and doctors. Pilgrim Health Care, Inc., Mass. Number of members * 380 Complaint ratio low Meets industry standards very good Measures satisfaction excellent Tracks members'health very good Overall monitoring very good Prevention and screening excellent Maternity care very good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Very satisfied members; has monitored mental health of members. Tufts Health Plan, Mass. Number of members * 448 Complaint ratio low Meets industry standards excellent Measures satisfaction very good Tracks members'health very good Overall monitoring very good Prevention and screening excellent Maternity care good Satisfied customers[a] excellent Overall quality results very good Overall score very good Comments Very good asthma and heart-disease tracking; too few certified doctors. U.S. Healthcare--HMO N.J. Number of members * 743 Complaint ratio low Meets industry standards excellent Measures satisfaction very good Tracks members'health good Overall monitoring very good Prevention and screening good Maternity care satisfactory Satisfied customers[a] very good Overall quality results good Overall score very good Comments Good health monitoring; unusually loyal members. AV-MED Health Plan, Fla. Number of members * 319 Complaint ratio average Meets industry standards very good Measures satisfaction good Tracks members'health satisfactory Overall monitoring good Prevention and screening satisfactory Maternity care satisfactory Satisfied customers[a] very good Overall quality results good Overall score good Comments Couldn't report Pap-smear rate, too many C-sections; members satisfied. ChoiceCare, Ohio Number of members * 203 Complaint ratio low Meets industry standards excellent Measures satisfaction excellent Tracks members'health satisfactory Overall monitoring good Prevention and screening good Maternity care satisfactory Satisfied customers[a] excellent Overall quality results good Overall score good Comments Couldn't report on prenatal care rate; too few vaccinations. CIGNA HealthCare of Florida Number of members * 180 Complaint ratio low Meets industry standards excellent Measures satisfaction very good Tracks members'health good Overall monitoring very good Prevention and screening good Maternity care good Satisfied customers[a] very good Overall quality results good Overall score good Comments Tied with Fallon for best prenatal score; too many C-sections. CIGNA Medical Group Healthplan, Calif. Number of members * 170 Complaint ratio n/a Meets industry standards very good Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening good Maternity care good Satisfied customers[a] good Overall quality results good Overall score good Comments Good start in tracking members' health but doesn't share results. FHP Health Care, Ariz. Number of members * 174 Complaint ratio high Meets industry standards good Measures satisfaction good Tracks members'health satisfactory Overall monitoring good Prevention and screening very good Maternity care very good Satisfied customers[a] good Overall quality results very good Overall score good Comments Tops in prenatal care and C-section rates; not enough certified doctors. FHP Inc, Calif. Number of members * 941 Complaint ratio n/a Meets industry standards good Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening very good Maternity care good Satisfied customers[a] satisfactory Overall quality results good Overall score good Comments Members report weak satisfaction; excellent C-section rating. Harris Methodist Health Plan, Texas Number of members * 229 Complaint ratio low Meets industry standards very good Measures satisfaction good Tracks members'health satisfactory Overall monitoring good Prevention and screening satisfactory Maternity care excellent Satisfied customers[a] excellent Overall quality results very good Overall score good Comments Very good prenatal care; too few vaccinations and mammographies. Health Insurance Plan of Greater New York Number of members * 853 Complaint ratio high Meets industry standards very good Measures satisfaction good Tracks members'health satisfactory Overall monitoring good Prevention and screening satisfactory Maternity care good Satisfied customers[a] satisfactory Overall quality results satisfactory Overall score good Comments Weak prevention results; members report low satisfaction. HMO--Oregon Number of members * 810 Complaint ratio average Meets industry standards good Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening good Maternity care very good Satisfied customers[a] good Overall quality results good Overall score good Comments Exceptional C-section rate; accreditation planned. Intergroup Healthcare Corp., Ariz Number of members * 268 Complaint ratio average Meets industry standards very good Measures satisfaction good Tracks members'health satisfactory Overall monitoring good Prevention and screening very good Maternity care very good Satisfied customers[a] good Overall quality results very good Overall score good Comments Doesn't track risk behaviors or regularly check if docs are satisfied. PacifiCare of California Number of members * 1,901 Complaint ratio n/a Meets industry standards very good Measures satisfaction very good Tracks members'health good Overall monitoring good Prevention and screening good Maternity care good Satisfied customers[a] good Overall quality results good Overall score good Comments Weak vaccination rate; tracks key maternity figures. PruCare of California Number of members * 615 Complaint ratio n/a Meets industry standards excellent Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening very good Maternity care good Satisfied customers[a] satisfactory Overall quality results good Overall score good Comments Meets all industry standards, but members give it low satisfaction scores. Rush Prudential HMO Inc., Ill. Number of members * 354 Complaint ratio low Meets industry standards very good Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening good Maternity care excellent Satisfied customers[a] satisfactory Overall quality results good Overall score good Comments Not paying enough attention to members' overall health. U.S. Healthcare, N.Y. Number of members * 581 Complaint ratio low Meets industry standards excellent Measures satisfaction very good Tracks members'health good Overall monitoring very good Prevention and screening good Maternity care satisfactory Satisfied customers[a] good Overall quality results good Overall score good Comments Weak in maternity care and disease-prevention activities. Aetna Health Plans of California, Inc. Number of members * 326 Complaint ratio n/a Meets industry standards excellent Measures satisfaction good Tracks members'health satisfactory Overall monitoring good Prevention and screening satisfactory Maternity care satisfactory Satisfied customers[a] satisfactory Overall quality results satisfactory Overall score satisfactory Comments Meets industry standards but doesn't track health or disease levels. CareAmrica Health Plans, Calif. Number of members * 218 Complaint ratio n/a Meets industry standards good Measures satisfaction satisfactory Tracks members'health satisfactory Overall monitoring good Prevention and screening satisfactory Maternity care satisfactory Satisfied customers[a] satisfactory Overall quality results satisfactory Overall score satisfactory Comments Didn't report on prevention, maternity care; doesn't check doc satisfaction. NYLCare Health Plan, Texas Number of members * 361 Complaint ratio high Meets industry standards good Measures satisfaction very good Tracks members'health satisfactory Overall monitoring good Prevention and screening satisfactory Maternity care good Satisfied customers[a] satisfactory Overall quality results satisfactory Overall score satisfactory Comments Accreditation planned; too few vaccinations and mammographies. * in thousands

Sources: 1996 Newsweek/Foundation for Accountability Survey; David Lansky, FACCT president; States' Departments of Insurance or Corporations. [a] Source: Caredata, Center for the Study of Services, Fortune 500 COs. The 43 HMOs listed above responded to the survey. The following 32 did not: CaliforniaCare Foundation Health, Calif.; Keystone Health Plan Est, Pa.; Allina Health Plan, Minn.; Blue Choice, N.Y.; Health Partners, Minn.; Health Alliance Plan of Michigan; M.D. Individual Practice Association, MD.; United Healthcare of Ohio; Health Options, Inc. Fla.; HMO Illinois; Tennessee Primary Care; Chicago HMO, Ltd.; United Healthcare, Ala.; PCA Family Health Plan, Fla.; Humana Medical Plan, Fla.; Humana Health Plan Inc., Ky.; Blue Shield of California HMO; HMO Health Ohio; Community Blue, the HMO of BC and BS of Western N.Y., Inc.; Humana Health Plan, Inc., Ill.; Heritage National Healthplan, Inc., Ill.; CAC-United Healthcare Plans of Fla., Inc.; Primecare Health Plan, Wis.; Keystone Health Plan West, Inc., Pa.; United Healthcare of Ohio, R.I.; Blue Care Network of Southeast Michigan; Physicians Health Plan, Mich.; United Health Plans of New England, Inc.; R.I.; HIP Health Plan of New Jersey; Capital District Physicians' Health Plan, N.Y.; Community Physician Network, Calif.