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HMO ENROLLMENT SOARS AS PREMIUMS DIP

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Enrollments are up sharply and premiums down slightly for the nation's health maintenance organizations, where 50 million Americans now get care at preset prices, an HMO trade group said this week.

The Group Health Association of America predicted that 6 million more Americans will join HMOs in 1995, lured partly by an expected 1.2 percent decline in premiums.The average HMO will charge $1,740 for an individual policy and $4,704 for family coverage in 1995. That works out to $145 and $392 a month, respectively.

HMOs, which charge one rate that does not vary by how sick or well a person is, have ridden the crest of an employer-driven wave of managed care that seeks high-quality care while curbing costs by cutting back on unnecessary procedures.

Enrollment in HMOs has surged from 9 million in 1982 to 26 million in 1986 to 45.2 million at the end of 1993 to an estimated 50.5 million today.

Average HMO premiums rose 10.6 percent in 1992, 8.1 percent in 1993 and 5.6 percent in 1994 before taking the 1.2 percent dip for 1995.

Karen M. Ignagni, the GHAA president, said Americans are drawn by the HMO "philosophy of prevention." Other surveys have found that most people in HMOs use them by choice, having opted against their employers' costlier, fee-for-service coverage, she noted.

HMOs come in a wide variety.

Two-thirds are operated by for-profit companies. Some are sponsored by Blue Cross-Blue Shield plans. Some, like giant Kaiser-Permanente, have their own full-time doctors on staff and own their own facilities; others contract with individual physicians and hospitals.

The private health-care market has shifted sharply away from untrammeled fee-for-service medicine, where patients could go to any specialist and count on their insurance to pick up 80 percent or more of the bill.

But there were also signs of a backlash against managed care in Congress this year when the American Medical Association and other specialty organizations lobbied strenuously for new restrictions on managed care companies, including HMOs.

The doctors want to force the companies to allow into their plans any physician who accepts their rates and meets their standards.

No health-reform legislation got through Congress, but HMOs and other managed care companies have also been battling "any willing provider" laws in dozens of states.

The Clinton administration, faced with charges that its original health-reform plan would restrict Americans' choice of coverage, proposed that every patient be able to choose a plan that allowed him to go outside the usual network of physicians.

The Group Health Association of America, which represents 373 of the nation's 545 HMOs, said 63 percent of HMOs offered members a point-of-service or open-ended option to select physicians outside the HMO's usual roster.

These options require patients to pay sharply higher deductibles or co-payments. Some 3.4 million HMO members were enrolled in point-of-service plans in 1994, up from 2.6 million in 1993.

HMO enrollment grew fastest in the Northeast (18 percent) and South (17 percent), a bit less rapidly in the Midwest (13 percent) and slowest in the West (4 percent), where the HMO movement began.

Eleven million Californians - 35 percent - are in HMOs, along with 3.9 million New Yorkers (21 percent), 2.4 million Floridians (18 percent), 2.3 million Pennsylvanians (19 percent) and 2 million Massachusetts residents (34 percent).

But enrollment is sparse in rural America. A handful of states have only a few thousand people or none at all in HMOs.