Marblehead/Swampscott YMCA program director
William Zazynski teaches Karin Martin to use the
Nautilus equipment at the fitness center. Martin
became a member of the YMCA because of the dis-
count she receives from her HMO.
News staff photo/Jonathan M. Whitmore

What is an ounce of prevention really worth?

By KELLEY BOUCHARD and MARY K. FITCH

News staff

Karin Martin was always impressed by the Marblehead YMCA's exercise equipment, fitness classes and outdoor pool. But it was her HMO that actually clinched her membership deal.

Harvard Pilgrim Health Care offers its members 20 percent off YMCA dues as part of its preventive care programs.

"I don't think I would join if had to pay full price," says Martin, 65. "Some other clubs cost $500 or $600 a year, so I couldn't afford to join. Now, for about $100 a year, I have no excuse not to be down there right now."

Although some people are critical about aspects of managed health care, there seems to be nearly unanimous praise for the prevention programs pushed by HMOs.

"Years ago, we just responded to illnesses. Now we're trying to prevent them. I think HMOs have done a good job allowing that to happen," said Dr. Steven Barrett, a Manchester-by-the-Sea family doctor.

The effort to keep you healthy isn't entirely altruistic, though. HMOs and their doctors save money when they keep you out of the doctor's office.

And while many doctors applaud HMOs for encouraging preventive care, some say more needs to be done. "HMOs aren't farsighted enough," Barrett says. "They're doing a good job, but they could do better."

For instance, HMOs pay for rehabilitation care immediately following a heart attack, but don't cover long-term cardiac maintenance programs. And HMOs often cover stop-smoking classes but won't pay for yoga or nutrition classes, even though stress and poor diet also contribute to heart attacks.

Still, under managed care, insurance companies and physicians are doing more now than ever before to keep people healthy.

HMOs send out monthly newsletters or quarterly magazines to keep members informed about medical advances, free seminars and covered programs. Martin joined the YMCA after she found a 20 percent-off coupon in her Harvard Pilgrim newsletter.

HMOs often pay for annual checkups, eye exams and regular screenings for diabetes, breast cancer, colon cancer and cholesterol levels.

They also encourage regular vaccinations for childhood illnesses and adult diseases such as the flu. Studies show immunization rates for both children and adults are higher under HMOs than with traditional fee-for-service health plans.

Harvard Pilgrim two years ago introduced an asthma management program that saved $1 million in emergency room visits during 1995. Under the program, nurses showed asthma patients how to use steroid inhalers to minimize breathing attacks and called to make sure they were following instructions.

Three years ago, Tufts Health Plan started its Healthy Birthdays Program to identify women with high-risk pregnancies and prevent premature births. The program helps mothers follow doctor's orders to get plenty of rest by paying for things like home-health care and baby-sitting for older children.

The full-term delivery rate increased from 67 percent in 1994 to 76 percent in 1996. Each baby that was born without complications saved Tufts between $300,000 and $500,000 in neonatal care. With savings like that, the benefits of preventive care seem obvious to HMO executives.

"If we deliver healthy babies, we get to keep costs down," says Tufts CEO Harris Berman, M.D.

Two of those cost-saving babies were twin girls born to Sheila Stamatopulos of Salem in February 1996. When premature labor confined her to bed just 27 weeks into her pregnancy, Tufts paid for a nurse to visit Stamatopulos and show her how to use equipment that monitored contractions at home.

Plus, a Tufts case worker called once or twice a week to discuss any concerns Stamatopulos might have. The healthy twins were born by Cesarean section at 38 1/2 weeks, close to the 40-week full term. The experience left Stamatopulos with a top-notch impression of the Healthy Birthdays Program.

"It was very, very helpful," she says. "Friends can only call so much. To have a professional call who knows that other people have been through it, it was very positive."

While HMOs admit they save money by pushing prevention, members seem to appreciate the effort.

"HMOs just have so many more programs to keep you healthy," Martin says. "You get quality care, that's for sure. We're going to live 'til we're 100."