Consumer’s Use of Quality Information When Selecting a Health Plan

Julie A. Rainwater, PhDPatrick S. Romano, MD MPHJorge Garcia, MD MSDaniel J. Tancredi, MSGeeta Mahendra, MS

UC Davis Center for Health Services Research in Primary Care

Information about Quality In a Randomized Evaluation (INQUIRE)

Funding from the Agency for Healthcare Research and Quality (“Making Quality Count for Consumers”)

The role of public reporting

Health plan performance information is increasingly available to consumers

Empower consumers to demand better health care and to make better informed choices so that providers will compete along quality dimensions

Background: Prospective Study Mixed findings regarding the extent to which consumers

actually make use of quality information and what factors may be related to using it

Previous studies have either been conducted in controlled settings or have evaluated factors associated with report card usage after distribution of the report card

We planned a prospective cohort study with assessment of consumer characteristics before distribution of quality report card followed by measurement of both self-reported use of quality information and observed plan-switching behavior

Information about Quality In a Randomized Evaluation (INQUIRE) – Setting

Mail survey – Pre-Open Enrollment 2002 and Post-OE CalPERS Health Benefits Program – 1.3 mil members - Open

Enrollment 2002– Stratified random sample of 2,000 CalPERS members – Separately sampled 500 members who were required to switch plans in

OE 2002 (three plans dropped in OE 2002)– Oversampled members facing higher monthly premium increases

10 HMOs, 2 self-funded PPOs. Largest plans: Kaiser (359,208), HealthNet (225,771), PacifiCare (112,726)

HMO and PPO Quality Performance Report included 11 HEDIS and 9 CAHPS measures, plans rated with 1-3 stars (website and mail)

Health Belief Model

Perceived Susceptibility to Illness

Perceived Seriousness (Severity) of Illness

Perceived Threat of Illness

Likelihood of Preventive Behavior

Demographic Variables: age, gender, race/ethnicity, SES

Social Psychological Variables: social networks, group pressure,

acculturation

Perceived Benefits

minus

Perceived Barriers

CUES TO ACTION Advice from friends, Prompt from MD,

Illness of family member, Newspaper or magazine article

The Health Belief Model (Becker and Maiman 1975)

INDIVIDUAL PERCEPTIONS

Readiness To Undertake Recommended Behaviors

MODIFYING FACTORS LIKELIHOOD OF ACTION

Study Hypotheses Derived from the Health Belief Model (Becker and Maiman 1975)

Poor general health status and high chronic disease burden will be associated with greater perceived “seriousness”, which will increase the likelihood of taking preventive action

– Health Status » Self-report of “poor” or “fair” overall health » One or more of 19 chronic health conditions (e.g., diabetes,

hypertension, COPD, arthritis, depression, …)

Study hypothesis (con’d)

Dissatisfaction with current plan or provider serves as a “cue to action” which will increase the likelihood of taking preventive action.

- CAHPS» Getting needed care - Reported problem with finding MD, getting

appointment, getting referral, switch MD (alpha=.69)» Getting care quickly – Problem with delays while waiting for plan

approvals (1 item)» Rating of care providers – Did not assign a 9 or 10 rating (where

0=worst possible, 10=best possible) to primary care provider, health plan, or all health care (alpha=.75)

Health beliefs related to using the quality report card

Individuals who perceive themselves as being at risk of receiving poor care will be more likely to take preventive action.

Susceptibility – Poor Care (individual level) – Likely to have a problem getting

appointment, referral, or test/treatment, likely to experience medical error, MD switch (alpha= .83)

– Variation in quality of available care (system level) - Believe there are “big” differences in the quality of local hospitals, medical groups, primary care or specialty providers, health plans (alpha=.86)

Health beliefs related to using the quality report card

Individuals who perceive there is a benefit to taking preventive action will be more likely to use quality information.

Perceived Benefits» Can improve own (or family’s) care by using quality

information (agree)

Health beliefs related to using the quality report card

Individuals who perceive there are barriers to taking preventive action will be less likely to use quality information.

Perceived Barriers» Information is too difficult to use or understand (agree)» Information is not applicable to own circumstances

(agree)

Information about Quality In a Randomized Evaluation (INQUIRE) – Analytic methods

Analyses weighted to account for stratified sampling design

Bivariate analyses of factors associated with self-reported use of quality report card in the post-OE survey

Multivariate logistic regression to identify factors independently associated with use of quality report card

Core model included sociodemographic, employment-related, and plan-related factors; other HBM variables entered in stages

Information about Quality In a Randomized Evaluation (INQUIRE) – Response rate

Pre-OE survey:N=1,592 (64% of sample)

Post-OE survey:N=1,299 (82% of Pre-OE respondents)

Information about Quality In a Randomized Evaluation (INQUIRE) – Overall results

17% of respondents used the quality report card Forced switchers much more likely to use the report card than

optional switchers (38% vs. 15%); About half of the members who used the report card spent at

least 30 minutes with it (51% of forced switchers, 40% of optional switchers)

Less than half of the members who used the report card found it at least somewhat useful (45% of forced switchers, 35% of optional switchers)

Forced switchers set aside

Results: Core modelFactor Estimate SE OR

Expected premium change > $50 0.548 0.334 1.73

Expected premium change $25-$49 0.647 0.324 1.91**

No premium change expected 0.228 0.623 1.26

Female -0.142 0.189 0.87

Non-English primary language 0.831 0.373 2.29**

Some College 0.505 0.297 1.67*

Age 18-40 -.654 0.322 0.52**

Age ≥60 -0.393 0.211 0.83

Income <$30K 0.270 0.276 1.31

Income >$75K -0.340 0.211 0.71

Family coverage -0.456 0.223 0.63**

Kaiser or PPO plan -0.567 0.204 0.57**

Results: Health Status, Satisfaction

Factor Estimate SE OR

Health status (poor/fair) 0.344 0.196 1.41*

Chronic disease (≥1) -0.199 0.289 0.82

CAHPS satisfaction ratings (9 or 10 in ≥2/4 areas)

-0.169 0.257 0.84

CAHPS no problem getting needed care (<2/4)

-0.168 0.274 0.92

CAHPS no problem with approval delays

-0.087 0.230 0.84

Results: Susceptibility, perceived benefits, perceived barriers.

Factor Estimate SE OR

Perceived individual susceptibility

(5 items)

0.501 0.237 1.65**

Perceived general susceptibility (5 items)

-0.057 0.189 0.94

Agree that quality information will help me select a plan that improves care

0.535 0.318 1.71*

Agree that quality information is too difficult to use

-0.517 0.252 0.60**

Agree that quality information does not apply to me or my situation

-0.284 0.220 0.75

Limitations Highly motivated respondents with stable employment and

long-term connection to sponsor; results may not generalize to other sponsors

Most respondents had previous experience with report cards Transition year from “any willing and qualified plan” to two

preferred plans in 2003 Some domains were represented by relatively few items that

were based on previous studies but not independently tested in the target population (e.g., benefits, barriers)

Policy implications Quality information is salient for individuals who are

– forced to switch health plans– face premium increases if they do not switch– perceive themselves to be in fair or poor health

The use of quality information could be increased through interventions targeted to decreasing pre-existing beliefs that information is too difficult to use or understand.

Belief that there are systemic quality differences does not affect RC use, but belief that you are susceptible to poor care (e.g., not getting a referral, not getting needed care) is related to using quality information and possibly health plan choice