Patrick S. Romano, MD MPH Julie A. Rainwater, PhD Jorge A. Garcia, MD MS Debora A. Paterniti, PhD

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A Randomized Controlled Trial of an Educational and Motivational Intervention to Enhance Consumers Use of Health Plan and Medical Group Quality Data. Patrick S. Romano, MD MPH Julie A. Rainwater, PhD Jorge A. Garcia, MD MS Debora A. Paterniti, PhD Daniel J. Tancredi, MS PhD - PowerPoint PPT Presentation

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  • A Randomized Controlled Trial of an Educational and Motivational Intervention to Enhance Consumers Use of Health Plan and Medical Group Quality DataPatrick S. Romano, MD MPHJulie A. Rainwater, PhDJorge A. Garcia, MD MSDebora A. Paterniti, PhDDaniel J. Tancredi, MS PhD Geeta Mahendra, MSJason A. Talavera, MD studentAcademyHealth 2006 ARMJune 27, 2006Seattle, WA

  • Background to INQUIRE (INformation about QUality In a Randomized Evaluation)Most previous studies of how consumers use report cards were conducted in laboratory settings, relied entirely on survey data, or did not randomly allocate participants.We planned a prospective study with 3 components: Focus group discussions of consumer choice and quality of careA prospective cohort study of factors associated with using a quality report card and switching health plans/medical groupsA randomized controlled trial of two interventions designed to improve the use of quality information, under the Health Belief Model.Funding from the US Agency for Healthcare Research and Quality

  • Health Belief Model

    INDIVIDUAL PERCEPTIONS

    Readiness To Undertake

    Recommended Behaviors

    LIKELIHOOD OF ACTION

    MODIFYING FACTORS

    Demographic Variables:

    age, gender, race/ethnicity, SES

    Social Psychological Variables: social networks, group pressure, acculturation

    The Health Belief Model (Becker and Maiman 1975)

    Perceived Susceptibility to Illness

    Perceived Seriousness (Severity)

    of Illness

    Perceived Benefits

    minus

    Perceived Barriers

    CUES TO ACTION

    Advice from friends, Prompt from MD, Illness of family member,

    Newspaper or magazine article

    Likelihood of Preventive Behavior

    Perceived Threat

    of Illness

  • Phase II Overview of MethodsPartnership between UC Davis and Pacific Health AdvantagePopulation: 76,000 employees of small businesses (with 2-100 eligible workers) in CA, excluding guaranteed associationsSetting: Open Enrollment 2003; members were offered a choice of 4 statewide and 4 regional HMOs (each with 3 copayment levels), 1 PPO (with 3 copayment levels), 1 point-of-service planStudy design: Randomized controlled trial Unit of randomization: Health insurance brokers (with their contracted employers and their employees)Measures: Observed behavior, post-Open Enrollment survey

  • Phase II Control groupControl group received usual care:Open Enrollment booklets on program rules and benefit options were mailed to employers (no quality information)No information went directly to employeesPacPlan Chooser web site allowed members to compare plans on cost, features, and quality (overall rating)Insurance brokers provided limited support

  • Phase II InterventionsIntervention group 1 received educational/motivational treatment:A special mailing to each employee, employer, and broker included a motivational letter (with negative framing), the California HMO Report Card, and the California HMO GuideA toll-free telephone line and e-mail address were offered for counseling and advice (during business hours)Intervention group 2 was delayed

  • Phase II Sample designStratified random sample of brokers with eligible employees scheduled for Open Enrollment in May-July 2003, after excluding employers intending to leave (N=1,579 with 26,249 EEs)Excluded 16 brokers with large number of eligible employees (to increase efficiency)Oversampled small brokers (4 strata), brokers for whom at least 40% of EEs were
  • Phase II Analytic methods and hypothesesAll analyses were (or will be) weighted to account for the cluster sampling design, using robust methods to correct CIsHypotheses:Intervention would increase overall switching across health plans and medical groupsIntervention would promote switching toward better health plans and medical groups, among those who switchIntervention would enhance perceived threat, enhance self-efficacy, promote migration from pre-contemplation to contemplation, and promote use of quality information in decision-making

  • Phase II Process results292 brokers with 1,835 eligible employees (EEs) were randomized to the intervention group246 brokers with 1,578 eligible employees (EEs) were randomized to the control group30.2% of EEs in the intervention group, and 37.1% of EEs in the control group, dropped out of Pacific Health Advantage22 intervention group members used the toll-free advice line3 intervention group members used the e-mail addressBroad array of questions and concerns

  • Phase II Primary outcome results (all weighted and nonsignificant)9.2% of intervention group versus 7.0% of control group switched plans.21% of intervention group switchers versus 35% of control group switchers moved to a plan with more stars.27-28% in both groups moved to a plan with fewer stars.

  • Secondary outcome, use of resources

  • Secondary outcome, reason for switchStated reason for switching in intervention group vs. control group, respectively (all p>0.10 unless stated):Change in geographic coverage of plan (10% vs. 2%, p=0.03)Cost (34% vs. 25%)Continuity of MD (1% vs. 5%)Better network of MDs (8% vs. 7%)Concern over poor report card scores (6% vs. 1%, p=0.099)Concern over poor access to care (6% vs. 5%)Poor service from previous plan (6% vs. 3%)Better benefits (5% vs. 3%)Other reason (7% vs. 1%, p=0.06)

  • Secondary outcome, expected outcome of switch (NS)

  • Secondary outcome, considered switch35% of intervention group respondents who did not actually switch considered switching28% of control group respondents who did not actually switch considered switching (p=0.07)Of those who considered switching, 31% of intervention group respondents and 30% of control group respondents seriously considered it (rating=6 on 1-6 scale)

  • Secondary outcome, reason for considering switchStated reason for considering switching in intervention group vs. control group, respectively:Cost (69% vs. 74%)Continuity of MD (6% vs. 11%)Better network of MDs (16% vs. 23%)Concern over poor report card scores (15% vs. 7%, p=0.08)Concern over poor access to care (17% vs. 17%)Poor service from previous plan (10% vs. 10%)Better benefits (25% vs. 25%)Other reason (14% vs. 7%) need to review comment fields

  • Secondary outcome, perceived differences in quality among plans (NS)

  • Secondary outcome, perceived differences in quality among medical groups (NS)

  • Secondary outcome, self-efficacy (NS)

  • Secondary outcome, perceived benefits and barriers (NS)

  • Secondary outcome, Difficulty of selecting plan (p=0.003)

  • LimitationsPrimary outcome (actual choice of health plan) may be difficult to change because of competing concerns (e.g., price, convenience) and information from other sources (e.g., friends and family)Analysis of secondary outcomes limited by poor response to post-OE survey despite two mailings, financial incentive, and follow-up abbreviated web-based survey (est. 41% excluding ineligibles)

  • Policy implicationsEducational/motivational interventions designed to increase perceived benefits and decrease perceived barriers, with negative framing, may increase use of quality information but are unlikely to affect actual choices in the health care market.Quality data with negative framing may make decision-making more difficult for price-sensitive consumers (especially if there is a perceived cost-quality tradeoff).Many other signals affect consumers behavior during Open Enrollment; cost is the dominant factor in the small business market in the USA.

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