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 MPHJulie A. Rainwater, PhDJorge A. Garcia, MD MSDebora A. Paterniti, PhDDaniel J. Tancredi, MS PhD Geeta Mahendra, MSJason A. Talavera, MD student

AcademyHealth 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

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

Phase II – Overview of Methods Partnership between UC Davis and Pacific Health Advantage Population: 76,000 employees of small businesses (with 2-100

eligible workers) in CA, excluding “guaranteed associations” Setting: 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 plan

Study 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 group

Control 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 – Interventions

Intervention 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 Guide

A 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 design

Stratified 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 EE’s)

Excluded 16 brokers with large number of eligible employees (to increase efficiency)

Oversampled small brokers (4 strata), brokers for whom at least 40% of EE’s were <39 yrs, and brokers for whom at least 50% of EE’s had 3 or more HMO options (total 10 sampling strata)

Brokers allocated in two stages

Phase II – Analytic methods and hypotheses

All analyses were (or will be) weighted to account for the cluster sampling design, using robust methods to correct CIs

Hypotheses: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 results

292 brokers with 1,835 eligible employees (EE’s) were randomized to the intervention group

246 brokers with 1,578 eligible employees (EE’s) were randomized to the control group

30.2% of EE’s in the intervention group, and 37.1% of EE’s in the control group, dropped out of Pacific Health Advantage

22 intervention group members used the toll-free advice line 3 intervention group members used the e-mail address Broad 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

Did you read or review…?Did you call or contact…?

Ed/Mot Control

Comparison of health plan benefits 60% 57%PacPlan Chooser web site 15% 14%CA HMO Guide (p<0.001) 40% 10%CA HMO Report Card (p<0.001) 38% 8%Health plan member services (p=0.02) 7% 9%OPA, HMO Help Center, Health Rights Hotline <2% <2%

Secondary outcome, reason for switch

Stated 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)

Do you expect that quality of care will be better, the same, or worse with your new health plan?

Ed/Mot(N=88)

Control(N=87)

Better 16% 9%

Same 17% 20%

Worse (p=0.07) 8% 1%

Uncertain or did not respond 59% 70%

Secondary outcome, considered switch

35% of intervention group respondents who did not actually switch “considered” switching

28% 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 switch

Stated 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)

Size of perceived difference Ed/Mot Control

Big 47% 48%

Small 31% 30%

None 7% 4%

Don’t know 15% 18%

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

Size of perceived difference Ed/Mot Control

Big 31% 35%

Small 35% 34%

None 7% 5%

Don’t know 27% 27%

Secondary outcome, self-efficacy (NS)

Agree or strongly agree… Ed/Mot ControlConfident in my ability to choose a health plan 78% 81%Confident in my ability to choose a medical group 80% 80%I felt well informed about my health plan choices 71% 69%I felt well informed about my medical group choices 66% 65%I used what I know…to make the best possible choice for me during Open Enrollment

77% 78%

Secondary outcome, perceived benefits and barriers (NS)

Agree or strongly agree… Ed/Mot ControlUsing the information in…, I was able to choose the best health plan for my family and me

58% 57%

Looking at the information about health plans was a waste of time for me (p=0.05)

16% 20%

The materials… helped me better understand my health plan choices

67% 65%

I guess my health plan has some drawbacks, but none of the others is really better

52% 54%

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

How much of a problem, if any, was it to find a health plan that suited you…?

Ed/Mot Control

Not a problem (p=0.01) 58% 66%

A small problem 27% 25%

A big problem (p=0.002) 15% 9%

Limitations Primary 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 implications Educational/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.