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

1. Consumer’s Use of Quality Information When Selecting a Health Plan Julie A. Rainwater, PhD Patrick S. Romano, MD MPH Jorge Garcia, MD MS Daniel J. Tancredi, MS Geeta Mahendra, MS UC Davis Center for Health Services Research in Primary Care

2. Information about Quality In a Randomized Evaluation (INQUIRE) • Funding from the Agency for Healthcare Research and Quality (“Making Quality Count for Consumers”)

3. 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

4. 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

5. 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)

6. Health Belief Model

7. 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, …)

8. 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)

9. 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)

10. 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)

11. 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)

12. 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

13. 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)

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

15. Results: Core model

16. Results: Health Status, Satisfaction

17. Results: Susceptibility, perceived benefits, perceived barriers.

18. 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)

19. 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