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Quality of Care

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Researchers examine the impact of consumer health plan reports on plan choices and quality of care

Improving U.S. health care depends at least in part on the presumption that health plan purchasers and consumers will get better care if they can choose care that meets their needs and expectations. The Consumer Assessment of Health Plans (CAHPS®) survey, which was developed by the Agency for Healthcare Research and Quality (AHRQ), lays the groundwork for informed health care choices and enhanced quality of care.

A recent conference, sponsored by AHRQ and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), examined ways to improve consumer/purchaser assessment reports and assess the impact of these reports on health plan choices and health care quality improvement. Selected conference papers by AHRQ researchers and AHRQ-supported researchers, published in a special issue of Health Services Research, examine these issues.

An overview by AHRQ Director John M. Eisenberg, M.D., and the articles, which are based largely on data generated by the CAHPS® survey, are described here. Reprints of the overview and two staff-authored articles are available from AHRQ, as noted.

Eisenberg, J.M. (2001, July). "Overview of the issue." Health Services Research 36(3), pp. 443-446.

Health care quality involves more than adherence to technical standards and the achievement of desirable physiologic outcomes. Once research identified what people are concerned about in the care they receive, the next step was to develop tools to measure it, leading to development of CAHPS®. Over 90 million Americans can get information on the health plans they are offered because of the CAHPS® surveys.

The goal now is both to inform Americans how to use results from the CAHPS® survey more effectively in making plan choices and to find out how CAHPS® itself can be improved. Articles in this journal issue examine considerations for producing reliable and valid measures when collecting data from people of different cultures, the types of information people want and whether they are getting it, the education needed to help individuals interpret and use the information, and the kind of support needed to arrive at a health plan decision. The researchers also examine what report developers need to know about their audiences, whether purchasers and consumers are using the data from reports such as CAHPS® to make health plan or other health care choices, and whether CAHPS® and similar assessments are being used to improve quality of care.

Reprints (AHRQ Publication No. 01-R024) are available from the AHRQ Publications Clearinghouse.

Harris-Kojetin, L.D., McCormack, L.A., Jael, E.F., and others. (2001, July). "Creating more effective health plan quality reports for consumers: Lessons from a synthesis of quality testing." (AHRQ grant HS09218). Health Services Research 36(3), pp. 447-476.

These researchers synthesized the results of five qualitative studies into seven major lessons learned. The studies involved 11 focus groups and 182 consumer interviews in 6 geographic areas with 268 publicly and privately insured consumers. Their objective was to gain insights into consumers' perceptions and preferences for written materials in order to develop pamphlets to help Medicaid, Medicare, and employed consumers choose a health plan, incorporating newly available measures of health plan quality (e.g., HEDIS and CAHPS®).

The researchers learned that the materials should link new unfamiliar information (such as care quality) to more familiar information, such as cost and coverage, that consumers already find important. Navigational aids such as visual clues, instructions, and section overviews are useful and often necessary. Pamphlets should reflect diversity among the target audience, including levels of education and available time to read materials. Materials should help consumers quickly and easily understand how health plan options differ on key aspects of coverage (e.g., choice of providers, access to specialty care, out-of-pocket costs, and premiums) and help consumers prioritize what is most important to them in choosing a health plan. More effective materials help break down the process of comparing and narrowing plan choices into a series of smaller, connected steps. Finally, materials should help consumers understand how and why to use quality of care information. The authors include illustrative examples of how these lessons were put into practice.

Reprints (AHRQ Publication No. 01-R029) are available from the AHRQ Publications Clearinghouse.

McCormack, L.A., Garfinkel, S.A., Hibbard, J.H., and others. (2001, July). "Health plan decision making with new Medicare information materials." (AHRQ grant HS09218). Health Services Research 36(3), pp. 531-554.

These investigators conducted telephone surveys with Kansas City Medicare beneficiaries in 1998 and 1999 to examine the effect of providing new Medicare information on health plan decisionmaking attitudes and behaviors. They randomly assigned the Medicare beneficiaries to a control group or one of three groups that received varying amounts and types of information: the Medicare & You 1999 handbook; the same version of the handbook and a Medicare version of the CAHPS® report; and the Medicare & You bulletin, an abbreviated version of the handbook.

Experienced beneficiaries in the experimental groups were significantly more confident with their current health plan choice than control group members. New beneficiaries (those just aging into the Medicare program) were significantly less likely to use the new materials to choose or change health plans relative to control group members. The authors hypothesize that this was due to the strong message in the 1999 version of the handbook that consumers did not have to change plans.

In general, the effects on confidence and health plan switching did not vary across the different treatment materials. Because providing more information to beneficiaries did not result in commensurate changes in confidence levels or rate of health plan switching, factors other than the amount of information, such as how it is presented, may be more critical than volume, conclude the researchers. They caution that careful attention should be given to the content and wording of key messages.

Weech-Maldonado, R., Morales, L.S., Spritzer, K., and others. (2001, July). "Racial and ethnic differences in parents' assessments of pediatric care in Medicaid managed care." (AHRQ grant HS09204). Health Services Research 36(3), pp. 575-594.

These researchers analyzed 1997-1998 data from the National CAHPS® Benchmarking Database on parents' evaluations of the pediatric care provided by 33 Medicaid HMOs in six States during the 6 months prior to the survey. In general, racial/ethnic minority parents reported more negative experiences with their health plan or providers than whites. However, among Hispanics and Asians, language barriers had a larger negative effect on reports of care than race/ethnicity. English-speaking Hispanics did not differ significantly from whites on any of the reports of care, and English-speaking Asians did not differ significantly from whites on four of the five reports of care.

Blacks, Asians who didn't speak English, and American Indians had lower scores than whites on their ability to get needed health care. Hispanics who did not speak English, Asians who did not speak English, blacks, and American Indians reported lower scores for timeliness of care and plan service than whites. These same groups, except for blacks, also reported lower scores for provider communication. Non-English-speaking Hispanics and Asians also reported lower scores for staff helpfulness. However, these differences did not translate necessarily into lower ratings of care. Compared with whites, American Indians had lower ratings for personal doctor and health plan, and non-English-speaking Asians had lower ratings for health care. On the other hand, English-speaking Asians rated specialist care higher than whites, and Spanish-speaking Hispanics rated personal doctor, specialist, and health plan higher than whites.

The authors conclude that health plans need to pay increased attention to racial/ethnic differences in assessments of care. Furthermore, the study's finding that language barriers are largely responsible for racial/ethnic disparities in care suggests that linguistically appropriate health care services are needed to address these gaps.

Scanlon, D.P., Darby, C., Rolph, E., and Doty, H.E. (2001, July). "Use of performance information for quality improvement." (AHRQ grant HS09204). Health Services Research 36(3), pp. 619-641.

Standardized health plan performance measures such as CAHPS® and the Health Plan Employer Data and Information Set (HEDIS) are typically used by consumers, States, employers, and others to evaluate health plans. Managed care organizations (MCOs) also use these performance measures to improve the quality of care they provide, but the degree and sophistication of use varies, according to this study. The researchers interviewed chief executive officers, medical directors, and quality improvement directors from 24 large health plans in four States where there had been public reporting of plan performance with HEDIS and CAHPS®. The researchers conducted a total of 42 interviews resulting in discussion of 116 quality improvement initiatives in preventive care, disease management, and customer service/member satisfaction.

Many MCOs used performance measures to target quality improvement initiatives, evaluate current performance, set goals (for example, a 20 percent increase in use of beta blockers after heart attack), identify root causes of problems (such as a low rate of prenatal care in the Medicaid population), and monitor progress of quality improvement initiatives already implemented. Performance measures were identified as a precipitating factor in 77 percent of quality improvement initiatives focused on purchasers, such as Medicaid programs, or accrediting bodies, such as the National Committee on Quality Assurance (NCQA). Health plans also used performance measures to compare their plan's performance with that of others.

Reprints (AHRQ Publication No. 01-R081) are available from AHRQ Publications Clearinghouse.

Morales, L.S., Elliott, M.N., Weech-Maldonado, R., and others. (2001, July). "Differences in CAHPS® adult survey reports and ratings by race and ethnicity: An analysis of the National CAHPS® Benchmarking Data 1.0." (AHRQ grant HS09204). Health Services Research 36(3), pp. 595-617.

For this study, the researchers examined racial/ethnic group differences in adults' reports and ratings of care using data from the National CAHPS® Benchmarking Database (NCBD) 1.0. Adult data from the NCBD 1.0 is made up of CAHPS® 1.0 survey data from 54 commercial and 31 Medicaid health plans from across the Nation. A total of 28,354 adult respondents were included in this study. Respondents were categorized as being either Hispanic (n = 1,657), white (n = 20,414), black (n = 2,942), Asian/Pacific Islander (n = 976), or American Indian/Alaska native (n = 588).

Four single-item global ratings (personal doctor, specialty care, overall rating of health plan, and overall rating of health care) and five multiple-item report composites (access to needed care, provider communication, helpfulness of office staff, promptness of care, and health plan customer service) from CAHPS® 1.0 were examined. The researchers assessed differences in global ratings and report composites between whites and members of other racial/ethnic groups, controlling for age, sex, perceived health status, educational attainment, and insurance type.

Findings revealed that members of ethnic/racial groups, with the exception of Asians/Pacific Islanders, reported experiences with health care similar to those of whites. Global ratings of care by Asians/Pacific Islanders, however, were similar to those of whites. The researchers conclude that improvements in quality of care for Asians/Pacific Islanders are needed, and that comparisons of care in racially and ethnically diverse populations based on global ratings of care should be interpreted cautiously.

Elliott, M.N., Swartz, R., Adams, J., and others. (2001, July). "Case-mix adjustment of the National CAHPS® Benchmarking Data 1.0: A violation of model assumptions?" (AHRQ grant HS09204). Health Services Research 36(3), pp. 555-573.

These researchers compared the models used for case-mix adjustment of consumer reports and ratings of health care. They used data from the CAHPS® survey 1.0 National Benchmarking Database on 54 commercial and 31 Medicaid health plans from across the United States. These included data on 19,541 adults older than age 18 in commercial plans and 8,813 adults in Medicaid plans who responded regarding their own health care and 9,871 Medicaid adults who responded regarding the health care of their minor children.

Four case-mix models (no adjustment; self-rated health and age; health, age, and education; and health, age, education, and plan interaction) were compared on 21 ratings and reports regarding health care for the three populations (adults in commercial plans, adults in Medicaid plans, and children in Medicaid plans). The researchers examined the magnitude of case-mix adjustments, the effects of adjustments on plan rankings, and the homogeneity of these effects across plans. They found that case-mix adjusters—especially self-rated health—have considerable effects, but these effects vary substantially from plan to plan in violation of standard case-mix assumptions. The researchers conclude that case-mix adjustment of CAHPS® data needs to be reexamined, perhaps by using demographically stratified reporting or by developing better measures of response bias.

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