The influence of patient characteristics on ratings of managed behavioral health care

Despite current emphasis on consumer-based performance measures, little is known about factors that influence consumer ratings of behavioral health care. This study examines the influence of patient characteristics, health care use, and insurance coverage on patients' ratings of their managed behavioral health care in both commercial and public plans. Older and healthier patients rated their behavioral health care and health plan more highly than did other patients. Patients with less education and those whose insurance paid all costs of care gave consistently higher plan ratings. Women and frequent users enrolled in commercial plans gave more positive care ratings. After adjusting for enrollee characteristics and coverage, there were no differences between ratings of patients in commercial and public plans. These results are consistent with other research that illustrates the importance of adjusting health care ratings for patient characteristics when comparing plans.The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs.     

Adjusting for risk selection in state health insurance exchanges will be critically important and feasible, but not easy

The Affordable Care Act calls for the establishment of state-level health insurance exchanges. The viability and success of these exchanges will require effective risk-adjustment strategies to compensate for differences in enrollees' health status across health plans. This article describes why the Affordable Care Act could lead to favorable or adverse risk selection across plans. It reviews provisions in the act and recent proposed regulations intended to mitigate the problem of risk selection. We performed a simulation that showed that under the premium rating restrictions in the law, large incentives for insurers to attract healthier enrollees will be likely to persist-resulting in substantial overpayment to plans with very healthy enrollees and underpayment to plans with very sick members. We conclude that risk adjustment based on patients' diagnoses, such as will be in place from 2014 on, will yield payments to insurers that will be more accurate than what will come solely from the age-adjusted and other rating allowed by the act. We also describe additional challenges of implementing risk adjustment.     

Do Commercial Managed Care Members Rate Their Health Plans Differently than Medicaid Managed Care Members?

OBJECTIVE: To determine if members of commercial managed care and Medicaid managed care rate the experience with their health plans differently. DATA SOURCES: Data from both commercial and Medicaid Consumer Assessment of Health Plan Surveys (CAHPS) in New York State. STUDY DESIGN: Regression models were used to determine the effect of population (commercial or Medicaid) on a member's rating of their health plan, controlling for health status, age, gender, education, race/ethnicity, number of office visits, and place of residence. DATA COLLECTION: Managed care plans are required to submit to the New York State Department of Health (NYSDOH) results of the annual commercial CAHPS survey. The NYSDOH conducted a survey of Medicaid enrollees using Medicaid CAHPS. PRINCIPAL FINDINGS: Medicaid managed care members in excellent or very good health rate their health plan higher than commercial members in excellent or very good health. There is no difference in health plan rating for commercial and Medicaid members in good, fair, or poor health. Older, less educated, black, and Hispanic members who live outside New York City are more likely to rate their managed care plan higher. CONCLUSIONS: Medicaid members rating of their health care equals or exceeds ratings by commercial members.     

Consumers’ interpretation and use of comparative information on the quality of health care: the effect of presentation approaches

Background Public reports about health‐care quality have not been effectively used by consumers thus far. A possible explanation is inadequate presentation of the information. Objective To assess which presentation features contribute to consumers’ correct interpretation and effective use of comparative health‐care quality information and to examine the influence of consumer characteristics. Design Fictitious Consumer Quality Index (CQI) data on home care quality were used to construct experimental presentation formats of comparative information. These formats were selected using conjoint analysis methodology. We used multilevel regression analysis to investigate the effects of presenting bar charts and star ratings, ordering of the data, type of stars, number of stars and inclusion of a global rating. Setting and participants Data were collected during 2 weeks of online questioning of 438 members of an online access panel. Results Both presentation features and consumer characteristics (age and education) significantly affected consumers’ responses. Formats using combinations of bar charts and stars, three stars, an alphabetical ordering of providers and no inclusion of a global rating supported consumers. The effects of the presentation features differed across the outcome variables. Conclusions Comparative information on the quality of home care is complex for consumers. Although our findings derive from an experimental situation, they provide several suggestions for optimizing the information on the Internet. More research is needed to further unravel the effects of presentation formats on consumer decision making in health care.     

Predictability and predictiveness in health care spending

This paper re-examines the relation between the predictability of health care spending and incentives due to adverse selection. Within an explicit model of health plan decisions about service levels, we show that predictability (how well spending on certain services can be anticipated), predictiveness (how well the predicted levels of certain services contemporaneously co-vary with total health care spending), and demand responsiveness all matter for adverse selection incentives. The product of terms involving these three measures of predictability, predictiveness, and demand responsiveness define an empirical index of the direction and magnitude of selection incentives. We quantify the relative magnitude of adverse selection incentives bearing on various types of health care services in Medicare. Our results are consistent with other research on service-level selection. The index of incentives can readily be applied to data from other payers.     

Differences in CAHPS adult survey reports and ratings by race and ethnicity: an analysis of the National CAHPS benchmarking data 1.0

OBJECTIVE: To examine racial/ethnic group differences in adults' reports and ratings of care using data from the National Consumer Assessment of Health Plans (CAHPS) survey Benchmarking Database (NCBD) 1.0. DATA SOURCE: Adult data from the NCBD 1.0 is comprised of CAHPS 1.0 survey data from 54 commercial and 31 Medicaid health plans from across the United States. A total of 28,354 adult respondents (age > or = 18 years) were included in this study. Respondents were categorized as belonging to one of the following racial/ethnic groups: Hispanic (n = 1,657), white (n = 20,414), black or African American (n = 2,942), Asian and Pacific Islander (n = 976), and American Indian or Alaskan native (n = 588). STUDY DESIGN: 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, office staff helpfulness, promptness of care, and health plan customer service) from CAHPS 1.0 were examined. Statistical Analyses. Multiple regression models were estimated to assess differences in global ratings and report composites between whites and members of other racial/ethnic groups, controlling for age, gender, perceived health status, educational attainment, and insurance type. PRINCIPAL FINDINGS: Members of racial/ethnic minority groups, with the exception of Asians/Pacific Islanders, reported experiences with health care similar to those of whites. However, global ratings of care by Asians/Pacific Islanders are similar to those of whites. CONCLUSIONS: Improvements in quality of care for Asians/Pacific Islanders are needed. Comparisons of care in racially and ethnically diverse populations based on global ratings of care should be interpreted cautiously.     

Assessing incentives for service-level selection in private health insurance exchanges

Even with open enrollment and mandated purchase, incentives created by adverse selection may undermine the efficiency of service offerings by plans in the new health insurance Exchanges created by the Affordable Care Act. Using data on persons likely to participate in Exchanges drawn from five waves of the Medical Expenditure Panel Survey, we measure plan incentives in two ways. First, we construct predictive ratios, improving on current methods by taking into account the role of premiums in financing plans. Second, relying on an explicit model of plan profit maximization, we measure incentives based on the predictability and predictiveness of various medical diagnoses. Among the chronic diseases studied, plans have the greatest incentive to skimp on care for cancer, and mental health and substance abuse.     

Health plan characteristics and consumers' assessments of quality

Many purchasers and consumers of health care have become concerned about the quality of care being delivered in managed care plans. Little is known, however, about the health plan characteristics that are associated with better performance. We used survey responses from 82,583 Medicare beneficiaries from 182 health plans to study the association of consumers' assessments of care with health plan characteristics. For-profit and nationally affiliated health plans received much worse scores on the outcomes of interest, particularly for overall ratings of the health plan and composite measures of customer service and access to care. Health plans accredited by the National Committee for Quality Assurance did not receive higher scores.     

Effects of employer-offered high-deductible plans on low-value spending in the privately insured population

Enrollment in plans with high deductibles has increased more than seven-fold in the last decade. Proponents of these plans argue that high deductibles could reduce wasteful spending by providing patients with incentives to limit use of low-value services that offer little or no clinical benefit. Others are concerned that patients may respond to these incentives by reducing their use of medical services indiscriminately and regardless of clinical benefit, which may negatively impact health outcomes. This study uses individual-level insurance claims data (2008–2013) and plausibly exogenous changes in plan offerings within firms over time to estimate the intent-to-treat and local-average treatment effects of high-deductible plan offerings on spending on 24 low-value services received in the outpatient setting. We find that firm offer of a high-deductible plan leads to a 13.7% ($5.23) reduction in average enrollee spending on low-value outpatient services and a 5.2% ($105.77) reduction in overall outpatient spending. We also find reductions in spending on measures of low-value imaging and laboratory services. We find some evidence that offering high-deductible plans disproportionately reduces low-value spending relative to overall spending, indicating that deductibles may be a way to incentivize value-based decision making.     

Case-mix adjustment of the National CAHPS benchmarking data 1.0: a violation of model assumptions?

OBJECTIVE: To compare models for the case-mix adjustment of consumer reports and ratings of health care. DATA SOURCES: The study used the Consumer Assessment of Health Plans (CAHPS) survey 1.0 National CAHPS Benchmarking Database data from 54 commercial and 31 Medicaid health plans from across the United States: 19,541 adults (age > or = 18 years) in commercial plans and 8,813 adults in Medicaid plans responded regarding their own health care, and 9,871 Medicaid adults responded regarding the health care of their minor children. STUDY DESIGN: Four case-mix models (no adjustment; self-rated health and age; health, age, and education; and health, age, education, and plan interactions) were compared on 21 ratings and reports regarding health care for three populations (adults in commercial plans, adults in Medicaid plans, and children in Medicaid plans). The magnitude of case-mix adjustments, the effects of adjustments on plan rankings, and the homogeneity of these effects across plans were examined. DATA EXTRACTION: All ratings and reports were linearly transformed to a possible range of 0 to 100 for comparability. PRINCIPAL FINDINGS: Case-mix adjusters, especially self-rated health, have substantial effects, but these effects vary substantially from plan to plan, a violation of standard case-mix assumptions. CONCLUSION: Case-mix adjustment of CAHPS data needs to be re-examined, perhaps by using demographically stratified reporting or by developing better measures of response bias.     

How patients' sociodemographic characteristics affect comparisons of competing health plans in California on HEDIS quality measures.

OBJECTIVE: To estimate effects of patient sociodemographic characteristics on differential performance within and between plans in a single market area on the HEDIS quality of care measures, widely used for purchasing and accreditation decisions in the United States. DESIGN: Using logistic regression, we modeled associations of age, sex, and zip-code-linked sociodemographic characteristics of health plan members with HEDIS measures of screening and preventive services. We calculated the impact of adjusting for these associations on measures of health plan performance. SETTING: Twenty-two California health plans provided individual-level HEDIS data and zip codes of residence for up to 2 years. PARTICIPANTS: 110 541 commercially insured health plan members. MAIN OUTCOME MEASURES: Ten HEDIS quality-of-care measures. RESULTS: Performance on quality measures was negatively associated with percent receiving public assistance in the local area (seven out of 10 measures), percent Black (three measures), and percent Hispanic (four measures), and positively associated with percent college educated (six measures), and percent urban (three measures), controlling for plan, while associations with percent Asian were positive for three measures and negative for one (P < 0.05 for six associations, P < 0.01 for four, P < 0.001 for 17). Associations were consistent across plans and over time. Adjustment for these characteristics changed rates for most plans and measures by <5 percentage points. CONCLUSIONS: Adjustment for socioeconomic case mix has little impact on the measured performance of most plans in California, but substantially affects a few. The impact of case mix on indicators should be considered when making comparisons of health plan quality.     

Effect of a gatekeeper plan on health services use and charges: a randomized trial.

A randomized trial was conducted to determine the effectiveness of a health care plan which uses physicians as gatekeepers to control health services use and charges. New enrollees in United Healthcare (UHC), an independent practice association, were randomly assigned to the standard UHC plan requiring a gatekeeper, or to an alternate plan with equal benefits but without a gatekeeper. Individuals in both plans were similar in demographic characteristics, perceived health status, and other health insurance coverage. The gatekeeper plan had 6 percent lower total charges per enrollee than the plan without a gatekeeper. There were minor differences in hospital use and charges. Ambulatory charges were $21 lower per person per year in the plan with a gatekeeper (95% CI = -39.9, -2.1) and these were due to .3 fewer visits to specialists (95% CI = -0.50, -0.10). We conclude that a health plan which incorporates incentives and penalties for physicians to act as gatekeepers can reduce the cost of ambulatory services by limiting specialist visits.     

Introducing managed care in Switzerland: impact on use of health services

The objectives of this study were to assess changes in the self-reported use of health care services after gatekeeping by general practitioners and a global budget were introduced in the health insurance plan for students at the University of Geneva, Switzerland, in October 1992. A random sample of 336 members of the University plan answered questions about their use of health care services during the year before (1992) and the year after (1993) the introduction of managed care. Similar data were collected among a random sample of 300 members of a comparison plan. All participants were 18–44 y old in 1992, spoke French and lived in Geneva. The proportion of insurees who visited specialists decreased by 10% in the University plan between 1992 and 1993 and remained unchanged in the comparison group. The proportion of insurees who visited general practitioners increased by 12% in the University plan and remained unchanged in the comparison group. No effects on the total number of health care visits, on hospitalisations or on use of medications were detected. The introduction of gatekeeping and of a global budget managed by physicians was associated with a transfer of patient visits from specialists to general practitioners.     

Health plan implementation of U.S. Preventive Services Task Force A and B recommendations--Colorado, 2010

The Patient Protection and Affordable Care Act (PPACA) is aimed at expanding access to health care and lowering cost barriers to seeking and receiving care, particularly high-value preventive care. The legislation requires Medicare and all qualified commercial health plans (except grandfathered individual and employer-sponsored plans) to cover routine preventive services graded A and B by the U.S. Preventive Services Task Force (USPSTF) at no cost to the consumer, along with recommended immunizations and additional preventive care and screenings for women. In 2009, Colorado passed a law with similar USPTF A and B service coverage requirements. To determine how Colorado health plans had interpreted the state and federal law, the Colorado Department of Public Health and Environment (CDPHE) interviewed representatives of commercial health plans serving Colorado residents. The results of those interviews indicated that different health plans interpreted certain USPSTF recommendations differently, including tobacco screening and pharmacotherapy, colorectal cancer screening, and obesity screening and counseling. One health plan communicated the scope, eligibility criteria, and content of the new preventive services coverage to its members or providers. The differences in interpretation of the USPSTF recommendations and limited communication to consumers or health-care providers in Colorado might be repeated in other states. To ensure optimal consumer and health-care provider utilization of preventive service benefits, the preventive services supported by USPSTF A and B recommendations should be clearly defined in health plan benefit language, with processes put in place for consistent implementation and eligibility criteria communicated to both consumers and providers. The experience in Colorado shows that public health organizations can play a key role in successfully implementing PPACA prevention services provisions.     

Health care plan decisions regarding preventive services.

BACKGROUND: Medical decisions previously made by physicians and patients are increasingly influenced by health plans. It is important to understand how these decisions are made and who makes them. OBJECTIVES: To determine protocols used by health plans for recommending preventive services and to identify methods used to develop these protocols. METHODS: An interviewer conducted semistructured telephone interviews with medical directors from 6 major types of health plans regarding coverage of certain procedural preventive services. Each medical director was asked: (1) Is this procedure paid for by the health plan? (2) What is the frequency recommended for this procedure? (3) What age groups do you recommend for this procedure? (4) Do you encourage patients to receive this procedure, and if so, how? (5) Who developed these preventive services recommendations? (6) How were these recommendations developed? RESULTS: Ten interviews were completed representing 6 chosen types of health plans. While the different plans varied little regarding the preventive services recommended, there was variation in efforts to promote recommended services to members. There were also differences among the plans in the decision-making process for developing preventive services recommendations. CONCLUSIONS: Managed care organizations promote certain preventive services to members. All health plans had at least 1 preventive medicine task force charged with making coverage decisions about preventive services. However, more could be done to rationalize development of preventive services recommendations, primarily, implementation of evidence-based guidelines.     

Reported Experiences with Medicaid Managed Care Models Among Parents of Children

The proportion of children enrolled in Medicaid managed care arrangements has grown significantly over the past decade. Yet, few studies have attempted to assess differences in parental reports and ratings of care for children enrolled in different types of Medicaid managed care. We examine parental reports and ratings of care to explore whether and how patient and parent experiences vary by child health status and managed care plan type, including provider-sponsored specialized plans serving only children. Parents of children in a Florida Medicaid demonstration project in two counties over 3 years were surveyed using Consumer Assessment of Health Providers and Systems surveys (n = 2,741–11,067). Ordered logistic regression models with interaction terms were used to assess relationships between plan type, presence of chronic condition, and measures of patient experience. Parents of children enrolled in provider-sponsored plans that focus on pediatrics were more likely to provide a positive rating for their doctor, health plan, and specialty care compared to parents of children in an health maintenance organization (HMO). Parents of children with a chronic condition were less likely than parents of children without a chronic condition to provide a favorable rating of overall health care, their doctor, or health plan. The interaction term that assessed whether patient experience by plan type was impacted by the child’s health status was not statistically significant. Parents of Medicaid children may prefer provider-sponsored arrangements over HMOs. Findings can inform the future development of other integrated models of care involving provider-sponsored arrangements, such as pediatric Accountable Care Organizations and Patient-Centered Medical Homes.     

The impact of health plan report cards on managed care enrollment

How does the release of health plan performance ratings influence employee health plan choice? A natural experiment at General Motors (GM) Corporation provides valuable evidence on this question. During the 1997 open enrollment period, GM disseminated a health plan report card for the first time. By comparing 1996 and 1997 enrollment patterns, our analysis estimates the impact of the report card information while accounting for fixed, unobserved plan traits. Results indicate that employees are less likely to enroll in plans requiring relatively high out-of-pocket contributions. Results with respect to report card ratings suggest that individuals avoid health plans with many below average ratings.     

Measuring adverse selection in managed health care

Health plans paid by capitation have an incentive to distort the quality of services they offer to attract profitable and to deter unprofitable enrollees. We characterize plans' rationing as a "shadow price" on access to various areas of care and show how the profit maximizing shadow price depends on the dispersion in health costs, individuals' forecasts of their health costs, the correlation between use in different illness categories, and the risk adjustment system used for payment. These factors are combined in an empirically implementable index that can be used to identify the services that will be most distorted by selection incentives.     

Evaluating selection out of health plans for Medicaid beneficiaries with substance abuse

In the absence of adequate risk adjustment, capitation for enrollees creates incentives for health plans to enroll and retain good risks and to avoid bad risks. This article examines whether Maryland Medicaid beneficiaries with histories of substance abuse disenroll from health plans more frequently than those without such histories. The findings indicate that enrollees with a history of substance abuse were more likely to switch plans than other enrollees, regardless of whether they chose the health plan or were randomly assigned to the plan. These results suggest that current risk-adjustment systems may fail to offset selection incentives in modern capitated health plans.