Employers that use standardized health plan performance. Choosing A Health Plan: What Information Will Consumers Use?

Transcription

1 I N F O R M A T I O N N E E D S Choosing A Health Plan: What Information Will Consumers Use? Few employees in this survey found customer satisfaction results or plan performance ratings by experts essential to their choice of health plan. by Anne Tumlinson, Hannah Bottigheimer, Peter Mahoney, Elliot M. Stone, and Ann Hendricks ABSTRACT: Employers and policymakers are looking for ways to encourage competition among health plans, thus lowering costs and improving quality. Employers hope to foster competition among health plans by creating standardized measures of quality that supplement the traditional benefits and cost information employees use to compare plans and make choices. This Data- Watch examines employees interest in standardized measures of plan performance. Results from a survey of Massachusetts state employees show that cost and benefit information receive high rankings, but certain plan performance information does not. DATAWATCH 229 Employers that use standardized health plan performance information to compare the quality and cost of plans they purchase may want to pass this information along to their employees. Whether employees will find plan performance information useful in comparing and choosing health plans, however, is largely unknown. In this DataWatch, we present the results of a pilot study of employees information needs and discuss the implications of the results. The purpose of the study was to answer the following questions: What information is essential to the most employees in choosing health plans? What information is essential to the fewest employees? What information do employees say is not useful or somewhat useful in choosing health plans? 1 How do employees Anne Tumlinson is senior research associate at the Center for Health and Long-Term Care Research, LifePlans, Inc., in Waltham, Massachusetts. Hannah Bottigheimer is training coordinator at the Center for Training and Health Education, Healthcare of Southeast Massachusetts, in Brockton. Peter Mahoney is vice-president of business development at Cambridge Health Resources, in Newton, Massachusetts. Elliot Stone is executive director of the Massachusetts Health Data Consortium, in Waltham. Ann Hendricks is senior economist at the Veterans Health Administration, Center for Health Quality, Outcomes, and Economic Research, in Bedford, Massachusetts. H E A L T H A F F A I R S ~ M a y / J u n e ThePeople-to-PeopleHealth Foundation, Inc.

2 D a t a W a t c h 230 INFORMATION NEEDS opinions about plan information differ by sex, income, and utilization? How many employees change health plans, who are they, and why do they switch? 2 Some results are not surprising. For example, a majority of employees find cost and benefit information essential. A striking result is that few employees find customer satisfaction results or ratings by independent experts essential. Although the survey sample may not be generalized to all health plan consumers, the results provide valuable insights about the health plan information needs of employees who are particularly interested in the health plan selection process. Previous research. Current knowledge about how consumers view plan performance measures has been pieced together from several sources, including the results of recent focus groups. 3 Studies on consumer choice since 1980 reveal that consumers have consistently ranked cost, choice of providers, and a strong doctor/patient relationship as very important in choosing and remaining in a specific health plan. 4 In more recent focus groups consumers confirm that their information needs are similar to the basic factors that are most important in health plan choice. 5 The state of Minnesota made available to state employees a brochure containing the results of a health plan customer satisfaction survey. Employees showed strong interest in the survey information but ranked it lower than other standard information such as cost, coverage, and choice of providers. 6 Harvard Community Health Plan (HCHP) conducted a consumer poll that asked respondents to choose the most important health plan information from five information items: choice of doctors, benefit package, standardized quality measures, patient satisfaction, and access. 7 Of the five, respondents ranked standardized quality measures the lowest. The marketplace could help us better understand the information needs of consumers. In 1994 Washington Consumers CHECK- BOOK sold about 23,000 copies of its health plan guide, CHECK- BOOK s Guide to 1995 Health Insurance Plans for Federal Employees. 8 Nearly half of the copies were sold directly to consumers. In addition to comparisons of cost and coverage, the guide contains information on customer service and employee satisfaction. 9 Although major research initiatives on the information needs of consumers are in process, our study is unique in that it examines the information needs of employees by asking them to rate the usefulness of a wide range of health plan information. Methods. The Massachusetts Group Insurance Commission (GIC) a semiautonomous agency that purchases health insurance for state employees initiated a survey of the health plan informa- H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 3

3 I N F O R M A T I O N N E E D S tion needs of Massachusetts state employees in conjunction with the Massachusetts Health Data Consortium. 10 The purpose of the survey was to help the GIC assess whether or not employees would use comparative health plan information it had recently collected. The questionnaire asked respondents to rate thirteen items of information on a four-point scale, including not useful at all, somewhat useful, very useful, and essential. The thirteen items were not ranked in relationship to each other. The survey also asked state employees to indicate whether they or a family member had visited a doctor more than five times in the past year, whether they or a family member had visited a hospital over the past year, and whether they had changed health plans, and why. The survey was designed in January 1994, after a review of instruments and report cards used by government agencies in other states, private-sector employers, managed care organizations, and consumer groups. 11 Survey design experts at the Division of Health Improvement at the New England Medical Center reviewed a draft of the survey, which was then tested with several groups of state employees. 12 The survey was distributed in three ways during the spring 1994 annual open enrollment period. First, the questionnaire was included as an insert to the health plan options information booklet, the GIC Benefit Decision Guide, which the GIC mails to all active and retired state employees. Second, the questionnaire was made available in state employees workplaces. Finally, some state employees were approached at random by survey administrators at informational health fairs conducted throughout the state. These strategies together yielded a total of 3,132 completed surveys. Of these, 48 percent were active younger employees (ages forty-nine and younger), 12 percent were active older employees (ages fifty and older), 34 percent were retirees, and the remainder did not indicate their age. This demographic profile is within two to four percentage points of the known distribution of the total pool of active and retired state employees across these age and employment status categories. Because of strict time and resource limitations, the researchers analyzed only 397 surveys for this study. A systematic sampling procedure (every tenth survey) was used to select 397 surveys after sorting the pool of 3,132 surveys into age and employment status categories. The selection process resulted in an age and employment status mix that parallels that of the total pool of active and retired state employees. Limitations. One possible limitation is that the survey asks respondents to rate the usefulness of information that they may never have seen. Respondents might rate information to which they had been previously exposed more favorably than information to which they had not. Indeed, respondents to the GIC survey had not been DATAWATCH 231 H E A L T H A F F A I R S ~ M a y / J u n e

4 D a t a W a t c h exposed to the information they most often ranked lowest. However, many employees gave high rankings to information they had not previously seen (for example, quality of primary care physicians, quality of specialty doctors ). Therefore, while employees might reconsider their low rankings of some information once they have had the chance to see it, they appear willing to give high rankings to information they have not seen. We also caution readers that the number of returned surveys was low relative to the number of state employees and that the employees who responded to the survey may have been more interested in plan information than were those who did not respond. Therefore, the results of the GIC survey cannot be generalized to the entire state employee population. As a large sample of convenience of interested employees, however, the results are informative. 232 INFORMATION NEEDS Study Findings Here we present descriptive statistics and bivariate analyses to answer the study questions posed at the outset. Multivariate analyses revealed that, holding other factors (such as age, sex, employment status, education, income, and health services utilization) constant, the results of the bivariate analysis continue to be significant. We note the results of multivariate analyses where appropriate. 13 What information is essential to the most employees? Of thirteen items of information, only five were rated as essential by a majority of employees (Exhibit 1). In general, these items relate to the cost, basic content, and quality of the providers in the plans. Almost three-quarters of employees ranked specific benefits in each plan (such as coverage limits for hospitals, drugs, physicians, and nursing home care) as essential. Information on the average out-of-pocket costs for each plan (such as deductibles, coinsurance, copayments, and noncovered items) won an essential rating from 62 percent of employees. Slightly more than half of all employees said the following items of information were essential: quality of primary care physicians available in each plan (such as training, communication skills, and experience), premium prices (How much do enrollees pay? How much does the state pay? How much have prices increased over the past three years?), and lists of physicians and hospitals participating in each plan (by location of office and by specialty). What information is essential to the fewest employees? Information on ratings of each plan by independent experts (such as Consumer Reports) was least likely to be considered essential by employees (Exhibit 1). Three other items were also not considered essential by a large proportion of employees: percentage of persons satisfied with the plan overall, quality of mental health and substance H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 3

5 I N F O R M A T I O N N E E D S EXHIBIT 1 Percentage Of Respondents Rating Items Essential, Very Useful, Somewhat Useful, Or Not Useful Type of information Specific benefits Average out-of-pocket costs Quality of primary care physicians available Premium prices Lists of participating physicians and hospitals Quality of specialty physicians Convenience of selecting and changing physicians and obtaining referrals to specialists Quality of preventive care Convenience of seeing a primary care physician Comparisons of the convenience of the paperwork and administrative aspects Quality of mental health and substance abuse care Percentage of persons who are satisfied with the plan overall Ratings of each plan by independent experts Rating Essential 72.0% Very useful 24.2% Somewhat useful 1.0% abuse care available in each plan, and comparisons of the convenience of the paperwork and administrative aspects of each plan (such as waiting times for obtaining ID cards or reimbursement). What information do employees say is not useful? Many items of information were not deemed essential by employees, but they were deemed very or somewhat useful. Only one item, quality of mental health and substance abuse care available in each plan, received a ranking of not useful by more than 10 percent of employees (Exhibit 1). Close to 7 percent of employees said that information on the percentage of persons who are satisfied with the plan overall was not useful. About 5 percent said that ratings of each plan by independent experts and information on the comparisons of the convenience of the paperwork and administrative aspects of each plan were not useful. In contrast, no employees ranked information on the specific benefits in each plan as not useful, and fewer than 1 percent found information on premium prices and average out-ofpocket costs for each plan not useful. What information do employees say is either not useful or somewhat useful? Combining the responses in the not-useful and somewhat-useful categories yields similar results (Exhibit 1). The quality of mental health and substance abuse care available in each Not useful 0.0% SOURCE: Massachusetts Health Data Consortium, Health Care Information Needs Survey, 1994/1995 Benefit Decision Guide (Waltham, Mass.: Massachusetts Group Insurance Commission, January 1994) H E A L T H A F F A I R S ~ M a y / J u n e

6 D a t a W a t c h 234 INFORMATION NEEDS plan received a ranking of either not useful or somewhat useful by more than 50 percent of respondents. Percentage of persons who are satisfied with the plan overall, ratings of each plan by independent experts, and comparisons of the convenience of paperwork received one of these rankings from about 39 percent of respondents. Between 1 percent and 11 percent of respondents ranked premium prices, specific benefits in each plan, and average out-of-pocket costs for each plan as either not useful or somewhat useful. How do employees opinions differ by income, sex, and utilization? Massachusetts state employees responses confirm the findings of earlier studies that information preferences vary significantly by income level and sex (Exhibits 2 and 3). In this study, information on average out-of-pocket costs and premium prices is essential to more people in lower-income categories. Similarly, the percentage of employees ranking average out-of-pocket costs as an essential item of information decreases significantly as income rises. This conclusion was unchanged when age, employment status, education, and sex were held constant in a multivariate analysis. Information on average out-of-pocket costs, lists of physicians and hospitals participating in each plan, and the quality of each plan s preventive care (such as prenatal care, immunizations, and screenings for cancer, high blood pressure, and diabetes) is essential to more women than men (Exhibit 3). More than two-thirds of all women, compared with half of all men, ranked information on average out-of-pocket costs essential (p <.05) Proportions were similar for rankings of information on lists of physicians and hospitals participating in each plan and information about the quality of each plan s preventive care. This conclusion was unchanged when other characteristics were held constant in a multivariate analysis. How many people change health plans, and why? Nearly onethird (29 percent) of employees switched plans in the three years prior to the survey. Seven percent were planning to switch plans during the current open enrollment season. According to employees EXHIBIT 2 Respondents Ratings Of Cost Information Items, By Annual Income Percentage rating item essential Income Premium price Average out-of-pocket cost Less than $25,000 $25,000 $49,000 $50,000 $74,000 $75,000 or more 71% % SOURCE: Massachusetts Health Data Consortium, Health Care Information Needs Survey, 1994/1995 Benefit Decision Guide (Waltham, Mass.: Massachusetts Group Insurance Commission, January 1994). H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 3

7 I N F O R M A T I O N N E E D S EXHIBIT 3 Respondents Ratings Of Information Items, By Sex Percentage rating item essential Type of information Female Male Average out-of-pocket cost Lists of physicians and hospitals participating in each plan Quality of preventive care SOURCE: Massachusetts Health Data Consortium, Health Care Information Needs Survey, 1994/1995 Benefit Decision Guide (Waltham, Mass.: Massachusetts Group Insurance Commission, January 1994). 69% who had switched or were planning to switch plans, the top reason for changing was that the plan had been canceled (Exhibit 4). Slightly fewer employees switched because plan premiums were too high. Employees rarely switched because their doctor left the plan. The frequency with which plan switchers ranked the cancellation of their plan as the reason for changing may be attributable, in part, to the consolidation of plan offerings caused by health maintenance organization (HMO) mergers and GIC actions. Who are plan switchers? Nearly 40 percent of active employees, compared with 14 percent of retired employees, said that they had % E X H IBI T 4 Respondents Reasons For Changing Health Plans Reason for change Plan was canceled 48 High premiums 40 High out-of-pocket costs Concern with quality of physician care Want to see provider not in plan Administrative problems Plan was inconvenient Concern with quality of hospital care Other Physician left plan Percent choosing reason SOURCE: Massachusetts Health Data Consortium, Health Care Information Needs Survey, 1994/1995 Benefit Decision Guide (Waltham, Mass.: Massachusetts Group Insurance Commission, January 1994). H E A L T H A F F A I R S ~ M a y / J u n e

8 D a t a W a t c h 236 INFORMATION NEEDS changed plans in the past three years (p <.05). Fewer employees in the youngest (ages eighteen to twenty-nine) and the oldest (over age sixty-five) age groups switched plans over the past three years, compared with those in the two middle age categories (thirty to forty-nine and fifty to sixty-four) (p <.05) (Exhibit 5). However, many more employees in the youngest age group compared with those in the middle groups indicated that they were planning to switch during the current open enrollment season (p <.05). Of those who had changed plans in the past three years, 66 percent rated information about lists of physicians and hospitals participating in each plan as essential to their decision to choose a health plan, compared with 46 percent of those who did not change plans (p <.05). Of employees who had changed plans in the past three years, 60 percent rated information about the convenience of selecting and changing physicians and obtaining referrals to specialists in plan (such as forms to fill out, approvals needed, and length of time involved) as essential, compared with 40 percent of employees who did not change plans (p <.05). Discussion And Policy Implications Many of our results are consistent with previous research: The information respondents consider most essential when comparing plans is related to cost, price, benefits, and availability and quality of providers. Not surprisingly, more lower-income than higher-income respondents rated price and out-of-pocket cost information as essential. More women than men highly valued information about cost, quality of preventive care, and providers available. Switching plans had little or no impact on employees ratings of information needs, but the high percentage who reported switching may be attributable to selection bias. The most striking result is the indication that the new wave of employer-generated plan performance measures may include information that employees do not yet find useful. Several points are important to consider, however. First, although this survey s re- EXHIBIT 5 Respondents Who Switched Or Plan To Switch Plans, By Age Percentage switching plans Age Switched in past three years Plan to switch this year and older 16% SOURCE: Massachusetts Health Data Consortium, Health Care Information Needs Survey, 1994/1995 Benefit Decision Guide (Waltham, Mass.: Massachusetts Group Insurance Commission, January 1994). 19% H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 3

9 I N F O R M A T I O N N E E D S spondents do not rank ratings of each plan by independent experts or percentage of persons who are satisfied with the plan high on usefulness, they were not exposed to this type of information. Perhaps if given the opportunity to review such information, employees would respond differently. 14 Second, plan performance information comes in many different forms. The key to getting employees to use such information may be a function of the clarity of its presentation. 15 Third, although many respondents do not rank ratings by experts as essential, quite a few rank this type of information as either somewhat useful or very useful. This suggests the possibility that consumers might be open to learning about these measures. Finally, survey respondents rank information about quality of primary care providers highly but give low rankings to expert ratings and the satisfaction of other plan users. This discrepancy may confirm that consumers are willing to make quality comparisons among providers and plans but are skeptical about the reliability of outside evaluators. Despite the lack of knowledge about consumer interest in plan performance measures, some employers and purchasers have begun to provide this information. 16 The California Public Employees Retirement System (CalPERS) recently distributed a performance report about its health plan offerings. The New England HEDIS (Health Plan Employer Data and Information Set) Coalition has published three annual performance profiles by health plan. The Health Care Financing Administration (HCFA) has been working with others to design plan performance information for Medicare and Medicaid recipients. 17 The investment in developing and distributing plan performance information to consumers warrants more research to better understand what types of consumer information will foster competitiveness. Our findings suggest caution in assuming that employees will want and use the same information that employers value. DATAWATCH 237 This research originated as a student management project at Brandeis University s Heller School for Social Policy. The views expressed herein are those of the authors and do not inany way represent the views of theagenciesor organizations with which the authors are now employed or affiliated. The authors thank Dolores Mitchell, executive director of the Massachusetts Group Insurance Commission, for providing information necessary to this study, and Charles Slavin of the Group Insurance Commission, Jon Chillingerian, Marc Cohen, Deborah Garnick, Mark Meterko, and Greg Stohr for comments on an earlier draft. NOTES 1. Employees rated the usefulness of health plan information on a four-point scale: not useful, somewhat useful, very useful, and essential. We examined the degree to which items were ranked both essential and not useful. H E A L T H A F F A I R S ~ M a y / J u n e

10 D a t a W a t c h 238 INFORMATION NEEDS 2. Plan switching is relevant to information needs because plan switchers may be the most likely to need or use certain types of information. 3. J. McGee and D. Knutson, Health Care Report Cards: What about Consumers Perspectives? Journal of Ambulatory Care Management (October 1994): 1 14; and S. Edgman-Levitan and P.D. Cleary, What Information Do Consumers Want and Need? Health Affairs (Winter 1996): G. Chakraborty, R. Ettenson, and G. Gaeth, How Consumers Choose Health Insurance, Journal of Health Care Marketing (Spring 1994): 21 33; National Committee for Quality Assurance, The Consumer Information Project: Final Report of Phase I (Washington: NCQA, 1994); M.S. Klinkman, The Process of Choice of Health Care Plan and Provider: Development of an Integrated Analytic Framework, Medical Care (Fall 1991): ; D. Mechanic, Consumer Choice among Health Insurance Options, Health Affairs (Spring 1989): ; S.H. Long, R.F. Settle, and C.W. Wrightson, Employee Premiums, Availability of Alternative Plans, and HMO Disenrollment, Medical Care 26, no. 10 (1988): ; S.E. Berki and M.L.F. Ashcraft, HMO Enrollment: Who Joins What and Why: A Review of the Literature, Milbank Memorial Fund Quarterly 58, no. 4 (1980): ; and D. Piontkowski and L.H. Butler, Selection of Health Insurance by an Employee Group in Northern California, American Journal of Public Health (March 1980): Edgman-Levitan and Cleary, What Information Do Consumers Want and Need? 6. J. McGee and M. Hunter, Final Report to the State of Minnesota Department of Employee Relations, Employee Response to Health Benefits Survey Results Brochure: Findings from Fall 1992 Interviews (Highland Park, Ill.: McGee Consulting, 1992). 7. Harvard Community Health Plan, Keeping Score: How Does Health Care Measure Up? (Cambridge, Mass.: HCHP, 1993). 8. Robert Krughoff, president, Washington Consumers CHECKBOOK, personal correspondence, 1 December W. Francis et al., CHECKBOOK s Guide to 1995 Health Insurance Plans for Federal Employees (Washington: Washington Consumers CHECKBOOK, 1994). 10. Interview with Dolores Mitchell, executive director, Group Insurance Commission, 16 November D. Lerner and E. Stone, Employee Health Benefits Survey and Users Manual (Brookfield, Wisc.: International Foundation of Employee Benefit Plans, 1990); Francis et al., CHECKBOOK s Guide; P. Tingstad, It s Your Health, a Consumer Guide (Brookfield, Wisc.: International Foundation of Employee Benefits, 1991); HCHP, Keeping Score; McGee and Hunter, Final Report to the State of Minnesota; American Association of Retired Persons, Choosing an HMO, an Evaluation Checklist (Washington: AARP, 1986); and S. Leatherman, Performance Indicators for Evaluating a Health Care Delivery System, a Report Card on Health Care (Minnetonka, Minn.: Center for Health Policy and Evaluation, United HealthCare Corporation, 1993). 12. A copy of the original report, Consumer Information Decisive Factors in Health Plan Choice, and the survey will be provided upon request. Contact Elliot Stone at the Massachusetts Health Data Consortium, Third Floor, 460 Totten Pond Road, Waltham, Massachusetts Multivariate analyses were conducted on thirteen logistic regression equations. Each equation contained one of the thirteen information items as the dependent variable. 14. McGee and Knutson, Health Care Report Cards. 15. Ibid.; and Mechanic, Consumer Choice among Health Insurance Options. 16. GAO, Employers and Individual Consumers Want Additional Information on Quality, GAO-HEHS (Washington: U.S. GAO, September 1995). 17. Ibid; and New England HEDIS Coalition, 1995 Performance Profile (Boston: New England HEDIS Coalition, 1996). H E A L T H A F F A I R S ~ V o l u m e 1 6, N u m b e r 3