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
Information about Quality In a Randomized
Evaluation (INQUIRE)
 Funding from
the Agency for Healthcare
Research and Quality (“Making Quality Count
for Consumers”)
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
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
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)
Health Belief Model
INDIVIDUAL PERCEPTIONS
Readiness To Undertake
Recommended Behaviors
MODIFYING FACTORS
LIKELIHOOD OF ACTION
Demographic Variables:
age, gender, race/ethnicity, SES
Social Psychological Variables:
social networks, group pressure,
acculturation
Perceived Benefits
minus
Perceived Barriers
Perceived Susceptibility to Illness
Perceived Seriousness (Severity)
of Illness
Perceived Threat
of Illness
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)
Likelihood of Preventive
Behavior
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, …)
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)
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)
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)
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)
Information about Quality In a Randomized Evaluation
(INQUIRE) – Analytic methods
 Analyses
weighted to account for stratified sampling
design
 Bivariate analyses of factors associated with selfreported 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, employmentrelated, and plan-related factors; other HBM variables
entered in stages
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)
Information about Quality In a Randomized
Evaluation (INQUIRE) – Overall results
 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
Results: Core model
Factor
Estimate
SE
OR
Expected premium change > $50
0.548
0.334
1.73
Expected premium change $25-$49
0.647
0.324
1.91**
No premium change expected
0.228
0.623
1.26
Female
-0.142
0.189
0.87
Non-English primary language
0.831
0.373
2.29**
Some College
0.505
0.297
1.67*
Age 18-40
-.654
0.322
0.52**
Age ≥60
-0.393
0.211
0.83
Income <$30K
0.270
0.276
1.31
Income >$75K
-0.340
0.211
0.71
Family coverage
-0.456
0.223
0.63**
Kaiser or PPO plan
-0.567
0.204
0.57**
Results: Health Status, Satisfaction
Factor
Health status (poor/fair)
Chronic disease (≥1)
CAHPS satisfaction ratings (9 or 10
in ≥2/4 areas)
CAHPS no problem getting needed
care (<2/4)
CAHPS no problem with approval
delays
Estimate
0.344
-0.199
SE
0.196
0.289
OR
1.41*
0.82
-0.169
0.257
0.84
-0.168
0.274
0.92
-0.087
0.230
0.84
Results: Susceptibility, perceived benefits, perceived barriers.
Factor
Estimate
SE
OR
Perceived individual susceptibility
(5 items)
0.501
0.237
1.65**
Perceived general susceptibility
(5 items)
-0.057
0.189
0.94
Agree that quality information will help
me select a plan that improves care
0.535
0.318
1.71*
Agree that quality information is too
difficult to use
-0.517
0.252
0.60**
Agree that quality information does not
apply to me or my situation
-0.284
0.220
0.75
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)
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