A Randomized Controlled Trial of an Educational and Motivational Intervention to Enhance Consumers’ Use of Health Plan and Medical Group Quality Data Patrick S. Romano, MD MPH Julie A. Rainwater, PhD Jorge A. Garcia, MD MS Debora A. Paterniti, PhD Daniel J. Tancredi, MS PhD Geeta Mahendra, MS Jason A. Talavera, MD student X X X Funding from the US Agency for Healthcare Research and Quality Phase II – Overview of Methods MODIFYING FACTORS LIKELIHOOD OF ACTION Demographic Variables: age, gender, race/ethnicity, SES Social Psychological Variables: social networks, group pressure, acculturation X X Perceived Benefits minus Perceived Barriers X Perceived Susceptibility to Illness Perceived Seriousness (Severity) of Illness Most previous studies of how consumers use report cards were conducted in “laboratory” settings, relied entirely on survey data, or did not randomly allocate participants. We planned a prospective study with 3 components: 9Focus group discussions of consumer choice and quality of care 9A prospective cohort study of factors associated with using a quality report card and switching health plans/medical groups 9A randomized controlled trial of two interventions designed to improve the use of quality information, under the Health Belief Model. AcademyHealth 2006 ARM June 27, 2006 Seattle, WA Health Belief Model INDIVIDUAL PERCEPTIONS Readiness To Undertake Recommended Behaviors Background to INQUIRE (INformation about QUality In a Randomized Evaluation) Perceived Threat of Illness Likelihood of Preventive Behavior CUES TO ACTION Advice from friends, Prompt from MD, Illness of family member, Newspaper or magazine article X X X Partnership between UC Davis and Pacific Health Advantage Population: 76,000 employees of small businesses (with 2-100 eligible workers) in CA, excluding “guaranteed associations” Setting: Open Enrollment 2003; members were offered a choice of 4 statewide and 4 regional HMOs (each with 3 copayment levels), 1 PPO (with 3 copayment levels), 1 point-of-service plan Study design: Randomized controlled trial Unit of randomization: Health insurance brokers (with their contracted employers and their employees) Measures: Observed behavior, post-Open Enrollment survey The Health Belief Model (Becker and Maiman 1975) Phase II – Control group Phase II – Interventions X Control X Intervention group group received “usual care”: 9Open Enrollment booklets on program rules and benefit options were mailed to employers (no quality information) 9No information went directly to employees 9PacPlan Chooser web site allowed members to compare plans on cost, features, and quality (overall rating) 9Insurance brokers provided limited support 1 received “educational/motivational treatment”: 9A special mailing to each employee, employer, and broker included a motivational letter (with negative framing), the California HMO Report Card, and the California HMO Guide 9A toll-free telephone line and e-mail address were offered for counseling and advice (during business hours) X Intervention group 2 was delayed Phase II – Sample design X X X X Stratified random sample of brokers with eligible employees scheduled for Open Enrollment in May-July 2003, after excluding employers intending to leave (N=1,579 with 26,249 EE’s) Excluded 16 brokers with large number of eligible employees (to increase efficiency) Oversampled small brokers (4 strata), brokers for whom at least 40% of EE’s were <39 yrs, and brokers for whom at least 50% of EE’s had 3 or more HMO options (total 10 sampling strata) Brokers allocated in two stages Phase II – Analytic methods and hypotheses X X All analyses were (or will be) weighted to account for the cluster sampling design, using robust methods to correct CIs Hypotheses: 9Intervention would increase overall switching across health plans and medical groups 9Intervention would promote switching toward “better” health plans and medical groups, among those who switch 9Intervention would enhance perceived threat, enhance self-efficacy, promote migration from pre-contemplation to contemplation, and promote use of quality information in decision-making Phase II – Primary outcome results (all weighted and nonsignificant) X 9.2% of intervention group versus 7.0% of control group switched plans. X 21% of intervention group switchers versus 35% of control group switchers moved to a plan with more stars. X 27-28% in both groups moved to a plan with fewer stars. Secondary outcome, reason for switch Stated reason for switching in intervention group vs. control group, respectively (all p>0.10 unless stated): X X X X X X X X X Change in geographic coverage of plan (10% vs. 2%, p=0.03) Cost (34% vs. 25%) Continuity of MD (1% vs. 5%) Better network of MDs (8% vs. 7%) Concern over poor report card scores (6% vs. 1%, p=0.099) Concern over poor access to care (6% vs. 5%) Poor service from previous plan (6% vs. 3%) Better benefits (5% vs. 3%) Other reason (7% vs. 1%, p=0.06) Phase II – Process results 292 brokers with 1,835 eligible employees (EE’s) were randomized to the intervention group X 246 brokers with 1,578 eligible employees (EE’s) were randomized to the control group X 30.2% of EE’s in the intervention group, and 37.1% of EE’s in the control group, dropped out of Pacific Health Advantage X 22 intervention group members used the toll-free advice line X 3 intervention group members used the e-mail address X Broad array of questions and concerns X Secondary outcome, use of resources Did you read or review…? Did you call or contact…? Ed/Mot Control Comparison of health plan benefits 60% 57% PacPlan Chooser web site 15% 14% CA HMO Guide (p<0.001) 40% 10% CA HMO Report Card (p<0.001) 38% 8% Health plan member services (p=0.02) 7% 9% OPA, HMO Help Center, Health Rights Hotline <2% <2% Secondary outcome, expected outcome of switch (NS) Ed/Mot (N=88) Control (N=87) Better 16% 9% Same 17% 20% Worse (p=0.07) 8% 1% Uncertain or did not respond 59% 70% Do you expect that quality of care will be better, the same, or worse with your new health plan? Secondary outcome, considered switch Secondary outcome, reason for considering switch 35% of intervention group respondents who did not actually switch “considered” switching X 28% of control group respondents who did not actually switch “considered” switching (p=0.07) X Of those who “considered” switching, 31% of intervention group respondents and 30% of control group respondents “seriously considered” it (rating=6 on 1-6 scale) Stated reason for considering switching in intervention group vs. control group, respectively: X X X X X X X X X Cost (69% vs. 74%) Continuity of MD (6% vs. 11%) Better network of MDs (16% vs. 23%) Concern over poor report card scores (15% vs. 7%, p=0.08) Concern over poor access to care (17% vs. 17%) Poor service from previous plan (10% vs. 10%) Better benefits (25% vs. 25%) Other reason (14% vs. 7%) – need to review comment fields Secondary outcome, perceived differences in quality among plans (NS) Secondary outcome, perceived differences in quality among medical groups (NS) Size of perceived difference Size of perceived difference Ed/Mot Control Ed/Mot Control Big 47% 48% Big 31% 35% Small 31% 30% Small 35% 34% None 7% 4% None 7% 5% Don’t know 15% 18% Don’t know 27% 27% Secondary outcome, perceived benefits and barriers (NS) Secondary outcome, self-efficacy (NS) Agree or strongly agree… Ed/Mot Control Confident in my ability to choose a health plan 78% 81% Confident in my ability to choose a medical group 80% 80% I felt well informed about my health plan choices 71% 69% I felt well informed about my medical group choices 66% 65% I used what I know…to make the best possible choice for me during Open Enrollment 77% 78% Agree or strongly agree… Using the information in…, I was able to choose the best health plan for my family and me Looking at the information about health plans was a waste of time for me (p=0.05) The materials… helped me better understand my health plan choices I guess my health plan has some drawbacks, but none of the others is really better Ed/Mot Control 58% 57% 16% 20% 67% 65% 52% 54% Secondary outcome, Difficulty of selecting plan (p=0.003) Limitations Ed/Mot Control Not a problem (p=0.01) 58% 66% A small problem 27% 25% A big problem (p=0.002) 15% 9% How much of a problem, if any, was it to find a health plan that suited you…? Policy implications X X X Educational/motivational interventions designed to increase perceived benefits and decrease perceived barriers, with negative framing, may increase use of quality information but are unlikely to affect actual choices in the health care market. Quality data with negative framing may make decision-making more difficult for price-sensitive consumers (especially if there is a perceived cost-quality tradeoff). Many other signals affect consumers’ behavior during Open Enrollment; cost is the dominant factor in the small business market in the USA. X Primary outcome (actual choice of health plan) may be difficult to change because of competing concerns (e.g., price, convenience) and information from other sources (e.g., friends and family) X Analysis of secondary outcomes limited by poor response to post-OE survey despite two mailings, financial incentive, and follow-up abbreviated webbased survey (est. 41% excluding ineligibles)