Heterogeneity of
Medicare Advantage and
Prescription Drug Plan
Experiences
p
by Beneficiary Race/Ethnicity:
Considerations for Public
Reporting by Race/Ethnicity
Marc N. Elliott, PhD, RAND
June 27,, 2010
Academy Health
Coauthors
This is joint, ongoing work with
– Amelia
A li M.
M Haviland
H il d (RAND)
– Katrin Hambarsoomian (RAND)
– David Kanouse (RAND)
– Elizabeth Goldstein (CMS)
Medicare CAHPS Surveys
y
• CAHPS Health Plan surveys originally developed by AHRQ
p
p
for Medicare
• Modified in CMS adaptation/implementation
setting
• Large annual survey, nationally representative of Medicare
b fi i i
beneficiaries
• Asks beneficiaries about a wide variety of health care
experiences and beneficiary characteristics
characteristics, including selfselfreported race/ethnicity
• Public reports of overall plan
plan--level MCAHPS data used
– By
y beneficiaries to inform choice
– By health care providers to aid QI efforts
– By CMS to monitor and incorporate into Value Based
Purchasing
MIPPA 185 Requires Analysis of
CAHPS Scores by Race/Ethnicity
for MA Plans and PDPs
Considerations:
• What CAHPS measures are best for racial/ethnic specific
reporting?
• What sample sizes are adequate to support reliable planplan-level
estimates for racial/ethnic subgroups?
• What groups can be reported reliably for more than a few plans?
• What disparities exist at the plan level?
• Are the best plans for each racial/ethnic group the same?
– If yes, subgroup estimates are just less accurate measures of plan
performance.
– If no, subgroup estimates may provide unique information to inform
choice. And heterogeneity
g
y of disparities
p
suggests
gg
potential
p
to improve
p
disparities.
• How do you convey such information to consumers?
Data for Our Study
y
• Combines data from 2008 and 2009
surveys for
f
– 541 Medicare Advantage (MA) plans
– 82 freefree-standing prescription drug plans
(PDP ) fielding
(PDPs)
fi ldi the
h survey in
i 2009
– ~800,000
800,000 tota
total respondents
espo de ts
• Excludes beneficiaries with original
Medicare (fee(fee-for
for--service) coverage and no
free--standing PDP
free
What CAHPS measures are best for
racial/ethnic specific reporting?
• Previous
i
researchh (Weech(Weech
(
h-Maldonado,
ld d Elliott
lli et
al. 2008, Elliott, Haviland et al. 2009) suggests
0-10 ratings are used differently by
race/ethnicity, so excluded them
• We examine
– 2 measures of immunization (flu,
(flu, pneumonia
pneumonia-- MA)
– 4 composite measures of Part C experience ((getting
getting
needed care, getting care quickly, doctor
communication, customer serviceservice- MA)
– 2 composite measures of Part D experience (getting
(getting
drugs, getting information
information-- MA and PDP)
What sample sizes are adequate
to support reliable planplan-level estimates
for racial/ethnic subgroups?
• Methods: Mixed linear regression models of CAHPS
measures
– R/E fixed effects
– Plan,
Plan r/e x plan random effects
• Answer (for minimum group
group--specific reliabilities
generally
ll >0.7)
>0 7)
– 100 item completes over 2 years by given r/e group within
MA plan
• Except for MD communication –would require 300 for similar reliabilityreliability- not
recommended for reporting
– 200 items completes within PDP contract (which vary less)
What groups can be reported reliably
f more than
for
th a ffew plans?
l ?
• Whites
Whites:: 390390-418/541 MA plans for 7 retained measures
• Blacks: 102
102--118 MA plans
p
• Hispanics
Hispanics:: 107107-125 MA plans
• API:
API 19
19--21 MA plans
l
• Essentiallyy none for AI/AN, multiracial
• Reportable for similar fractions of PDPs
What percentage of minorities are
included in reportable
p
MA p
plans?
• Reportable plans are larger and higher in
minority percentage
• Reportable MA plans cover:
– 85
85--93% Hispanics/Blacks
– 66
66--67% of API
What are overall disparities
in MA?
• Significantly worse than Whites 7/8 measures for
– Blacks ( MD comm no diff)
– Hispanics (MD comm better)
– API (flu immunization better)
• Same pattern (still 7/8 worse in each case) but smaller differences
within plans, HRRs (Black MD comm now > White)
• Disparities quite variable at plan level relative to average
disparity
– SD of Black/Hispanic x plan about equal to average disparity
– SD of API x plan about half of (larger) average disparity
What are disparities,
absolute experiences
in high minority MA plans?
• Experiences are significantly worse overall as % minority goes up
–
–
–
–
Blacks ( 8/8. pp<0.05))
Hispanics (7/8, customer service p<0.10)
API (3/8
(3/8-- getting needed care, getting care quickly, pneumonia immunization )
No cases of getting significantly better
• Smaller disparities vs. White as % your group rises
–
–
–
–
Blacks ( 3/8
3/8-- customer service, flu, PDP info)
Hispanics
Hi
i (6/8,
(6/8 all
ll bbutt iimmunization)
i ti )
API (4/8
(4/8-- getting needed care, getting care quickly, both PDP )
No cases of getting significantly worse
• Net effects
– High minority plans consistently bad for Whites, minorities other than the one in
question
– Low disparities but poor overall translate into minorities having roughly similar or
somewhat worse experiences in high samesame-minority plans as in high White plans
The best plans
for each racial/ethnic group
sometimes differ
• Significant heterogeneity (plan x r/e interactions) for Black,
Hispanic, API vs. Overall 29/30 times (correlations <1, p<.05)
• Within MA, median squared correlations of racial/ethnic
racial/ethnic--specific
plan scores with overall plan scores 0.52 (API) , 0.59 (Hispanic),
and 0.71 (Black).
– MD Comm striking
striking--0.83 Black, but 0.24 Hispanic and 0.08
API (language?)
• Region (HRR) explains only a little of this heterogeneity, except
for MD Comm, where it explains almost all (adding HRR, HRR
* r/e)
How do you convey such
information to consumers?
• Disparity information, or racial/ethnic specific health
experience information is typically presented to
researchers, policymakerspolicymakers- rarely directly to consumers
• Cognitive
C
i i testing
i suggests that
h many consumers do
d not
expect such information and may have difficulty
understanding its purpose
• CMS approach is likely to offer plan
plan--level results for a
given racial/ethnic group (e.g. CAHPS scores for Blacks
in individual MA plans) as a “drill
drill down option
option”
Conclusions--1
Conclusions
• Many
M
considerations
id ti
in
i reporting
ti Medicare
M di
CAHPS
experiences with specific plans by race/ethnicity
• 7 measures provide reliable measurement for Hispanics,
Blacks,, Whites,, and API with 100 (MA)
(
) or 200 ((PDP)) item
completes over two years
• Enough heterogeneity in plan quality by r/e for subgroup
reporting to be informative
Conclusions--2
Conclusions
• Blacks and Hispanics tend to be in worse plans and have worse
experiences within those plans
– Disparities are smaller but overall experiences not generally markedly
better in plans high in one’s own minority group
– The best WhiteWhite-majority plans may be among the best for minorities, even
in the presence of disparities
– Further research is needed to assess how minority experiences and
disparities are related to the cost of plans
– Variable disparities
p
suggest
gg QI
Q models as well as pplans needing
g
improvement
• Communication of such results to consumers inherently
challenging
Support
pp
• CMS: HHSM
HHSM--500
500--2005
2005--000281