Judy H. Ng

Managed Care, Primary Care, and the Patient‐practitioner Relationship

OBJECTIVES: This study examines how specific attributes of managed health plans influence patients’ relationships with their primary care practitioners (PCPs) and determines whether these effects are mediated by access to, continuity with, or perceived choice of PCPs. DESIGN, SETTING, PATIENTS: The data source was the nationally representative 1996/97 Community Tracking Study Household Survey (cumulative response rate 65%). The study population (N=19,415) was composed of 18- to 64-year-old adults whose most recent visit in the past 12 months was made to their primary care delivery site. MAIN OUTCOME MEASURE: Patients’ ratings of their interpersonal relationships with their PCPs as measured by a 7-item scale. RESULTS: Gatekeeping arrangements that require patients to select a primary care physician or obtain authorization for specialty referrals were associated with lower ratings of the patient-PCP relationship. Health plan use of a provider network had no effect on the patient-PCP scale score. Although there were no significant differences across any insurance payer categories, uninsured adults rated their relationships with PCPs as significantly poorer than did their insured counterparts. Shorter office waits, having a specific clinician at the primary care site, better perceived choice of PCPs, and a longer duration of relationship with the primary care practitioner were associated with higher ratings of the patient-PCP relationship. Perceived choice of primary care practitioners, but not access to or continuity with PCPs, attenuated some of the negative effects of gatekeeping arrangements on patients’ relationships with their primary care practitioners. CONCLUSIONS: Managed health plans that loosen restrictions on provider choice, relax gatekeeping arrangements, or promote access to and continuity with PCPs, are likely to experience higher patient satisfaction with their primary care practitioner relationships. Lack of health insurance impedes the development of patients’ relationships with their primary care practitioners.

Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) Performance With Outcomes of Enrollees With Diabetes

Background:Few quality of care evaluations examine the relationship between clinical processes and patient outcomes. Objective:To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes. Research Design:Secondary data analysis of 2002 HEDIS and 2001–2003 HOS data. Subjects:This study focused on Medicare plan enrollees with self-reported diabetes (N = 8184). Measures:Plan-level HEDIS diabetes care measures for 2002 and longitudinal, patient-level 2001–2003 HOS physical and mental health outcomes scores. Hierarchical linear models estimated the relationship between plan HEDIS performance on diabetes process of care and intermediate outcome measures and 2-year changes in enrollee HOS physical and mental health scores. Results:Each 10% point improvement in plan performance on HEDIS intermediate outcomes (ie, the proportion of well-controlled diabetes) was related to significant positive increase in the probability of being healthy as measured by both enrollee physical health scores (7 percentage point increase, P < 0.05) and mental health scores (11 percentage point increase, P < 0.01). Similar increases in plan process of care measures were associated with increases in the probability of being healthy as measured by enrollee mental health scores (11 percentage point increase, P < 0.001). Conclusions:This study represents one of the first attempts to link plan HEDIS performance to changes in enrollee health. The results suggest that improved quality of care, as measured by process and intermediate outcomes measures for diabetes, can result in better health among patients with diabetes. Further research should address whether this relationship exists in other quality measures, clinical conditions, and populations.

Predictors of voluntary disenrollment from Medicare managed care.

Background: Prior research on selection bias in Medicare plans has demonstrated favorable enrollment of healthier beneficiaries, resulting in plan overpayment. However, total selection bias depends not only on who enrolls, but also on who disenrolls. Few studies examine selectivity in disenrollment; it is unclear how those who leave plans differ from those who remain. Objective: The examination of health status and plan characteristics as potential predictors of voluntary disenrollment from Medicare managed care. Research Design: Baseline data on health of Medicare managed care enrollees are from the 1998 Medicare Health Outcomes Survey, merged with data on enrollment status and plan characteristics. Beneficiary voluntary disenrollment, versus continuous enrollment, 24 months after completing the survey was modeled as a function of perceived health in 1998 and plan characteristics. The sample included 109,882 community-dwelling elderly. Results: Between 1998 and 2000, 24% of Medicare managed care enrollees voluntarily disenrolled from plans. Poor perceived physical and mental health significantly increased the odds of voluntary disenrollment. Odds of disenrollment were higher for members of plans that increased premiums and had low market share between 1998 and 2000. Conversely, gaining drug coverage in a plan between 1998 and 2000 lowered the odds of disenrollment (relative to no coverage). Conclusion: Medicare plans experience favorable selection bias partly because sicker members are likelier to disenroll. Plan-level policies that influence market share and benefits, particularly pharmaceutical coverage, also have important effects on disenrollment, regardless of health effects. Understanding both individual and plan influences on disenrollment is critical to benefit coverage and disenrollment restriction (“lock in”) policies.

Self-Reported Delays in Receipt of Health Care among Women with Diabetes and Cardiovascular Conditions

PURPOSE Midlife and older adults have high rates of chronic conditions, and differences in health insurance coverage may affect their access to care. Women may be particularly at risk for access problems. This study examines the association of gender and health insurance status with delays in care, a dimension of access to care, among midlife (age 45-64) and older (age > or = 65) adults with diabetes and cardiovascular conditions. METHODS Data were from the 2004 through 2006 national Medical Expenditure Panel Survey. A total of 4,706 adults with self-identified diabetes and 17,636 adults with self-identified cardiovascular conditions, aged 45 years and older, were included. The analyses examined associations of gender and insurance status with self-reported delays in medical care, dental care, prescription medication, and illness/injury care, using bivariate and multivariate analyses adjusted for race/ethnicity, education, income, and perceived health status. MAIN FINDINGS Midlife women with diabetes or cardiovascular conditions were more likely to report delays in care than men, even after adjusting for key factors (85%-111% higher odds of delays among diabetes patients, 56%-84% higher odds of delays among cardiovascular patients; all p < .01). Many, but not all, of these gender differences were eliminated among Medicare-insured older adults. Among midlife adults, health insurance coverage differences were also significantly associated with delays in care. CONCLUSION Women are more likely to experience delays in health care, even after adjusting for health coverage. Efforts are needed to understand factors that influence gender differences in these delays and to determine whether policy reforms eliminate or exacerbate these differences.

Shortening a Patient Experiences Survey for Medical Homes.

The Consumer Assessment of Healthcare Providers and Systems—Patient-Centered Medical Home (CAHPS PCMH) Survey assesses patient experiences reflecting domains of care related to general patient experience (access to care, communication with providers, office staff interaction, provider rating) and PCMH-specific aspects of patient care (comprehensiveness of care, self-management support, shared decision making). The current work compares psychometric properties of the current survey and a proposed shortened version of the survey (from 52 to 26 adult survey items, from 66 to 31 child survey items). The revisions were based on initial psychometric analysis and stakeholder input regarding survey length concerns. A total of 268 practices voluntarily submitted adult surveys and 58 submitted child survey data to the National Committee for Quality Assurance in 2013. Mean unadjusted scores, practice-level item and composite reliability, and item-to-scale correlations were calculated. Results show that the shorter adult survey has lower reliability, but still it still meets general definitions of a sound survey for the adult version, and resulted in few changes to mean scores. The impact was more problematic for the pediatric version. Further testing is needed to investigate approaches to improving survey response and the relevance of survey items in informing quality improvement.

Identifying older adults at high risk of mortality using the Medicare health outcomes survey.

The Vulnerable Elders Survey (VES), a screening tool for at-risk elderly, has been validated in the community. This study used VES-based criteria to develop a modified version that can be calculated from the Medicare Health Outcomes Survey (HOS) to identify Medicare members at high risk of mortality. Data were from 97,258 HOS respondents in 164 plans. Using age, self-rated health, and function items from the 2005 HOS, an a priori approach modeled on VES scoring and items predicted two-year mortality (c-statistic 0.74). Routinely-collected Medicare survey data may be used to assess patterns of enrollment of high-risk beneficiaries across health plans.

Data On Race, Ethnicity, And Language Largely Incomplete For Managed Care Plan Members

The Affordable Care Act requires the federal government to collect and report population data on race, ethnicity, and language needs to help reduce health and health care disparities. We assessed data availability in commercial, Medicaid, and Medicare managed care plans using the Healthcare Effectiveness Data and Information Set. Data availability varied but remained largely incomplete.

Health Quality Measures Addressing Disparities in Culturally and Linguistically Appropriate Services: What are Current Gaps?

Abstract:Purpose. Disparities in health care persist among many at-risk groups. This study examines the current state of health quality measures addressing disparities and culturally and linguistically appropriate services (CLAS), and identifies important gaps in existing measures and their implementation. Methods. We searched key quality reporting databases and websites to identify measures and structural program requirements addressing disparities or CLAS. We also conducted a dozen semi-structured interviews to obtain expert perspectives. Results. Twenty-four measures and eight private or public-sector programs with relevant structural requirements were identified. Half the measures focused on language needs. Few measures were used in national reporting programs and adoption of requirements has been limited. Barriers to implementation included lack of data among health plans, lack of health workforce training, and challenges in defining cultural competence. Conclusions. Future efforts should seek to enhance implementation of existing quality measures addressing disparities and CLAS, and address barriers to their adoption.

Few Disparities in Baseline Laboratory Testing After the Diuretic or Digoxin Initiation by Medicare Fee-For-Service Beneficiaries

Background—Despite the persistence of significant disparities, few evaluations examine disparities in laboratory testing by race/ethnicity, age, sex, Medicaid eligibility, and number of chronic conditions for Medicare fee-for-service beneficiaries’ newly prescribed medications. In Medicare beneficiaries initiating diuretics or digoxin, this study examined disparities in guideline-appropriate baseline laboratory testing and abnormal laboratory values. Methods and Results—To evaluate guideline-concordant testing for serum creatinine and serum potassium within 180 days before or 14 days after the index prescription fill date, we constructed retrospective cohorts from 10 states of 99 711 beneficiaries who had heart failure or hypertension initiating diuretic in 2011 and 8683 beneficiaries who had heart failure or atrial fibrillation initiating digoxin. Beneficiaries initiating diuretics were less likely to have testing if they were non-Hispanic Black (relative risk [RR], 0.99; 95% confidence interval [CI], 0.98–0.99) than non-Hispanic White. Beneficiaries initiating diuretics and beneficiaries initiating digoxin were more likely to have testing if they had multiple chronic conditions relative to 0 to 1 conditions. Beneficiaries initiating diuretics with laboratory values were more likely to have an abnormal serum creatinine value at baseline if they were non-Hispanic Black (RR, 2.57; 95% CI, 1.91–3.44), other race (RR, 2.11; 95% CI, 1.08–4.10), or male (RR, 2.75; 95% CI, 2.14–3.52) or an abnormal serum potassium value if they were aged ≥76 years (RR, 1.29; 95% CI, 1.09–1.51) or male (RR, 1.17; 95% CI, 1.03–1.33). Conclusions—Testing rates were consistently high, so there were negligible disparities in guideline-concordant testing of creatinine and potassium after the initiation of digoxin or diuretics by Medicare beneficiaries.