Health plan characteristics and consumers' assessments of quality.

Many purchasers and consumers of health care have become concerned about the quality of care being delivered in managed care plans. Little is known, however, about the health plan characteristics that are associated with better performance. We used survey responses from 82,583 Medicare beneficiaries from 182 health plans to study the association of consumers' assessments of care with health plan characteristics. For-profit and nationally affiliated health plans received much worse scores on the outcomes of interest, particularly for overall ratings of the health plan and composite measures of customer service and access to care. Health plans accredited by the National Committee for Quality Assurance did not receive higher scores.

Development of a consumer survey for behavioral health services.

A consumer survey was designed to assess the quality of mental health and substance abuse services and evaluate insurance plans that provide such services. This paper describes the development of the Consumer Assessment of Behavioral Health Services instrument, which began with a review of existing consumer satisfaction surveys and input from several groups working toward development of nationally standardized satisfaction instruments. Consumer focus groups were used to ensure that all the important domains of quality were included, and group members were interviewed to ensure that all items on the instrument were understandable. Results of a pilot test conducted with 160 consumers, 82 enrolled in Medicaid plans and 78 in commercial plans, suggested that the survey was able to distinguish between the two groups in terms of evaluations of their care and insurance plans. Future efforts will focus on further testing of larger, more diverse samples and on developing scoring and reporting formats for the survey that will be useful to consumers and purchasers in choosing behavioral health services and plans.

Toward a national consumer survey: evaluation of the CABHS and MHSIP instruments.

This article describes a study evaluating the Consumer Assessment of Behavioral Health Survey (CABHS) and the Mental Health Statistics Improvement Program (MHSIP) surveys. The purpose of the study was to provide data that could be used to develop recommendations for an improved instrument. Subjects were 3,443 adults in six behavioral health plans. The surveys did not differ significantly in response rate or consumer burden. Both surveys reliably assessed access to treatment and aspects of appropriateness and quality. The CABHS survey reliably assessed features of the insurance plan; the MHSIP survey reliably assessed treatment outcome. Analyses of comparable items suggested which survey items had greater validity. Results are discussed in terms of consistency with earlier research using these and other consumer surveys. Implications and recommendations for survey development, quality improvement, and national policy initiatives to evaluate health plan performance are presented.

Hip arthroplasty in mentally impaired patients.

The outcome of elective hip arthroplasty in 11 mentally impaired patients was compared with a cohort of 244 mentally competent patients. The impaired patients had a diagnosis of cerebral palsy, schizophrenia, or Down's syndrome, and were unable to give their own surgical consent. Major complications requiring additional surgery occurred in 5 of the mentally impaired patients. Three patients sustained fractures of the femur below the stem and were treated with plating, 1 developed a deep infection requiring prosthesis removal, and 1 developed a thoracic decubiti with bone involvement requiring debridement and rotation flap coverage. Three of these patients also developed urinary tract infections. Of the other 6 mentally impaired patients, 3 developed urinary tract infections, and 1 had a deep venous thrombosis. Functional independence was improved after surgery in the mentally impaired patients. However, the average cost of hospitalization, length of stay, and complication rate were significantly higher (p < 0.05) than those of the mentally competent patients.

Providing consumers with information about the quality of health plans: the Consumer Assessment of Health Plans demonstration in Washington State.

BACKGROUND: In 1995 the Agency for Health Care Policy and Research began a five-year project, Consumer Assessment of Health Plans (CAHPS), to create instruments to collect data from consumers about their health care experiences, to develop sophisticated methods to convey these data to consumers, and to evaluate the value of these data to consumers who are selecting health plans. Results were obtained from one of the first CAHPS demonstration sites, the Washington State Health Care Authority. METHODS: The survey was distributed in May-June 1997 to 15,885 enrollees in 20 health plans; 8,204 (51.6%) surveys were completed. Survey results were summarized in a report that described the performance of plans, which was distributed to 97,000 enrollees, and reactions to the report were obtained from more than 1,500 individuals. RESULTS: Nearly everyone who was mailed the report said they saw it. A large proportion said they read most or all of it, and most thought the report was easy to understand, contained information needed to rate plans, and was helpful to learning about differences between plans. Those who used the CAHPS performance report were more likely to switch plans and to report that they were confident they had selected the best plan for their situation. DISCUSSION: The study was unique in that it attempted to evaluate whether employees read the performance report, how they reacted to it, and whether reading it influenced their decision to switch plans or their confidence that they had selected a suitable plan. Choosing a new plan probably stimulated more intense scrutiny of the report than not anticipating switching.

The impact of having parents report about both their own and their children's experiences with health insurance plans.

OBJECTIVES: The aim of this study was to determine whether parents rate their children's care differently when they also rate their own care than when they do not. METHODS: Subjects were employees of Washington State who had been enrolled in a health plan for at least 6 months and who had at least one covered child. Subjects were randomly assigned to four study groups that were surveyed using different protocols. To assess the stability of responses over time, a follow-up telephone interview was conducted with individuals in two of the groups. RESULTS: Parents or guardians who received both the Adult and Child Surveys were less likely to complete a survey than those who received only one survey. Responses to selected survey questions were quite stable between survey administrations. Parents who rated only their child's health care experiences generally gave more positive responses than those who also rated their own care, although few of these differences were statistically significant. This may have been due, in part, to the lower response rates in the latter group. The pairs of survey questions that ask about the adult's and child's experiences with the same aspects of care had moderate to high levels of association. The pair with the weakest association asked how clearly the doctor or nurse explained things to the adult or the child. CONCLUSIONS: Sending both an adult and child survey to an adult could have an effect on the pattern of responses and result in lower response rates, but this might be a cost-effective way to collect reports about both adult and child health care.

Psychometric properties of the CAHPS 1.0 survey measures. Consumer Assessment of Health Plans Study.

OBJECTIVES: Consumer surveys are being used increasingly to assess the quality of care provided by health plans, physician groups, and clinicians. The purpose of the Consumer Assessment of Health Plans Study (CAHPS) is to develop an integrated and standardized set of surveys designed to collect reliable and valid information about health plan performance from consumers. This article reports psychometric results for the CAHPS 1.0 survey items in samples of individuals with Medicaid or private health insurance coverage. METHODS: Reliability estimates for CAHPS 1.0 measures were estimated in a sample of 5,878 persons on Medicaid and 11,393 persons with private health insurance. Correlations of the CAHPS global rating of the health plan with willingness to recommend the plan and intention to re-enroll were estimated in a sample of 313 persons on Medicaid. The association of the rating of the health plan with ratings using a 5-point Excellent-to-Poor response scale also was investigated in the latter sample and in a sample of 539 persons with private health insurance. RESULTS: The CAHPS measures appeared to have good reliability, particularly at the health-plan level. Responses from 300 consumers per health plan tend to yield estimates that are reliable enough for health plan comparisons, especially among the privately insured. The global health plan rating was significantly correlated with consumers' willingness to recommend the plan to family and friends and to their intention to re-enroll in the plan if given a choice. CONCLUSIONS: The CAHPS 1.0 survey instrument appears to have excellent psychometric properties.

Use of consumer ratings for quality improvement in behavioral health insurance plans.

BACKGROUND: The Consumer Assessment of Behavioral Healthcare Services (CABHS) survey collects consumers' reports about their health care plans and treatment. The use of the CABHS to identify opportunities for improvement, with specific attention to how organizations have used the survey information for quality improvement, is described. METHODS: In 1998 and 1999, data were collected from five groups of adult patients in commercial health plans and five groups of adult patients in public assistance health plans with services received through four organizations (one of three managed behavioral health care organizations or a health system). Patients who received behavioral health care services during the previous year were mailed the CABHS survey. Non-respondents were contacted by telephone to complete the survey. RESULTS: Response rates ranged from 49% to 65% for commercial patient groups and from 36% to 51% for public assistance patients. Promptly getting treatment from clinicians and aspects of care most influenced by health plan policies and operations, such as access to treatment and plan administrative services, received the least positive responses, whereas questions about communication received the most positive responses. In addition, questions about access- and plan-related aspects of quality showed the most interplan variability. Three of the organizations in this study focused quality improvement efforts on access to treatment. DISCUSSION: Surveys such as the CABHS can identify aspects of the plan and treatment that are improvement priorities. Use of these data is likely to extend beyond the behavioral health plan to consumers, purchasers, regulators, and policymakers, particularly because the National Committee for Quality Assurance is encouraging behavioral health plans to use a similar survey for accreditation purposes.