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The American Journal of Accountable Care June 2016
A Hospital Discharge Navigation Program: The Positive Impact of Facilitating the Discharge Navigation Process
Sayeh Bozorghadad, BS; James Dove, BA; Leah Scholtis, PA-C; Chung-Yin Sherman, CRNP; Joseph Blansfield, MD; Marie Hunsinger, RN, BSHS; Anthony Petrick, MD; and Mohsen Shabahang, MD, PhD
A Novel Nursing-Driven Standardized Diabetes Education Process in Primary Care
Carlos E. Mendez, MD; Ashar Ata, MBBS, MPH, PhD; Joanne M. Rourke, NP, CDE; David Greenawalt, PhD; and Jorge Calles-Escandón, MD
The Pediatric Medical Home: What Do Evidence-Based Models Look Like?
Bita Kash, PhD, MBA, FACHE; Debra Tan, MPH; Katherine Tittle, MS, RN, FACHE; and Lesley Tomaszewski, PhD, MS
The Ingredients of Success in a Medicare Accountable Care Organization
Peter A. Gross, MD; Mitchel Easton, BS; Edward Przezdecki, MBA; Morey Menacker, DO; Edward Gold, MD; Vinita Chauhan, MBA, PhD; Juliana Hart, BSN, MPH; Ihor Sawczuk, MD; Robert C. Garrett, MPH; and Robert L. Glenning, CPA
The Hidden Value of Behavioral Health
John Santopietro, MD, DFAPA
Launching a Payer Venture and Innovation Group: Options and Trade-Offs
Ezra Mehlman, MBA
Better Integration to Improve Care Outcomes Highlighted at AJMC's ACO Coalition
Laura Joszt, MA
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What Performance Measures Do Consumers Find Useful When Selecting Marketplace Health Plans?
William Encinosa, PhD; Chun-Ju Hsiao, PhD; Kirsten Firminger, PhD; Jennifer Stephens, MPH; Lise Rybowski, MBA; and Kourtney Ikeler, BA

What Performance Measures Do Consumers Find Useful When Selecting Marketplace Health Plans?

William Encinosa, PhD; Chun-Ju Hsiao, PhD; Kirsten Firminger, PhD; Jennifer Stephens, MPH; Lise Rybowski, MBA; and Kourtney Ikeler, BA
Marketplace consumers desire more health plan measures on how well plans support long-term patient—physician relationships. Consumers are skeptical of measures about rewarding providers for high quality.

As the marketplaces prepare to report mandatory health plan quality information in the 2018 season, it is critical to explore what consumers view as crucial when choosing a health plan.

Study Design: Four focus groups were selected from marketplace plans and from the uninsured to cover 4 populations: 1) healthy and aged 18 to 34 years (young), 2) healthy and aged 35-64 years, 3) aged 18 to 64 years with at least 1 chronic condition, and 4) aged 18 to 64 years with low income.

Methods: Within the focus groups, we explored consumers’ ability to use measures from eValue8, the leading tool that large employers use to compare and select health plans.

Results: We found that consumers have different views of health plan measures compared with employers. First, consumers care most about measures indicating how well plans support long-term patient–physician relationships—many plan measures were seen to be intrusive in this relationship. Second, consumer distrust of health plans made them skeptical of many value-based purchasing measures preferred by employers, such as rewarding providers for high quality. Consumers do not like plans interfering with medical care.

Conclusions: Overall, new types of measures are needed to enable consumers to make an informed health plan selection in the marketplaces.
By July 2015, 7.2 million consumers had purchased coverage through the 37 federally facilitated marketplaces and federally supported state-based marketplaces, and 2.7 million purchased coverage through the remaining state-based marketplaces.1 For many of these consumers, choosing a health plan can be a daunting task, especially since most of the marketplaces offer a wide array of plan choices. For example, in the 2016 Maryland Health Connection, each county offers a 40-year-old enrollee a choice between 31 and 49 health plans provided by 5 carriers.2

To aid consumers, all marketplace websites are required to start providing consumers with plan quality ratings during the enrollment period for 2018 coverage.3 These ratings will come from plan data submitted to the federal Quality Reporting System (QRS), which, in 2016, will report 1 aggregate star rating for each carrier’s plan type, based on 31 clinical measures and patient experience measures.4,5 Although the QRS serves as a base of important performance measures for the marketplaces, many state-based marketplaces may also desire to report on a broader set of performance measures, as 9 states did in 2014.6

The vast number of available detailed measures raises the question of what consumers need in order to best compare health plans. Historically, employers develop health plan choices for employees, and many large employers are experienced in selecting measures for the comparison of health plans. One prime example is the National Business Coalition on Health (NBCH), which represents over 4000 employers and approximately 35 million employees and their dependents.7 Working with large healthcare purchasers, such as Marriott and General Motors, the NBCH has collected a large set of health plan performance measures to help employers develop the choice of health plans for their employees. This set of measures, known as eValue8 (eV8), has hundreds of detailed plan measures to guide employers in making wise, value-based purchasing decisions, and to save their employees from having to digest a lot of the complicated business and medical details needed to compare plans.8

There is a debate over what would be an optimal set of performance measures that consumers could reasonably use on their own to compare health plans if such large employers were not serving as intermediaries in the marketplaces. To address this issue, we take a first step in this paper by reporting on the Agency for Healthcare Research and Quality’s (AHRQ) research results from focus groups of marketplace consumers and the uninsured to assess what information they would want to know when comparing health plans. In particular, various employer eV8 plan performance measures were tested for use among consumers. We highlight how large employers and marketplace consumers have differing perspectives on the healthcare system and how this may impact health plan comparisons. Overall, our results may help bridge this gap in terms of transforming sophisticated performance measures from a purchaser-centric use to a very consumer-centered focus in the marketplaces.


Study Population

We worked with 2 firms to recruit participants in the Baltimore, Maryland, and Raleigh, North Carolina, areas. All participants either 1) had purchased a health insurance plan through their local marketplace during the 2013 to 2014 open enrollment season, or 2) were currently uninsured. Four target populations were selected to reflect the marketplace enrollees’ traditionally hard-to-reach populations, as well as a diverse marketplace risk pool9: 1) young (aged 18-34 years) and healthy (must not have been diagnosed with any chronic health condition), 2) healthy and aged 35 to 64 years; 3) adults aged 18 to 64 years with at least 1 chronic condition, and 4) adults aged 18 to 64 years with low income. See Table 1 for sample demographics.

Materials for Testing

We selected and organized the 2014 eV8 measures in a way that could be understandable to consumers. Out of 280 eV8 measures, 237 were selected for inclusion based on systematic evaluation of the relevance and possible use in consumer health plan decision making. Along with these eV8 measures, we included additional topics that might help consumers select a health plan. To reduce the amount of information needed to be processed by consumers, individual measures and topics were organized into domains. The domains were then grouped by theme into the following 7 modules for focus group testing: 1) providing customer service and information about the health plan, 2) rewarding doctors and hospitals that provide the best care, 3) helping members get the care they need, 4) supporting communication about members’ care across different providers, 5) helping members prevent and manage health issues, 6) helping members make decisions based on quality and cost, and 7) helping members get the right care at the right time. The development of the displays for each module and domain was based on the principle of plain language to generate consumer-friendly labels.10

Focus Groups

We conducted 4 focus group discussions, with a total of 36 participants. The moderator first asked the participants to explain what a health plan is in their own words, what the health plans do, and how they might evaluate health plans. Next, the moderator presented a short overview about quality measurement in general and the eV8 measures specifically. The moderator explained how this information may be used to help individuals to select health plans. Subsequently, participants reviewed a summary page with ratings for all 7 modules being tested. They were asked what the display told them about the health plans, their understanding and interpretation of consumer-friendly labels and quality rating display, and which 3 modules were most important.

After viewing the summary page with all 7 modules, the participants were asked to look at detailed display ratings for the domains under the selected modules. The participants were again asked what the more detailed displays told them about the health plans, their understanding and interpretation of the domains within each module, whether each domain fit within the module, the importance of each domain, and whether any topics were missing from the module. After reviewing 1 or 2 modules in depth, the participants revisited the overall list of modules to see if any changed their mind about the interpretation or importance of the modules.


Table 2 shows what consumers voted as the top 3 modules that they thought were most important in choosing a health plan. The order of the rankings breaks into 3 distinct groups: Costs and Quality, Access and Quality, and Quality Incentives. The module that addressed Costs and Quality had the highest ranking, with 75% of the consumers agreeing that the module, “Helping members make decisions based on quality and cost,” was among the 3 modules most important in choosing a plan. The second group of important modules addressed the concept of Access and Quality: “Helping members get the care they need” (61%), “Helping members prevent and manage health issues” (56%), and “Providing customer service and information about the health plan” (56%). Finally, the modules that focused on Quality Incentives received the least amount of votes, and included “Supporting communication about members’ care across different providers” (31%), “Helping members get the right care at the right time” (17%), and “Rewarding doctors and hospitals that provide the best care” (3%).

To understand these rankings, we performed deep dives within the focus groups. Not surprisingly, participants from each focus group agreed that cost is the deciding factor: “it all comes down to cost.” This is well known in the literature11-16; however, what is new here is that we observed 2 surprising implications of the consumers’ struggle to manage high out-of-pocket costs. First, we found that consumers view the selection of a health plan as a “long-term investment” in their healthcare that protects them from large, unexpected healthcare bills and as supporting the physician–patient relationship. Second, because overall healthcare costs are so persistently high and viewed by some consumers as being the result of profit-taking in the healthcare industry, a segment of consumers have a “deep distrust” in health plans and any type of incentive scheme to improve quality. For these participants, incentives are just an added cost that they end up paying for without sharing in the cost savings. These 2 contrasting concepts—long-term investment motives and deep distrust—influence how consumers view measures of health plan performance.


Measures That Enable Long-Term Patient–Physician Relationships

What do consumers think they are investing in for the long run through a health plan? Many are seeking a long-term personal relationship with a physician; the uninsured and marketplace consumers are not interested only in catastrophic plans. Here, when consumers voted for the top 3 of 8 domains of interest in the module “Helping members prevent and manage health issues,” they voted overwhelmingly for the domain “Members get the care they need for their long-lasting health problems” (89%) compared with the low-scoring catastrophic care measure domain, “Members get the health services and support for major life events” (33%). Costs seem to be a driving factor in this ranking. As one participant noted, premiums for catastrophic plans are nowadays just as expensive as regular health plans. Another participant mentioned that one saves money in the long run by focusing on long-term health needs and prevention. Some consumers had specific experiences with this issue, with one noting that his past catastrophic plan would pay for a leg amputation for diabetes, but not cover his long-term use of an insulin pump.

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