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The American Journal of Managed Care April 2015
Clinical Provider Perceptions of Proactive Medication Discontinuation
Amy Linsky, MD, MSc; Steven R. Simon, MD, MPH; Thomas B. Marcello, BA; and Barbara Bokhour, PhD
Optimizing the Use of Telephone Nursing Advice for Upper Respiratory Infection Symptoms
Rosalind Harper, PhD, RN; Tanya Temkin, MPH; and Reena Bhargava, MD
Redefining and Reaffirming Managed Care for the 21st Century
David Blumenthal, MD, MPP; and David Squires, MA
Managing Specialty Care in an Era of Heightened Accountability: Emphasizing Quality and Accelerating Savings
John W. Peabody, MD, PhD, DTM&H; Xiaoyan Huang, MD; Riti Shimkhada, PhD; and Meredith Rosenthal, PhD
Antibiotic Prescribing for Respiratory Infections at Retail Clinics, Physician Practices, and Emergency Departments
Ateev Mehrotra, MD, MPH; Courtney A. Gidengil, MD, MPH; Claude M. Setodji, PhD; Rachel M. Burns, MPH; and Jeffrey A. Linder, MD, MPH
Persistent High Utilization in a Privately Insured Population
Wenke Hwang, PhD; Michelle LaClair, MPH; Fabian Camacho, MS; and Harold Paz, MD, MS
Currently Reading
Self-Efficacy in Insurance Decision Making Among Older Adults
Kathleen Kan, MD; Andrew J. Barnes, PhD; Yaniv Hanoch, PhD; and Alex D. Federman, MD, MPH
Observation Encounters and Subsequent Nursing Facility Stays
Anita A. Vashi, MD, MPH, MHS; Susannah G. Cafardi, MSW, LCSW, MPH; Christopher A. Powers, PharmD; Joseph S. Ross, MD, MHS; and William H. Shrank, MD, MSHS
Elderly Veterans With Dual Eligibility for VA and Medicare Services: Where Do They Obtain a Colonoscopy?
Ashish Malhotra, MD, MS; Mary Vaughan-Sarrazin, PhD; and Gary E. Rosenthal, MD
Costs of Venous Thromboembolism Associated With Hospitalization for Medical Illness
Kevin P. Cohoon, DO, MSc; Cynthia L. Leibson, PhD; Jeanine E. Ransom, BA; Aneel A. Ashrani, MD, MS; Tanya M. Petterson, MS; Kirsten Hall Long, PhD; Kent R. Bailey, PhD; and John A. Heit, MD
Binary Measures for Associating Medication Adherence and Healthcare Spending
Pamela N. Roberto, MPP; and Eberechukwu Onukwugha, PhD
Functional Status and Readmissions in Unilateral Hip Fractures
Paul Gerrard, MD; Richard Goldstein, PhD; Margaret A. DiVita, PhD; Chloe Slocum, MD; Colleen M. Ryan, MD; Jacqueline Mix, MPH; Paulette Niewczyk, PhD, MPH; Lewis Kazis, ScD; Ross Zafonte, DO; and Jeffrey C. Schneider, MD

Self-Efficacy in Insurance Decision Making Among Older Adults

Kathleen Kan, MD; Andrew J. Barnes, PhD; Yaniv Hanoch, PhD; and Alex D. Federman, MD, MPH
Older adults who prefer to delegate insurance decisions tend to be female and married, to have less Medicare knowledge, and to have someone in their lives they trust to make decisions for them.
The aim was to understand older adults’ self-efficacy with insurance decision making by examining their preferences for delegating insurance decisions to others.

Study Design: Cross-sectional analysis of data from an observational cohort study. Methods: English- and Spanish-speaking adults aged ≥60 years were recruited and interviewed in residential and senior center locations in New York City neighborhoods with median annual household incomes <$50,000. The analyses included the subset of individuals 65 years and older and without Medicaid. Self-efficacy in insurance decision making was measured with a 7-item assessment of perceived understanding of Medicare, preferences for decision support, and decision-making anxiety. We used multivariable linear regression to examine the association of self-efficacy with subject characteristics, including sociodemographics, insurance coverage, and health and functional status.

Results: Among the 250 subjects, 55% were aged ≥75 years, 29% were black, and 33% were Hispanic. Half (53%) reported difficulty understanding insurance information and concern (45%) about making wrong insurance choices, yet 89% preferred to make decisions themselves. In adjusted analysis, greater decision-making self-efficacy was associated with male gender (P = .02), higher educational attainment (P = .04), better health (P = .0003), greater Medicare knowledge (P = .0002), and lack of a spouse or partner (P = .04) or any person who they trust to assist with decision making (P <.0001).

Conclusions: Most older adults preferred to make insurance decisions themselves while also wanting to receive advice, and those who preferred to delegate decisions had less Medicare knowledge. Programs that support insurance decisions among older adults should identify clients who prefer delegating decisions and have the right support available to them.

Am J Manag Care. 2015;21(4):e247-e254
Older adults often prefer to delegate the selection of health plans. Those with that preference have poorer health, less education, and less knowledge of Medicare. They also tend to have a spouse and/or another person in their lives that they trust to make decisions for them.
  • This research extends existing knowledge by identifying the characteristics of older adults who prefer to delegate decisions about insurance coverage.
  • This information can be used by managed care decision makers to design programs that meet the decision support needs of their current and potential beneficiaries.
  • Such programs should be designed to promote confidence and trust.
Older Americans face a large number of health and prescription plan options through Medicare. In 2013, there were an estimated 37.5 million older adults enrolled in a Medicare Part D plan—two-thirds of them in a stand-alone prescription drug plan (PDP), and the remaining in a Medicare Advantage plan.1 In 2014, 1169 PDPs were offered nationwide, and on average, beneficiaries chose from 35 stand-alone plans.1 The vast number of choices in health and prescription plan options may enhance opportunities to obtain plans of higher quality at competitive costs, but also presents a challenge to informed decision making.2,3 Research shows that having many options to choose from increases the complexity of the decision-making process, affects the decision strategy utilized, and can result in suboptimal decision making.4-6 This may be a particularly challenging problem for older adults, in whom limitations in literacy and numeracy are fairly prevalent and significant.4,5 Further, multi-morbidity and polypharmacy add to the complexity of plan selection.4,5,7-12

The combination of a daunting array of insurance options, complex personal needs to consider (eg, provider choice, formularies, affordability), and barriers to understanding coverage options (eg, limited health literacy) may diminish an individual’s self-efficacy regarding his or her health insurance or prescription coverage decisions. Within the reasoned action framework, self-efficacy (or control), attitude, and social norms determine intentions, which ultimately influence behavior.13 Health literacy is a faculty realized in Medicare knowledge that affects self-efficacy, potentially influencing decision-making behaviors about insurance coverage. Self-efficacy—or the belief in one’s ability to organize and execute the courses of action needed to manage new situations—is a situation-specific internal evaluation14 and is associated with a wide range of behaviors.15 For example, older adults with high self-efficacy expectations are more likely to engage in positive health behaviors such as exercising and maintaining a low-fat diet.16 Similarly, an individual with high self-efficacy regarding insurance plan selection may be more likely to seek out information and take steps proactively to optimize their coverage. On the other hand, those with low self-efficacy may be more likely to delegate decisions about coverage
to others.

A preference for delegating insurance decisions to others may place individuals at greater risk of obtaining inadequate coverage upon initial enrollment, particularly if those assisting them are also not experts. Additionally, these individuals may be less likely to switch plans during open enrollment when their healthcare needs or current plan benefits change. However, whether older adults are “self-effective” decision makers, and how self-efficacy relates to the quality of the insurance choices they make, remain open questions. To inform this critical gap, we examined preferences for delegating insurance decisions in a cohort of community-dwelling older adults in New York City along with characteristics that might be associated with these preferences, including low health literacy.17

We examined perceived self-efficacy in prescription drug insurance decision making among independently living, English- and Spanish-speaking adults aged ≥60 years in Manhattan, New York City. Participants were recruited from 30 community-based settings, including 11 senior centers and 19 Naturally Occurring Retirement Communities (so designated by the New York City Department for the Aging) in zip code areas with median household incomes below $50,000. Senior centers were identified through New York City Department for the Aging listings, and federally supported low-income housing facilities were identified using a listing from the US Department of Housing and Urban Development. Each adult received $20 for a baseline interview and $20 for a follow-up interview—both were performed in English or Spanish by bilingual interviewers. For the purpose of this analysis, we excluded participants with Medicaid because New York state auto-assigns Medicaid beneficiaries to health plans and those below age 65 because we were focused on decision making among Medicare beneficiaries.

The study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai, and written informed consent was obtained from all participants prior to the start of interviews. The funding organization had no role in the collection of data, its analysis or interpretation, or in the right to approve or disapprove publication of the finished manuscript.

Outcome Measures
The study’s main outcome is a validated measure of self-efficacy in insurance decision making.18,19 The 7 items in the survey address understanding of Medicare materials, individuals’ preferences for support when making insurance decisions, and anxiety associated with decision making. Self-efficacy contains 2 subdomains: capacity, the belief that one has the ability to accomplish a task; and autonomy, the belief that accomplishing the task is “up to you.”13 In our self-efficacy scale, items such as “I have difficulty understanding information about my health insurance” appear to reflect the capacity domain, while items such as “I would prefer to make decisions about my health insurance with the help of someone in my family” reflect aspects of the autonomy domain.13 Each question had 5 response options ranging from strongly agree to strongly disagree. Responses to all questions were summed to create a summary score of overall self-efficacy, with higher scores indicating greater preference for delegating decisions.

We also assessed subjects’ knowledge of the Medicare program with 9 true-or-false questions.18 These items required participants to identify Medicare fee-for-service and Medicare Advantage covered services (ie, mammography, prostate-specific antigen testing, flu shots), plan selection options, costs associated with fee-for-service Medicare and Medicare Advantage plans, prescription coverage, premium support, and access to clinicians. Correct answers were summed to provide an overall knowledge score.

Independent Variables
We included various measures that are associated with self-efficacy and which we hypothesized would be associated with a preference to delegate insurance decisions.14,20-23 These variables fell into demographic and experiential categories. Demographic characteristics included age, gender, race and ethnicity, English speaking ability, education, and health literacy. Health literacy was assessed with the Short Test of Functional Health Literacy in Adults (S-TOFHLA)24—a 36-item reading and 4-item numeracy assessment. There are 2 timed (7-minute) clinically oriented reading passages that omit key words and phrases from sentences, and the study participant chooses from 4 options to correctly complete the sentence. The numeracy section assesses the patient’s ability to read health information, such as that found on a prescription label, and to interpret numerical information. Overall scores range from 0 to 100. We dichotomized health literacy as adequate (score ≥67) or marginal and low (score <67).25 The S-TOFHLA has been validated for use in both English and Spanish.24

Experiential variables included current insurance coverage. The source of the primary insurance coverage was determined by the research assistant who reviewed the subjects’ insurance and prescription cards at the time of the interview. Coverage was categorized as traditional Medicare (fee-for-service), Medicare Advantage (private Medicare plan), and employer-sponsored or self-purchased insurance (excluding Medigap plans). Participants were also asked whether they knew of someone they could trust to help them if they needed help making a health insurance decision.

To further characterize study participants, we also assessed health status with a measure of general health, as well as number of chronic diseases and medications, history of hospitalization and emergency department (ED) use, and functional status. Functional status was measured using the basic and instrumental Activities of Daily Living (ADL and IADL, respectively) scales.26

Our analyses focused on the subset of individuals who were 65 years and older and did not have Medicaid as their primary source of coverage. We calculated Cronbach’s alpha to determine the inter-item correlation for the self-efficacy scale in the study sample. Since the scale was normally distributed, we conducted univariate analysis of the self-efficacy scale with subject characteristics using the t test or analysis of variance. Key variables of interest were then included in linear regression models. Post hoc model diagnostics found no evidence of collinearity among our regressors. All analyses were conducted with SAS version 9.3 (SAS Institute, Cary, North Carolina).

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