Consumer Willingness to Make Trade-offs to Obtain Higher Performing Health Plans

Judith Hibbard's presentation "Consumer Willingness to Make Trade-offs to Obtain Higher Performing Health Plans" presented at the March 2000 conference "Quality from the Consumer Perspective" suggests that consumers responded more effectively to messages that were framed in a negative way versus in a positive way.

The conference was sponsored by the Agency for Healthcare Research and Quality and the Health Care Financing Administration.

Judith Hibbard, Dr.P.H.; University of Oregon
Lauren Harris-Kojetin, Ph.D.; Research Triangle Institute
Paul Mullin, Ph.D.; Research Triangle Institute
James Lubalin, Ph.D.; Lubalin Associates
Steve Garfinkel, Ph.D.; Research Triangle Institute

CAHPS® is funded by the Agency for Healthcare Research and Quality.

Presented March 10, 2000, at the “Quality from the Consumer Perspective” conference, sponsored by AHRQ and HCFA.

Research Questions

• Does a decision frame that emphasizes a potential risk or loss have a greater impact on consumers’ comprehension, valuing, and use of comparative information in decisions, over a decision frame that emphasizes a potential gain?
• Is the effect of risk avoidance framing dependent on the inclusion of elaboration messages that provide a rationale for use and directions on how to use the information?

Random assignment into one of four conditions

Risk avoidance message:

• Compare your health plan choices.
• You could be at risk for lower quality care.
• Use this guide to choose a health plan where people had fewer problems.

Gain maximizing message:

• Compare your health plan choices.
• You can get high quality.
• Use this guide to choose a health plan with high quality care and services.

Risk avoidance message:

• Protect yourself.
• You could be at risk for lower quality care from your health plan.

Gain maximizing message:

• Get the best.
• Health plan quality from the consumer’s point of view.

Models

Gain Maximizing, Unelaborated

You are more likely to have better quality in some health plans than in others

Health plan quality varies. A higher quality health plan can mean better care for you and your family:

• Doctors spend enough time with you.
• Doctors listen to you.
• Doctors explain things well.
• You wait in the doctor’s office 15 minutes or less past your appointment time.
• You get the care you really need.
• You can see specialists you want to see.
• You get approvals for tests or treatments without delays.

Risk Avoidance Elaborated

You are more likely to have problems in some health plans than in others. Here’s why…

Today when you pick a plan, you are required to use a particular set of doctors. If these doctors are overworked or don’t have good people skills, this may cause you the following problems:

• Doctors don’t spend enough time with you.
• Doctors don’t listen to you.
• Doctors don’t explain things well.
• You wait in the doctor’s office more than 15 minutes past your appointment time.

Most plans also require you to get prior approval for certain types of care and have rules about when you can see a specialist. This may cause you the following problems:

• You don’t get the care you really need.
• You aren’t able to see specialists you want to see.
• You have delays in getting approvals for tests or treatments.

That’s why it’s important to consider health plan problems along with cost and covered services when you compare plans.

A quick look at how plans compare

It’s as easy as 1,2,3 to choose the plan that’s right for you.

(1) Read these seven topics. Circle the topics most important to you.
(2) For each topic you circled, compare the stars for each plan. Three stars means a plan had fewer problems for a topic. One star means a plan had more problems for a topic.
(3) See which plan had fewer problems for the topics most important to you.

How well doctors communicate:

• Doctors who listen.
• Doctors treat you with respect.
• Doctors spend enough time.

Atlantic plan, 2 stars; Pacific plan, 2 stars

Getting needed care:

• Getting a referral to a specialist when you need it.
• Getting approvals for care without long waits.

Atlantic plan, 3 stars; Pacific plan 1 star

Getting care without long waits:

• Getting care quickly for an illness or injury.
• Getting routine care without long waits in the waiting room.

Atlantic plan, 1 star; Pacific plan, 2 stars

How people rated their health care:

• Based on people’s answers to a single question rating their health care on a scale form 0 to 10.

Atlantic plan, 1 star; Pacific plan, 2 stars

Courtesy, respect and helpfulness of office staff:

• Getting care from courteous, respectful, and helpful office staff.

Atlantic plan, 1 star; Pacific plan, 2 stars.

Health plan customer service:

• Health plan customer service staff gives help that is needed.
• Finding information easily in the plan’s written materials.

Atlantic plan, 2 stars; Pacific plan 2 stars

Health plan paperwork and claims processing:

• Reasonable number of forms to fill out.
• Health plan handles claims quickly and correctly.

Atlantic plan, 3 stars; Pacific plan, 1 star

The stars tell you how each plan compares to survey average for all plans in the Washington, DC area: 3 stars, fewer problems than average; 2 stars, about average; 1 star, more problems than average. The number of stars depends on how big the difference was between a plan’s score and the average score for all plans in the Washington, DC area.

207 Study participants

• Adults ages 18 to 64.
• Have private health insurance, now or within last 12 months.
• Live in Washington, DC metro area or Raleigh/Durham area.
• No vision or hearing problems.
• Can read English fluently.

Demographic characteristics (n=207)

• Education: 72% at least some college.
• Household Income: 21% $60+ K.
• Gender: 65% female.
• Race: 61% black or other non-white.
• Age: 48% 18-34 years, 44% 35-54 years, 8% 55+ years.

Procedures

Pre-intervention questionnaire:

• Comprehension
• Importance
• Demographics
• Health status/utilization.

Booklet and benefits sheet:

• All plans have some benefits and coverage.

Post-Intervention questionnaire with booklet and benefits sheet:

• Comprehension
• Importance
• Decision-making.

Comprehension of Comparison Chart (Framing p < .01)

Average percent correct: Risk avoidance 91%, gain maximizing 84%.

Those in the risk avoidance frame condition responded correctly more often to questions about the comparison chart than did those in the gain maximizing frame condition.

Comprehension of Implications of Choice (Framing p is less than or equal to .01)

Percentage agreement: Risk avoidance 92%, gain maximizing 81%.

Those in the risk avoidance frame condition were more likely to think that their plan choice makes a difference in the quality of care and services they receive.

Relative Importance of CAHPS

• Respondents had to divide up 100 points among 4 factors based on how important each would be in their plan choice.
• Factors
  • Plan member ratings.
  • Convenience.
  • Monthly premium.
  • Whether doctor is in the plan.

Relative importance of CAHPS (Framing efficacy p < .05)

Risk avoidance frame: Elaborated, 20.2; unelaborated, 21.9; total, 21.1
Gain maximizing frame: Elaborated, 20.6; unelaborated 18.7; total, 19.7
Total of all: Elaborated, 20.4; unelaborated, 20.3

Respondents given a risk avoidance frame and unelaborated messages, placed a higher importance on plan member ratings (relative to other factors).

Decision making outcomes: Trade-offs

• Participants made decisions about pairs of plans, in each case one of which was clearly a higher qualtiy plan.
  • Lower quality plan, 2 stars for all 7 factors.
  • Higher quality plan, 3 stars for 5 factors, 2 for the others.
• After each choice, participants indicated what they would trade to get the higher quality plan
  • Premium cost ($0 to over $100).
  • Driving time convenience (0 min. to over 60 min.).
  • Enroll in a plan where they had to give up regular doctor.

Trading Cost for Higher Quality (Framing*Income p < .05)

• Risk avoidance frame: $51; low income, $41; high income $62*.
• Gain maximizing frame $47; low income $47; high income $46.

Higher income participants in the risk avoidance frame condition were willing to trade more in premium cost than other groups to obtain a plan rated higher in quality.

Trading Convenience for Higher Quality (Framing*Income p < .05)

• Risk avoidance frame: 33 minutes; low income, 30 minutes; high income, 36 minutes*.
• Gain maximizing frame: 28 minutes; low income 29.5 minutes; high income, 26.5 minutes.

Higher income participants in the risk avoidance frame condition were willing to trade more in driving time to obtain a plan rated higher in quality.

Trading Own Doctor for Higher Quality (Framing*income p is less than or equal to .01)

• Risk avoidance frame: 64%; low income, 60%; high income, 85%*.
• Gain maximizing frame: 66%; low income, 65%; high income, 50%.

Percentages unadjusted for covariate

Higher income participants in the risk avoidance frame condition were more willing to give up their regular doctor to obtain a plan rated higher in quality.

Summary

A risk avoidance frame:

• Increases consumers’ understanding of the reports.
• Increases the perceived importance of CAHPS data relative to other factors.
• Increases consumers’ willingness to trade-off cost, convenience, and their own doctor for a higher quality plan.

Elaborated messages:

• Reduce consumers’ understanding of the reports.
• Reduce the perceived importance of CAHPS data relative to other factors.
• Have no effect on willingness to make trade-offs for quality.

Implications for Reporting Comparative Performance Data

• It is better to be brief and to the point; fewer words may make the reports easier to use.
• Risk avoidance frame more effective than current approaches.
• It is important to be evidence based in our approaches to reporting.