Medicaid Managed Care “Switchers” Characteristics and ...€¦ · enrollee fails to indicate...

Medicaid Managed Care “Switchers” Characteristics and Reasons for Switching Allyson Hall, PhD Heather Steingraber, MAC (ABT) Amanda Bhikhari, MHA

The Agency for Health Care272

Tallahassee

September

Sponsored by Administration7 Mahan Drive, Florida 32308

The Florida Center for Medicaid and the UninsuredCollege of Public Health and Health Professions University of Florida 352/273-5059

, 2004

Table of Contents

Figures

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Executive Summary ...........................................................3 Background and Introduction ..........................................5 Medicaid Managed Care Organizations .......................5 Changing MCOs............................................................5 Methodology and Sample Selection............................. 6 Outcome Rates ................................................................ 7 Demographics ................................................................. 7 Gender............................................................................7 Age ..................................................................................7 Race ................................................................................8 Ethnicity ...........................................................................8 Health Status ..................................................................9 Plan Choice .........................................................................9 Health Utilization ............................................................9 Reasons for Switching .................................................10 HMO to MediPass ........................................................11 HMO to HMO................................................................12 MediPass to HMO ........................................................13 Negative Experiences with Health Plans.................13 Comparison of Old and New Managed Care Arrangements.......................................14 Sources of Information about Managed Care ............15 Medicaid Stigma.........................................................16 Comparison of 2003 vs. 2004 ..........................................17 Health Status ................................................................17 Reasons for Switching .................................................17 Summary and Recommendations.................................18 Figure 1. Mean Age of Switchers ...................................8 Figure 2. Race and Ethnicity of Switchers ....................8 Figure 3. Self-Reported Health Status of Switchers .....9 Figure 4. Health Plan Choice..........................................9 Figure 5. Health Utilization .............................................10 Figure 6. Reasons for Switching, Overall.....................11 Figure 7. Reasons for Switching, HMO to MediPass..12 Figure 8. Reasons for Switching, HMO to HMO .........12 Figure 9. Reasons for Switching, MediPass to HMO..13 Figure 10. Source of Negative Experience with Health Plan ......................................................14 Figure 11. Perceived Differences Between Old and New Plans ........................................15 Figure 12. Source of Information about New Plan......16

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Appendices

Survey

Tables

…………………………………………………………..20 FCMU “Switchers” Survey Instrument Table 1: Demographic Characteristics of Plan Switchers Overall and by Switch Group Table 2: Reasons for Switching Managed Care Arrangements: Overall and by Switch Group Table 3: Perceived Differences between Old Plan and New Plan: Overall and by Switch Group Table 4: Sources of Information About New Plan, Medicaid Bias, and Health Plan Choice

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Executive Summary
The Medicaid “Switcher” survey was conducted by the
Florida Center for Medicaid & the Uninsured (FCMU) under contract with the Agency for Health Care Administration (AHCA). This survey was designed to provide outcome rates and assess the reasons why Medicaid enrollees voluntarily change or “switch” from one managed care arrangement to another during open enrollment. Demographic information and overall satisfaction with care measures was also collected so that these dimensions can be compared with the overall Medicaid population. AHCA has two main types of managed care arrangements to oversee the health care of Medicaid enrollees: Health Maintenance Organizations (HMOs) and the Medicaid Provider Access System (MediPass). As of the fall of 2003, which is the time period when the survey sample was drawn, Medicaid HMOs were available in 34 of the 67 Florida counties, and 23 counties offered more than one HMO to their enrollees. All counties offer the MediPass program. In the winter of 2003, AHCA identified 4,409 adult non-elderly Medicaid enrollees, who had switched managed care arrangements in the months of October or November, 2003. This group of enrollees was chosen as a potential subject pool to participate in telephone surveys regarding the reasons for their MCO switch. After removing duplicate records and taking multiple measures to find valid contact information for respondents, only 82% (n=3,632) of the sample remained valid; that is each record had a 10-digit telephone number and was not a duplicate record. Survey data was analyzed across three switch groups (HMO to MediPass, MediPass to HMO, and HMO to HMO). Among the demographic variables analyzed, significant differences were found between the 3 switch groups in the proportion of Black and White races. The HMO to HMO group was made up of a larger percentage of Blacks and a smaller percentage of Whites than the other groups. In 2004, a greater proportion of respondents said they were either in poor or fair health (40%) as compared to only 27% in 2003. This indicates a worse reported health status overall in 2004 as compared to the previous year. The health status between switch groups for both years was relatively similar and not statistically significant.

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Survey respondents were more likely to report that they chose (rather than were assigned) to their new plan compared to their old plan. The percent choosing their old managed care arrangement varied significantly across the 3 switch groups. Those who switched from an HMO to MediPass were less likely than the other groups to report choosing their old plan. Respondents were asked to compare their old and new MCOs on several attributes such as choice of providers, ease of obtaining a medical appointment, and suitability for people who take multiple prescriptions. On the overall ratings of the two managed care arrangements, respondents rated their new plan higher than their old plans. However, no statistically significant differences were found. In conclusion, approximately 4,400 Medicaid beneficiaries switched managed care arrangements during a period of two months. In a one-year period, approximately 26,500 beneficiaries can be expected to change their managed care arrangements. The switching of managed care arrangements can create significant administrative burden for Medicaid administration and can have implications for continuity of care for patients. Increasing provider selection and availability, providing choice to beneficiaries instead of assigning them and reviewing the open enrollment periods may help to address these issues. This study provides an initial look into the experiences of Medicaid beneficiaries who switch health plans. Further research, especially longitudinal studies, are needed. Additional research questions include understanding:

• the extent to which switchers vary by health plan and by geographic region

• how provider availability within regions across the state influences switching

• the impact of an HMO market exit on future choice of managed care arrangement

• how the actual process of switching may deter or encourage plan switching

• the extent to which switchers are more satisfied 1 or 2 years later

• the role health plan marketing plays in encouraging beneficiaries to switch managed care arrangements.

Background and Introduction

Medicaid Managed CareOrganizations

Changing MCOs

The purpose of this report is to provide outcome rates for the Medicaid “Switcher” survey conducted by the Florida Center for Medicaid & the Uninsured (FCMU) under contract with the Agency for Health Care Administration. This survey was designed to assess the reasons why Medicaid enrollees voluntarily change or “switch” from one managed care arrangement to another during open enrollment. In addition, the survey gathered demographic information and overall satisfaction with care measures on “Switchers,” so that these dimensions can be compared with the overall Medicaid population. The Agency for Health Care Administration (AHCA) has two types1 of managed care arrangements to oversee the health care of Medicaid enrollees: Health Maintenance Organizations (HMOs) and the Medicaid Provider Access System (MediPass). The HMOs and the MediPass program offer benefits packages that are substantially similar, though the HMOs may offer additional special services such as transportation to medical appointments, and over-the-counter drug reimbursement. The two types of managed care arrangements differ in how they manage the care of their enrollees and in how they manage the providers in their network. Further information on the differences can be found in the Florida Medicaid Summary of Services. As of the fall of 2003, which is the time period when the survey sample was drawn, Medicaid HMOs were available in 34 of the 67 Florida counties, and 23 counties offered more than one HMO to their enrollees. All counties offer the MediPass program. Upon enrollment, those who reside in counties without HMOs are automatically enrolled in MediPass, while those who reside in counties with HMOs must choose from MediPass and the HMO(s) offered in their county. If an enrollee fails to indicate his or her choice to Medicaid within 30 days of the date Medicaid eligibility began, he or she is assigned to one of the MCOs by AHCA. Each year, an open enrollment period is offered, in which recipients have 90 days to try a new plan. After this initial 90-day period, the recipient is “locked-in” to the plan and must remain in this plan for the next 9 months, barring loss of Medicaid eligibility or a “good cause” to change plans. To make the switch, a recipient must telephone the Medicaid Options toll-free help line during operating hours (Monday through Friday, 8 am – 7 pm) to indicate the desired MCO change.

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1 Another type of managed care arrangement, the Provider Service Network, or PSN, also exists in Florida Medicaid. However, it is offered on a very limited basis. As of April, 2004, only residents of Broward and Miami-Dade counties could enroll in the PSN, and PSN enrollment totaled 17,949 members, or approximately 1.25% of Medicaid managed care enrollment. PSNs are not considered in this report because they are offered in such a limited area, and their enrollment represents such a small portion of Medicaid enrollment overall.

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Methodology and SampleSelection

In the winter of 2003, the Agency for Health Care Administration identified 4,409 adult non-elderly Medicaid enrollees, who had voluntarily switched managed care arrangements in the months of October or November, 2003. This group of enrollees was chosen as a potential subject pool to participate in telephone surveys regarding the reasons for their MCO switch. The Survey Research Center at the University of Florida’s Bureau of Economic and Business Research was contracted to carry out the survey process in the winter of 2003 and spring of 2004. The quality of the contact information for enrollees was poor, with nearly 12% (N=534 out of 4,409) of the sample having no telephone number on file with AHCA. Many measures were taken to find valid contact information for respondents. Measures included contacting commercial organizations that provide contact information for telephone surveyors and marketers and matching the records with current Driver’s License records obtained from the Florida Department of Highway Safety and Motor Vehicles. Following these steps, and the removal of duplicate records, only 82% (N=3,632) of the sample remained valid; that is, each record had a 10-digit phone number and was not a duplicate record. Subjects were contacted up to 42 times by phone in an attempt to secure cooperation or obtain updated contact information. Despite these attempts, a large number of respondents proved to be unreachable. Perhaps this should not come as a surprise, considering that a common reason for switching MCOs may be that enrollees have moved, and thus, have easier access to providers on a different MCO. An important aspect in determining whether survey results are truly representative of the population in question is to determine whether “non-response effects”exist. Non-response effects occur when non-respondents from the original sample differ from those who did respond in significant ways that might affect results of the study. One important step in determining whether non-response effects exist is to calculate outcome rates. The American Association for Public Opinion Research (AAPOR) recognizes the use of a number of different types of outcome rates, and a number of different methods for calculating each of those types1. One type of outcome rate is the Response Rate (RR), which takes into account the number of interviews in proportion to the number of eligible respondents.

1The American Association for Public Opinion Research. 2000. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Ann Arbor, Michigan: AAPOR

Outcome Rate

Demographic

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Numerous methods exist to calculate Response Rates, with major differences being in the way in which the number of eligibles is determined and the way partial interviews are allocated. Another type of outcome rate is the Cooperation Rate (COOP), which takes into consideration the number of interviews in proportion to all eligibles ever contacted. Cooperation Rates exclude from calculation those respondents who could not be located. Like Response Rates, there are numerous ways to calculate Cooperation Rates, with the major differences being in the way that the number of eligibles is determined and the way partial interviews are allocated. Researchers consider various criteria in determining which outcome method to use, with the quality of the sample being a major criterion in their decision. A total of 353 surveys were completed, yielding a confidence interval of ±5% for all results. The response rates for the surveys ranged from 58% to 63%, depending on the RR calculation method. The cooperation rates for the survey was also good, with rates ranging from 73% for COOP1 to 80% for COOP4. The refusal rates ranged from 14% to 16%. Demographic information such as gender, age, race, ethnicity, and health status was gathered for all survey respondents. Generally, respondents do not show a significant difference in demographic dimensions. Results are given below. The majority of switchers are female (84 percent) rather than male (17 percent) reflecting the general distribution of the Medicaid population. The three switch groups were found not to be statistically significantly different from each other; however, with the MediPass to HMO group being slightly younger than either of the other two groups. This group’s mean age was 38.66 ±14.56 years, compared with 42.77±15.77 years for the HMO to MediPass group and 42.63 ±18.10 years for the HMO to HMO group (Figure 1).

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Figure 1 : Mean Age of Switchers

42 43 39 43

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Figure 2 : Race of Switchers

16% 18%9%

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Just over half of the switchers (54.11%) indicated that their race was White, while 33% were Black, 3% were Native American, and 2% were Asian. A further 16.15% of respondents described their race as something “Other” than any of these categories. There were significant differences between the 3 switch groups in the proportion of Black and White races. The HMO to HMO group was made up of a larger percentage of Blacks (p≤0.05) and a smaller percentage of Whites than the other groups. Forty-one percent of respondents in this group described themselves as being Black, compared with 23.9% of the HMO to MediPass group and 37.66% of the MediPass to HMO group. (Figure 2).

Thirty-two percent of Medicaid plan switchers surveyed reported that they were Hispanic, while 68% reported that they were not Hispanic. The three switch groups did not differ significantly in terms of Hispanic makeup.

Race

Ethnicity

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Health Status

Plan Choice

Health Utilization

Almost 40 percent of all switchers reported that they were in fair or poor health. However, differences in health status across the three groups were found not to be statistically significant. (Figure 3).

Respondents were more likely to report that they chose (rather than were assigned) to their new plan compared to their old plan. Overall, about 47 percent of respondents reported that the chose their old plan (data not shown). In comparison 89 percent reported that they chose their new plan. The percent choosing their old managed care arrangement varied significantly across switcher types (p=.001). Those who switched from an HMO to MediPass were less likely than the other groups to report choosing their old plan (Figure 4)

Overall, about 82 percent of respondents reported “yes”, they used the new plan for medical care or prescriptions. This is proof that the medical care and prescriptions provided are being used by a majority of patients, and supports the need for effective health

Figure 3 : Self Reported Health Status of Switchers

24% 17% 22%

18% 20% 20% 14%

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Figure 4: Health Plan Choice

89% 83% 91% 95%

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Chose New Plan Was Assigned New Plan

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Reasons for Switching Rsrw Rtbb(ttwwdsaocntinrObao

care to reach out to the minority of respondents who are not using the services available to them. However, there are no significant differences in utilization across the three switch groups. (Figure 5)

Figure 5: Health Utilization

82%85%

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MediPass toHMO

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espondents were asked about the reasons why they witched MCOs. Subjects were given eight possible easons and asked whether they agreed or disagreed ith each reason. Results are given below.

espondents were most likely to strongly agree or agree hat they switched health plans because of better enefits available to them in the health plan (79.18%) and ecause of a better selection of providers (PCPs)

77.68%). Seventy percent strongly agreed or agreed that hey switched because a specific provider was not on heir old plan. When asked what type of provider that as, 47% indicated that it was a primary care provider, hile 32% indicated it was a specialist, 10% said it was a entist and 12% indicated some other type of provider,

uch as a nurse. Sixty-nine percent of respondents greed that they switched plans because the new plan ffered providers and facilities that were more onveniently located than the ones on their old plan. The ext most commonly cited reason for switching plans was hat the enrollee believed that the new plan would result fewer out-of-pocket expenses than the old plan. This

eason was cited by nearly half (48.4%) of respondents. ther reasons given included that the enrollee wanted to e in the same MCO as another family member (26.5%) nd that they or a friend had a bad experience with the ld plan (28.5%). (Figure 6)

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HMO to MediPass

Figure 6 : Reasons for Switching, Overall

32% 32% 24% 27%31%13% 13% 7%

47%46%45% 38% 37%

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Strongly Agree Agree

There were some differences between the three switch groups in terms of reasons for changing MCOs. For those going from an HMO to MediPass, most agree that they switched because they felt they had a better selection of providers under the new arrangement. In contrast those moving from MediPass to HMO were more likely to agree that they received better benefits in the new plan. And those going from one HMO to another HMO were about as equally as likely to agree that better benefits and a better selection of providers were available in the new plan. Among the HMO to MediPass group, 81% indicated that they switched to MediPass because they felt it had a better overall selection of providers than the HMO(s). The next most frequently cited reason for switching among this group was that there were better benefits and features in MediPass as compared to HMO. This reason was cited by 79% of respondents in this group. Seventy percent of respondents indicated that they switched because their old plan was too restrictive regarding provider choice and visits, and 74% indicated that they switched because the facilities and providers in the new plan were more conveniently located. Seventy-seven percent of HMO to MediPass switchers indicated that they switched because a specific provider was not on the HMO plan. Fifty-two percent indicated they thought they would pay less out-of-pocket in MediPass than in their HMO. Thirty-four percent of respondents switched because they had a bad experience with their HMO. Twenty-seven percent switched because another family member was on MediPass (Figure 7).

HMO to HMO

Respondents who switched from one HMO to another most commonly indicated that they did so because they felt that the new plan had a better overall selection of providers than the old plan. This reason was cited by 76% of respondents in this group. The next most commonly cited reason for switching, given by 75% of respondents, was that the new plan had better benefits or features than the old plan. Sixty-eight percent indicated that they felt the providers and facilities in the new plan were more conveniently located than those in the old plan. Sixty-four percent switched because a specific provider was not on their old plan, and 60% reported that their old plan was too restrictive regarding provider choice and visits. Thirty-nine percent of this group thought that their new plan would cover more of their out-of-pocket expenses, and 29% switched to be on the same plan as a family member. The reason cited least frequently was that they had a bad experience with their old plan. This was cited by 26% of respondents in the HMO to HMO group. (Figure 8)

Figure 8, Reasons for Switching, HMO to HMO

27% 28% 22% 33% 23% 10% 12% 10%

49% 47% 46% 31%37%

29% 14% 19%

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Figure 7: Reasons for Switching, HMO to MediPass

5%16%13%35% 33%29%32%36% 22%18%

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MediPass to HMO

Negative Experiences withHealth Plans

Among respondents who switched from MediPass to an HMO, the most common cited reason for making this switch (cited by 83% of respondents) was that the HMO had better benefits or features than MediPass. Next most common (72%) was that they felt the HMO had a better overall selection of providers. There were equal respondents (61%) who switched due to either a more convenient location and facility or because a specific provider was not on the MediPass plan. Fifty-seven percent of the respondents in this group indicated that they felt MediPass was too restrictive regarding provider choice and visits. Fifty-four percent said that they felt enrolling in the HMO would result in fewer out-of-pocket expenses than in MediPass. Twenty-two percent of respondents switched because another family member was on the HMO, and 20% reported switching due to a bad experience with MediPass (Figure 9).

Those respondents who reported having switched plans due to (at least in part) a bad experience with their old plan (n=97) were asked for more detail about that negative experience. Fifty-six percent of these respondents overall indicated that the experience was with a doctor or doctor’s staff, while 67% said the bad experience had to do with getting a referral. Negative experiences with the MCO’s customer service or complaint department were reported by 42% of this group. Other sources of negative experiences included health providers other than doctors, dentists, or pharmacists (45%), billing or claims issues (46%), pharmacists or other pharmacy staff (28%), and dentists (18%). Twenty-eight percent of this group reported another source of negative experiences. (Figure 10).

Figure 9: Reasons for Switching, Medipass to HMO

6%9%17%21% 19%18%37%30% 16%11%

38%36%41%43%42% 46%

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Figure 10 : Source of Negative Experience with Health Plan

28%

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Percent of "yes" responses

Respondents were asked to compare their old and new MCOs on several attributes, including the following:

• Choice of Primary Care Physicians, • Choice of Specialist Physicians, • Choice of Dentists, • Mental/emotional health benefits, • Suitability for people with special health care

needs, • Suitability for people who take multiple prescription

medicines, • Suitability for people who need to minimize out-of-

pocket expenses, • Suitability for non-English speakers, • Courteousness overall, and • Ease of obtaining a medical appointment.

Respondents were also asked to provide an overall rating on a scale of 1 to 10 of both their old and new health plans. Results are given below. On the overall ratings of the two managed care arrangements, respondents rated their new plan (8.21) higher than their old plans (6.13). Similarly, for all attributes, respondents rated their new plan as being better than their old plan. Of note, is the fact that along a number of dimensions, a number of respondents reported that there was no difference between their old and new managed care plans. In addition, there was no statistically significant difference across the three switch groups in reported differences between old and new plans (Figure 11).

Comparison of Old and NewManaged Care Arrangements

Sources of Information aboutManaged Care

Figure 11: Perceived Differences Between Old and New Plans

9 8 12 109 12 9 6 99

5855 50 4755 52

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36 34 38 4435 36 34

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Old Plan New Plan No Difference

Respondents were asked how they heard about their new MCO. Subjects were offered five possible sources of information and allowed to indicate whether they had received information from each of these sources. They were also able to provide a free text response about the source of information. Results are discussed below. The most common source of information about new MCOs was received through the mail. Forty-eight percent of respondents overall indicated that they had received information from the new plan through the mail, though it is not known whether the mail was sent in response to a request for information from the enrollee, or was unsolicited. Those moving from MediPass to HMO were more likely to report getting new information from the mail relative to the other two groups. Furthermore, respondents were not asked who sent the information to them, so it is not known whether the MCO or plan sent the information, or whether the Agency sent it. Another common source of information about MCOs, given by 27% of respondents, were State agencies, such as AHCA or the Department of Children and Families (DCF). It is not known whether this information was obtained in person at an Agency office, over the phone, or through the Medicaid Options hotline. Many respondents received information via word of mouth from friends and family (29%), and through advertisements about the plan (23%). Twenty-one percent of respondents indicated they received a

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Medicaid Stigma

telephone call from the new plan, and 32% indicated that a doctor or other health provider gave them information about the plan. Other sources of information reported included health fairs, in-person visits from plan representatives, and information distributed at the enrollee’s workplace. (Figure 12)

Figure 12: Source of Information about New Plan

48%

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Percent of "yes" responses

Because Medicaid is a State/Federal program, it may be perceived by many to be “Welfare” or an entitlement. Many Medicaid enrollees have reported that they experience prejudice from health providers and others. In order to gauge the extent to which this occurs among Florida Medicaid population, all respondents in this survey were asked whether they had ever felt that they were treated differently because they were enrolled in Medicaid compared with enrollees in other types of health insurance. Those who had experienced bias were also asked who showed bias, and to describe the event in their own words. Results are discussed below. Approximately 26 percent of respondents indicated that they felt they been treated differently due to their Medicaid enrollment on at least one occasion. When asked who had shown this bias, half of these respondents said that a doctor or doctor’s staff had shown bias, while 5% indicated that it was a dentist or dentist’s staff, and 7% said it was someone at a pharmacy. Another 9% of respondents indicated that it was another type of health provider or that it was multiple types of providers who showed bias. Thirty percent indicated that the bias was shown by a non-health provider. There were no differences between the three switch groups on these measures.

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17

As a whole, subjects reported experiencing three types of bias associated with Medicaid:

1) Longer waiting periods for medical appointments.

2) Longer wait times in doctor’s offices. 3) Perfunctory or cursory treatment and

examinations.

When reviewing survey results from the previous year, and comparing them to the current year, there were a few disparities among the different categories as well as between the 3 different groups. The overall categories are presented below. In 2004, a greater proportion of respondents said they were either in poor or fair health (40%) as compared to only 27% in 2003. This indicates a worse reported health status overall in 2004 as compared to the previous year. The health status between switch groups for both years were relatively similar and not statistically significant. While there are many similarities between the two years regarding reasons for switching arrangements, there were several differences as well. For example, in 2004, there was a higher number of respondents (72%) who either strongly agreed or agreed that their new plan would have a better selection of providers than compared to the previous year (56%). Also, there was a decrease in the HMO to HMO group in 2004 (39%), regarding their thoughts that switching would result in lower out of pocket costs as compared to 2003 (51%). This is noteworthy because for the other two groups, MediPass to HMO and HMO to MediPass there was an increase regarding thoughts that the new plan would result in lower out of pocket costs.

Comparison of 2003 vs. 2004

Health Status

Reasons for Switching

18

Summary andRecommendations

As indicated, approximately 4,400 Medicaid beneficiaries switched managed care arrangements during a period of two months. In a one- year period, approximately 26,500 beneficiaries can be expected to change their managed care arrangements. The switching of managed care arrangements can create a significant administrative burden for Medicaid administration and can have implications for continuity of care for patients. A clue to understanding the motivation of switchers is the fact that the majority of respondents indicated that they were assigned to rather than chose their original health plan. The original assignment, therefore, may not be particularly suited to a patient’s needs. One need that appears to prompt switching is provider availability. Specifically, the majority of respondents agreed that they switched because the new arrangement had a better selection of providers, provider location was more convenient or that a specific provider was not available under the old plan. The degree to which respondents strongly agreed with statements about provider availability varies across the switcher groups, providing some indication that some forms of managed care may have better provider accessibility than others. Another point to be recognized is that switching seems to be prompted by assignment to a specific plan. For example, as the survey shows, HMO to MediPass patients are more likely to chose their own plan, which indicates a higher level of dissatisfaction with Medicaid automatic assignment choices. Respondents also indicated that restrictions regarding provider choice and that there may be better benefits under a new plan are also significant reasons for changing. Interestingly, few respondents indicated they switched because of a bad experience with a plan. Another stimulus for switching could be from health plan marketing efforts. Forty-eight percent of respondents indicated that mail from the health plan was a major source of information about that plan. Twenty-three percent of the switchers found out about the plan through an advertisement.

19

Switchers tended to provide a higher rating for the new managed care arrangement. However, it also important to note that many respondents found no difference between the two arrangements. Very few people found the new plan to be worse than the old plan. Those respondents that did change were motivated by their own personal choice. This may indicate some bias in the higher rating of new arrangements due to the fact that personal choice was the driving factor. This study provides an initial look into the experiences of Medicaid beneficiaries who switch health plans. Further research, especially if it is longitudinal in nature is needed. Additional research questions include understanding:

• the extent to which switchers vary by health plan and by geographic region

• how provider availability within regions across the state influences switching

• the impact of an HMO market exit on future choice of managed care arrangement

• how the actual process of switching may deter or encourage plan switching

• the extent to which switchers are more satisfied 1 or 2 years later

• the role health plan marketing plays in encouraging beneficiaries to switch managed care arrangements.

APPENDICIES

20

FCMU Switcher Survey

Survey conducted in Fall 2003 with Adult Medicaid Enrollees who voluntarily switched from the MediPass program to an HMO or vice versa, or switched from one HMO to another. Interviewer notes/administration instructions in italics. Field names in ALL CAPS to the left of each item. For all items: -8 = Don’t Know, -9 = Refused. Unless noted, the skip sequences for these options are the same as for “No” or “Disagree.” OLDPLAN = The program that the respondent disenrolled from: Either an HMO name or “MediPass” NEWPLAN= The program that the respondent switched to: Either an HMO name or “MediPass” Programmer note: please use the field names and response category values indicated on this hard copy! HELLO Hello. My name is _______, and I am calling from the Survey Research Center at the

University of Florida. I’m calling on behalf of the Florida Medicaid program.

May I speak to (target name)? If yes, reintroduce yourself if necessary

If no, Is there another time I could call back to talk to him/her? Schedule a call back if necessary and thank the respondent for his/her time.

INTRO The Medicaid program has asked the University of Florida to conduct a survey of people who are

enrolled in their programs. Specifically, Medicaid would like to know about people’s experiences with their programs.

ADVISE I need to tell you a couple of things before we get started. You do not have to answer any question you don’t want to. You don’t have to participate in the survey at all. No one – not even Medicaid - will know if you participated or not, and your name will not be reported to anyone else. All of the participant responses will be totaled together when presented to Florida Medicaid. In addition, data from this survey may be published publicly, but again, it will be presented in totals, not in individual responses. . If you don’t have any questions, would you like to participate in this survey? (if no, then “thank you very much for your time” – if yes, then “let’s get started with the interview”)

CONFIRM My records show that you used to be covered by (insert OLDPLAN), but you are now covered by (insert NEWPLAN). Is this correct?

1. Yes Go to NEWOPEN 2. No

MCAID It is possible that my records are wrong. Are you currently enrolled in Medicaid?

1. Yes 2. No Apologize for the inconvenience and thank the respondent for his/her time.

21

COVERAGE What Medicaid program or health plan are you currently covered by? If respondent

needs help recalling the name, read the list below. Otherwise, just code their response.

1. MediPass

2. Amerigroup 3. 4. 5. Buena Vista 6. 7. 8. HealthEase 9. Healthy Palm Beaches 10. 11. Healthy Palm Beaches 12. Humana 13. JMH Health Plan 14. Neighborhood Health Partnership 15. 16. Preferred Medical Plan 17. 18. Staywell 19. United Healthcare Plans 20. United Eldercare 21. Vista Healthplan of S. Florida 22. 23. Other (Specify __________) Apologize for the inconvenience and thank the respondent for his/her time.

NEWOPEN The first I thing I want to ask is about NEWPLAN. Can you tell me, in your own words, how

you first found out that you could choose NEWPLAN as your Medicaid health plan? Interviewer: Record response verbatim

HOWHEAR Ok. Now I’m going to ask you a series of questions about specific ways you might have

found out that NEWPLAN is a Medicaid health plan in your county. NEWCALL Did someone from NEWPLAN call you?

1....................... Yes 2....................... No

NEWMAIL Did you get something in the mail from NEWPLAN?

1. Yes 2. No

22

NEWFRIEN Did a friend or family member tell you about NEWPLAN?

1. Yes 2. No

NEWPROVI Did a doctor or other health provider tell you about NEWPLAN?

1. Yes 2. No

NEWSTATE Did someone from Medicaid or DCF tell you about NEWPLAN?

1. Yes 2. No

NEWPLAN Did you see an ad for NEWPLAN?

1. Yes 2. No

NEWOTHE Is there some other way you heard about NEWPLAN?

1. Yes (go to NEWOPEN) 2. No (go to OLDCHOIC)

SWWHY I am interested in the reason or reasons why you switched from OLDPLAN to

NEWPLAN. Can you explain to me in your own words why you switched? (Interviewer: Record response verbatim) DEFINITI Keep in mind throughout this survey that when I use the word “provider,” I am talking

about people like doctors, dentists, nurse practitioners, and therapists. When I use the word “staff” I am talking about people who work for or work with the provider. So, for example, that might be a nurse, a receptionist, or a laboratory technician. Does that make sense?

SWREASON Ok. Now I’m going to read you a list of reasons that other people have given for

switching plans. For each statement I read to you, I’d like you to tell me whether strongly agree, agree, disagree, or strongly disagree with that statement.

SWPROV I switched plans because a specific provider that I wanted to see was not on OLDPLAN

but was on NEWPLAN? 1. Strongly Agree (go to SWPROTYP) 2. Agree (go to SWPROTYP) 3. Disagree (go to SWDOCCHO) 4. Strongly Disagree (go to SWDOCCHO)

23

SWPROTYP What kind of provider was it that you wanted to see? Was it a…

1. Primary care provider, (If needed, “A primary care physician is a doctor who…get definition from CAHPS) 2. A specialist, (get definition from CAHPS) 3. A dentist 4. Other ________

SWDOCCHO I switched plans because NEWPLAN had a better overall selection of providers than OLDPLAN?

1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree

SWLIMIT I switched plans because OLDPLAN had too many limitations on what providers I could

see and how often I could see them?


SWBENEFI I switched plans because there were certain benefits that were not included in OLDPLAN

but were included in NEWPLAN


SWMONEY I switched plans because I felt I would pay less for my medical care on NEWPLAN as

compared to OLDPLAN?


SWSAME I switched plans because someone else in my family was on NEWPLAN and I wanted to be on the same plan as they were?


24

SWTRANS I switched plans because the doctors offices and other health care facilities on

NEWPLAN are more conveniently located or easier for me to get to than the ones on OLDPLAN?


SWBAD I switched plans because I had a bad experience or someone I know had a bad experience

with OLDPLAN?

1. Strongly Agree 2. Agree 3. Disagree (skip to COMPLAIN) 4. Strongly Disagree (skip to COMPLAIN)

BADDOC Did this bad experience involve a doctor or doctor’s staff?

1. Yes 2. No

BADDENT Did this bad experience involve a dentist or dentist’s staff?

1....................... Yes 2....................... No

BADPHARM Did this bad experience involve a pharmacist or pharmacy staff?

1....................... Yes 2....................... No

BADPROV Did this bad experience involve a health care provider or provider’s staff

other than a doctor, dentist, or pharmacist?

1....................... Yes 2....................... No

BADREFER Did this bad experience involve getting a referral to a specialist or a

referral for treatment?

1....................... Yes 2....................... No

BADCLAIM Did this bad experience involve billing or insurance claims?

1. Yes

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2. No

BADCUST Did this bad experience involve the plan’s customer service or complaint department?

1....................... Yes 2....................... No

BADOTHE Did this bad experience involve some part of the program that I did not ask about?

1....................... Yes (Specify:___________) 2....................... No

COMPLAIN Did you ever register a complaint with OLDPLAN while you were on it or after you left? I am talking about a complaint about this particular plan, not about Medicaid in general.

1. Yes 2. No Go to STIGMA

RESOLVE Please tell me whether you strongly agree, agree, disagree, or strongly

disagree with this statement: “My complaint was resolved to my satisfaction?”


STIGMA Did you ever feel like you were treated differently than others because you were on the

Medicaid program?

1. Yes 2. No Go to DIFFEREN

STIGWHO Who was it that treated you differently?

1. A doctor or doctor’s staff 2. A dentist or dentist’s staff 3. A pharmacist or pharmacy staff 4. A health care provider other than a doctor, dentist, or

pharmacist 5. Someone else? ___________________

STIGMADE Can you tell me about that experience? ______________________________________

26

OLDCHOIC Did you choose to become enrolled in OLDPLAN, or were you assigned to it by

Medicaid?

1. I chose it 2. I was assigned to it

NEWCHOIC And how about NEWPLAN? Did you choose NEWPLAN, or were you assigned to it?

1. I chose it 2. I was assigned to it

USEDPLAN Have you had any doctor’s appointments, medical procedures, or medical services, or

have you gotten any prescriptions using NEWPLAN? 1. Yes

2. No (skip to OLDRATE) DIFFEREN Now I’m going to ask you to compare some parts of OLDPLAN and NEWPLAN. I want

you to tell me which plan you feel is better, or if you feel they are the same. DIFFPCP Which plan do you feel offers a better choice of primary care doctors: OLDPLAN or

NEWPLAN, or are they equally good?

1. OLDPLAN 2. NEWPLAN 3. No Difference

DIFFSPEC Which plan do you feel offers a better choice of specialist doctors: OLDPLAN or

NEWPLAN, or are they equally good?


DIFFDENT Which plan do you feel offers a better choice of dentists: OLDPLAN or NEWPLAN, or

are they equally good?


DIFFMENT Which plan do you feel offers a better mental and emotional health benefits: OLDPLAN

or NEWPLAN, or are they equally good?

1. OLDPLAN 2. NEWPLAN

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3. No Difference

DIFFSHCN Which plan do you feel is better for people with special health needs or with a serious

illness:


DIFFMEDS Which plan do you feel is better for people who need a lot of prescription medicines?


DIFFPOOR Which plan do you feel is better for people who need to pay as little as little money as

possible for their health care?


DIFFLANG For people who prefer to speak another language with their health care providers?


DIFFCOUR Would you say that overall you were treated with more courtesy in NEWPLAN or in

OLDPLAN?


DIFFAPPT Would you say that it is easier to get an appointment in NEWPLAN or in OLDPLAN?


DIFFOTHE Besides the differences we have just talked about, is there any other way that you feel one

plan is better than the other? _________________________________________ (describe the difference and code which plan is better)


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OLDRATE Ok. I’d like you to rate the OLDPLAN health plan overall using any number between 0 and 10.

Zero is for the worst health plan possible, and ten is for the best health plan possible. What is your rating of OLDPLAN?

Interviewer: Record rating in whole numbers only. If USEDPLAN = 2 or -8, skip to DEMOINTR. (Next question asked only of those who

have used their new plan.) NEWRATE Now I’d like you to rate the NEWPLAN health plan overall using any number between 1 and 10.

Zero is for the worst health plan possible, and ten is for the best health plan possible. What is your rating of NEWPLAN? Interviewer: Record rating in whole numbers only.

DEMOINTR Ok. We are almost done with the survey. I just have a few more questions to ask you. (Note: In order to ensure comparability with the Medicaid HMO surveys being conducted by AHCA, the demographic questions for this survey were taken from the CAHPS 2.0, except where noted. The response categories and the questions themselves are identical to those used in CAHPS. However, for some items an introduction to the questions was added in an attempt to make respondents more comfortable with the questions and the response categories offered.) HEALTH In general, how would you rate your overall health now?

1. Excellent 2. Very Good 3. Good 4. Fair 5. Poor

DOB What is your date of birth? Programmer – This can be entered as a single field, or as a

separate field for month, day, and year. Use whichever format is easiest for SAS programming.

Note - CAHPS does not ask for DOB. It asks for the respondent to indicate which of a list of age ranges he or she falls into.

SEX Are you male or female?

1. Male 2. Female

EDUCAT What is the highest grade or level of school that you have completed?

1. 8th grade or less 2. Some high school, but did not graduate 3. High school graduate or GED 4. Some college or 2-year degree 5. 4-year college graduate 6. More than 4-year college degree

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ETHNIC Are you of Hispanic or Latino origin or descent?

1. Hispanic or Latino 2. Not Hispanic or Latino

RACE I am going to read you a list of race categories, and I’d like you to tell me which one or ones you think

describe you best. Just so you know, the reason I’m asking you about this is because the researchers want to make sure they have gathered the opinions of enough people from all different races and ethnicities.

Here is the list. Tell me yes or no for each category. Are you: RACEWH White 1. Yes 2. No RACEBL Black or African American 1. Yes 2. No RACEAS Asian 1. Yes 2. No RACEHAW Native Hawaiian or other Pacific Islander 1. Yes 2. No RACEIND American Indian or Alaska Native 1. Yes 2. No (Note: Race categories are identical to those from the CAHPS 2.0, but the question introduction is modified.) LANGUAGE What language do you mainly speak at home?

1. English 2. Spanish 3. Some other language (please print) ___________________

OUT Ok. That’s all the questions I have for you. Thank you very much for your time.

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Table 1: Demographic Characteristics of Plan Switchers Overall and by Switch Group

Switchers OverallN=353

Group 1 HMO to MediPass

N=159

Group 2 MediPass to HMO

N=77

Group 3 HMO to HMO

N=117 Tests of Significance

N % or s N % or s N % or s N % or s χ2 or F

p

Self-Assessed Overall Health Excellent 44 12.61% 16 10.19% 13 17.11% 15 12.93%Very Good 63 18.05% 28 17.83% 17 22.37% 18 15.52%Good 103 29.51% 43 27.39% 18 23.68% 42 36.21%Fair 76 21.78% 38 24.20% 13 17.11% 25 21.55%Poor 63 18.05% 32 20.38% 15 19.74% 16 13.79%

8.98 0.344

Mean Age 41.83 ± 16.38 42.77 ± 15.77 38.66 ± 14.56 42.63 ± 18.10 1.85 0.158

Sex Male 58 16.43% 32 20.13% 12 15.58% 14 11.97%Female 295 83.57% 127 79.87% 65 84.42% 103 88.03%

3.32 0.190

Highest School Grade Completed 8th Grade or Less 27 7.74% 11 6.96% 4 5.33% 12 10.34%Some High School, but Didn’t Graduate 72 20.63% 30 18.99% 15 20.00% 27 23.28%High School Graduate, or GED 135 38.68% 61 38.61% 33 44.00% 41 35.34%Some College or 2-Year Degree 94 26.93% 44 27.85% 18 24.00% 32 27.59%4-Year College Degree 13 3.72% 8 5.06% 3 4.00% 2 1.72%Post Baccalaureate or Beyond 8 2.29% 4 2.53% 2 2.67% 2 1.72%

5.78 0.834

Hispanic or Latino Origin or Descent Yes 113 32.47% 54 34.84% 21 27.27% 38 32.76%No 235 67.53% 101 65.16% 56 72.73% 78 67.24%

1.35 0.509

Race (choose all that apply)

White 191 54.11% 97 61.01% 42 54.55% 52 44.44% 7.45 0.024Black or African-American 115 32.58% 38 23.90% 29 37.66% 48 41.03% 10.16 0.006

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Switchers OverallN=353


N=159


N=77

Group 3 HMO to HMO

N=117 Tests of Significance

N % or s N % or s N % or s N % or s χ2 or F

p

Asian 8 2.27% 3 1.89% 1 1.30% 4 3.42% N/A N/ANative American 12 3.40% 4 2.52% 1 1.30% 7 5.98% N/A N/AOther 57 16.15% 29 18.24% 7 9.09% 21 17.95% 3.63 0.163 Primary Language English 266 75.57% 114 72.15% 61 79.22% 91 77.78%Spanish 78 22.16% 39 24.68% 15 19.48% 24 20.51%Other 8 2.27% 5 3.16% 1 1.30% 2 1.71%

2.34 0.673

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Table 2: Reasons for Switching Managed Care Arrangements: Overall and by Switch Group

Switchers Overall N=353

Group 1 HMO to

MediPass N=159

Group 2 MediPass to

HMO N=77

Group 3HMO to

HMO N=117

Tests of Significance

N % or s N % or s N % or s N % or s χ2 or F p

Reasons for Switch (choose all that apply)

specific provider was not on old plan trongly Agree 106 31.36% 53 35.33% 15 20.55% 38 33.04%gree 129 38.17% 63 42.00% 30 41.10% 36 31.30%

Disagree 76 22.49% 28 18.67% 18 24.66% 30 26.09%trongly Disagree 27 7.99% 6 4.00% 10 13.70% 11 9.57%

13.85 0.031

etter overall selection of providers in new plan

trongly Agree 107 31.85% 55 36.18% 22 29.73% 30 27.27%gree 154 45.83% 69 45.39% 31 41.89% 54 49.09%


4.71 0.582

ld plan too restrictive regarding provider choice and visits



8.40 0.210

Better benefits/features of new plan



4.09 0.664

ASA

S

BSA

S

OSA

S

SA

S

33


Group 1 HMO to

MediPass N=159

Group 2 MediPass to

HMO N=77

Group 3HMO to

HMO N=117



hought new plan would result in less out-of-pocket costs



6.42 0.377

Wanted to be on same plan as another family member



5.30 0.506

ore convenient location of providers and facilities in new plan



6.97 0.324

Had a bad experience with old plan or heard of a bad experience

Strongly Agree 45 13.24% 25 16.23% 7 9.21% 13 11.82%gree 52 15.29% 28 18.18% 8 10.53% 16 14.55%


6.63 0.357

TSA

S

SA

S

MSA

S

A

S

34


Group 1 HMO to

MediPass N=159

Group 2 MediPass to

HMO N=77

Group 3HMO to

HMO N=117



(For those who indicated they switched plans because a specific provider was not on the old plan) Provider type

Primary care provider 108 46.55% 54 46.96% 18 40.00% 36 50.00%Specialist 74 31.90% 42 36.52% 13 28.89% 19 26.39%Dentist 23 9.91% 7 6.09% 7 15.56% 9 12.50%Other 27 11.64% 12 10.43% 7 15.56% 8 11.11%

6.57 0.362

(For those who indicated they switched plans due to a negative experience with the old plan) Source of Negative Experience with the Old Plan(choose all that apply)

A doctor or doctor's staff 54 56.25% 30 56.60% 8 57.14% 16 55.17% 0.02 0.990 A dentist or dentist's staff 17 17.89% 10 19.23% 4 26.67% 3 10.71% 1.83 0.400

A pharmacist, pharmacist's staff, or prescription problem 27 28.13% 18 33.96% 3 21.43% 6 20.69%2.00 0.368

Another type of health care provider or staff 43 44.79% 25 47.17% 7 50.00% 11 37.93% 0.83 0.661 Getting a referral 63 67.02% 37 69.81% 9 69.23% 17 60.71% 0.72 0.698 Billing or claims 43 45.74% 26 49.06% 4 33.33% 13 44.83% 0.99 0.610 Plan's customer service or complaint department 40 42.11% 19 35.85% 7 50.00% 14 50.00% 1.92 0.382 Other 27 28.42% 18 34.62% 3 21.43% 6 20.69% 2.17 0.338 Filed one or more complaints with old plan 37 10.57% 19 11.95% 6 7.79% 12 10.53% 0.95 0.622 (For those who had filed a complaint) Complaint resolved satisfactorily

Strongly Agree 6 16.67% 5 26.32% N/A N/A 1 8.33%gree 8 22.22% 5 26.32% 1 20.00% 2 16.67%


4.260 0.642 A

S

35

Table 3: Perceived Differences between Old Plan and New Plan: Overall and by Switch Group



N=159


N=77

Group 3 HMO to HMO

N=117 Tests of

Significance


Better Choice of Primary Care Doctors Old plan 24 8.86% 13 10.32% 8 13.79% 3 3.45%New plan 149 54.98% 69 54.76% 28 48.28% 52 59.77%No Difference 98 36.16% 44 34.92% 22 37.93% 32 36.78%

5.72 0.221

Better Choice of Specialist Doctors Old plan 20 7.72% 9 7.50% 6 10.71% 5 6.02%New plan 150 57.92% 71 59.17% 31 55.36% 48 57.83%No Difference 89 34.36% 40 33.33% 19 33.93% 30 36.14%

1.18 0.881

Better Choice of Dentists Old plan 27 12.00% 16 16.00% 5 9.26% 6 8.45%New plan 113 50.22% 37 37.00% 36 66.67% 40 56.34%No Difference 85 37.78% 47 47.00% 13 24.07% 25 35.21%

14.39 0.006

Better mental/emotional health benefits Old plan 19 8.64% 12 11.65% 4 8.00% 3 4.48%New plan 104 47.27% 52 50.49% 23 46.00% 29 43.28%No Difference 97 44.09% 39 37.86% 23 46.00% 35 52.24%

4.87 0.301

Better for people with special health care needs or illnesses

Old plan 25 9.84% 11 9.24% 11 20.00% 3 3.75%New plan 139 54.72% 71 59.66% 22 40.00% 46 57.50%No Difference 90 35.43% 37 31.09% 22 40.00% 31 38.75%

12.85 0.012

36



N=159


N=77

Group 3 HMO to HMO

N=117 Tests of

Significance


Better for people who need many prescriptions


17.37 0.002

Better for people who "need to pay as little as possible" for their health care


9.12 0.058

Better for non English speakers Old plan 12 5.58% 5 5.26% 4 8.16% 3 4.23%New plan 81 37.67% 33 34.74% 16 32.65% 32 45.07%No Difference 122 56.74% 57 60.00% 29 59.18% 36 50.70%

3.10 0.0542

Overall more courteous Old plan 26 9.25% 14 10.94% 7 11.29% 5 5.49%New plan 131 46.62% 58 45.31% 25 40.32% 48 52.75%No Difference 124 44.13% 56 43.75% 30 48.39% 38 41.76%

3.74 0.442

Easier to get an appointment Old plan 26 9.42% 8 6.30% 13 21.31% 5 5.68%New plan 151 54.71% 77 60.63% 22 36.07% 52 59.09%No Difference 99 35.87% 42 33.07% 26 42.62% 31 35.23%

17.84 0.001

On a scale of 0 to 10, overall rating of old plan 6.13 ± 2.86 5.92 ± 3.03 6.48 ± 2.69 6.19 ± 2.74 0.96 0.38 On a scale of 0 to 10, overall rating of new plan 8.21 ± 2.27 8.39 ± 2.18 7.86 ± 2.56 8.18 ± 2.18 1.18 0.31

37

Table 4: Sources of Information About New Plan, Medicaid Bias, and Health Plan Choice


Group 1 HMO to

MediPass N=159

Group 2 MediPass to

HMO N=77

Group 3 HMO to

HMO N=117



Source(s) of Information about New Plan (choose all that apply)

Telephone call from new plan 72 20.87% 21 13.64% 23 29.87% 28 24.56% 9.60 0.008 Mail from new plan 167 48.27% 77 49.68% 44 58.67% 46 39.66% 6.82 0.033 Friend or family member 103 29.26% 47 29.56% 21 27.27% 35 30.17% 0.20 0.905 AHCA or DCF 92 26.51% 42 26.75% 19 25.33% 31 26.96% 0.07 0.966 Advertisment about new plan 79 22.70% 26 16.56% 24 32.00% 29 25.00% 7.42 0.024 In-person visit Doctor or Clinic 114 32.39% 72 45.57% 20 25.97% 22 18.80% 23.84 0.001 Work Other 104 29.55% 46 28.93% 25 32.89% 33 28.21% 0.54 0.764

Reported Being treated differently due to Medicaid enrollment 90 25.57% 43 27.04% 18 23.38% 29 25.00%0.40 0.820

Type of Provider who showed bias (For those who reported they had been treated differently because of Medicaid enrollment

A doctor or doctor's staff 44 50.00% 24 58.54% 11 61.11% 9 31.03%A dentist or dentist's staff 4 4.55% 2 11.11% 2 6.90%A pharmacist or pharmacist's staff 6 6.82% 3 7.32% 1 5.56% 2 6.90%

Health provider (non-specfic) or more than one category 8 9.09% 2 4.88% 1 5.56% 5 17.24%Other 26 29.55% 12

29.27% 3 16.67% 11 37.93%

11.98 0.15

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Group 1 HMO to

MediPass N=159

Group 2 MediPass to

HMO N=77

Group 3 HMO to

HMO N=117



Respondent chose/was assigned to old plan chose 159 46.49% 54 35.29% 40 52.63% 65 57.52%was assigned 183 53.51% 99 64.71% 36 47.37% 48 42.48%

14.39 0.001

Respondent chose/was assigned to new plan chose 312 88.64% 131 82.91% 70 90.91% 111 94.87%was assigned 40 11.36% 27 17.09% 7 9.09% 6 5.13%

10.05 0.007

Respondent has use new plan for medical care or prescription drug

Yes 289 82.10% 134 84.81% 63 81.82% 92 78.63%No 63 17.90% 24 15.19% 14 18.18% 25 21.37%

1.75 0.417

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