Consumer Choice and Health Care Quality
Research SummaryPublished 2002
Research SummaryPublished 2002
Consumer choice is a key approach to improving the quality of health care for Americans. The idea is this: Survey people about the quality of their health care experiences and report the results so that consumers can make informed decisions about a variety of health issues, such as selecting a health plan.
A project known as CAHPS® is furthering the goals of consumer choice by developing reliable survey and reporting tools. CAHPS began in 1995 as a way to collect and report consumer information about the quality of health plans, but its objectives have expanded to include other areas as well, such as chiropractic and nursing home care. Its original name—Consumer Assessment of Health Plans Study—has been dropped, and the acronym is now a stand-alone term. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ), the project's sponsor.
The CAHPS tools are continuously assessed and refined, a process that is helping to inform the debate about consumer choice. This research brief describes the lessons learned during the initial CAHPS effort to develop survey and reporting tools for health plans. Key insights include the following:
CAHPS has its roots in a study commissioned in 1994 by AHRQ to evaluate existing health plan satisfaction surveys. The study found that most surveys were not designed to provide information for consumer choice.[1]
Armed with these results, AHRQ funded the initial five-year, $15 million CAHPS project beginning in 1995. The project's goals were (1) develop a standardized survey to collect feedback from consumers about things important to them in a health plan and (2) present survey results to consumers in an easily understood format for use in making health plan decisions.
AHRQ awarded cooperative agreements to three institutions to carry out CAHPS:
In addition, Westat was selected to coordinate activities among the CAHPS investigators and to operate the CAHPS Survey Users Network, which distributes CAHPS tools and provides technical assistance.
In today's health care market, choosing a health plan often means picking the doctors, hospitals, and other providers that can be used. That is why it is important for consumers to consider the quality of a health plan along with its costs and covered services when choosing a plan for the first time or switching plans.
Many organizations that purchase health plans for consumers, such as private employers and government agencies, are helping the decisionmaking process by sponsoring a CAHPS survey. The sponsor typically hires a vendor to administer the CAHPS survey to a sample of current plan enrollees. The survey results are then analyzed and compiled into report cards that people can use to make health plan decisions. The Center for Medicare & Medicaid Services, for example, sponsors CAHPS surveys, and the resulting health plan report cards are available to all Medicare beneficiaries.
Other CAHPS sponsors include the U.S. Office of Personnel Management and the Department of Defense; state Medicaid offices; private employers and business coalitions; and health plans (for internal quality improvement or for accreditation).
The CAHPS survey and reporting tools are in the public domain and are available without cost through the CAHPS Survey Users Network (see "For More Information" below).
Unlike many existing consumer surveys that only ask people how satisfied they are with their health plan, a CAHPS survey probes deeper, posing questions that are meaningful to individuals (see "CAHPS Survey Questions" below). The survey asks people to rate their health care and health plan overall (called global ratings) and to report on their health care experiences. Results are summarized in five different aspects of care:
The first version of the CAHPS survey was released in 1997. An updated version, CAHPS 2.0, was released a year later, incorporating the results of field-testing and other analyses. This version consists of the following:
Based on additional research and refinements, an updated version of the core survey questions will be available in the fall of 2002. In addition, the beta version of a questionnaire about people's experiences with group medical practices is available. Other CAHPS surveys in various stages of development will expand consumer assessments into such areas as dental, chiropractic, and nursing home care, as well as behavioral health care.
CAHPS provides software that analyzes answers to the survey questions and summarizes the results for each of the five categories of care. The software also generates the global ratings of the health plan and the care provided. These results can then be assembled into a report card for consumers, either in a printed form or in an interactive computer display. CAHPS provides the following two suggested formats for the report cards, which can be modified for different audiences:
Adults who had been enrolled in their current health plan for at least 12 months answered survey questions about the care they received in the previous 12 months.
Getting care that is needed | Getting care without long waits | How well doctors communicate | How people rated their health care | Courtesy, respect, and helpfulness of office staff | Health plan customer service | How people rated their health plan | |
---|---|---|---|---|---|---|---|
HMO 1 | ★ | ★★ | ★ | ★ | ★★ | ★ | ★ |
HMO 2 | ★★★ | ★★ | ★★ | ★★★ | ★★★ | ★★★ | ★★ |
PPO 1 | ★ | ★ | ★ | ★★ | ★★ | ★ | ★★ |
PPO 2 | ★★★ | ★★ | ★★★ | ★★★ | ★★★ | ★★ | ★★★ |
★★★ = BETTER than survey average; ★★ = ABOUT THE SAME as survey average; ★ = WORSE than survey average
Unlike previous consumer survey efforts, CAHPS took a rigorous approach to developing a standardized questionnaire that captures data from consumers in a range of health plan options—from fee-for-service to managed care—and in both commercial plans and publicly funded ones, such as those offered through Medicare and Medicaid.
In developing the survey, the CAHPS researchers relied heavily on input from stakeholders. Early on, they held numerous focus groups—meetings with consumers and experts—to find out what they thought should be asked in the survey. Then, the researchers fine-tuned the wording of the questions by recording how volunteers interpreted them during one-on-one in-depth interviews. The questionnaires were also field-tested extensively to ensure that the questions were reliable and valid indicators of quality of care from the consumer's perspective.
Using a rigorous translation process to achieve high quality, CAHPS produced the questionnaires in foreign languages commonly spoken in the United States, translating them first into Spanish, then later into Vietnamese, Korean, Mandarin, and Russian.
Finally, the survey and reporting tools were tested under real-life conditions in several large demonstrations, including in Washington State, Kansas, New Jersey, Iowa, Oregon, and Pennsylvania.
Today, CAHPS report cards are available for health plans serving 125 million Americans. Early lessons from the CAHPS project underscore that using information about quality when making health plan decisions is still new for consumers, who are more accustomed to making choices based on a plan's costs and benefits. The lessons also identify the challenges ahead in reaching the diverse American population with information about quality. Key findings are highlighted below.
In laboratory trials, both privately insured individuals and those on Medicaid who read CAHPS report cards were more likely to choose health plans that performed better.[2,3] In the real world, however, consumers are inundated with information, and getting their attention will require time and education.[4] Still, early field tests of CAHPS report cards showed some positive signs. For example, a large proportion of Washington State employees said that reading the CAHPS report cards at open enrollment time influenced their health plan decisions on some level.[5] In addition, an analysis of New Jersey Medicaid beneficiaries who read the CAHPS report cards sent to them found some indication that the information influenced them to choose HMOs with better CAHPS ratings.[6]
The table below summarizes data from eight CAHPS evaluations that showed the widely varying, initial responses that consumers had to CAHPS information about health plan quality.
CAHPS evaluations identified a number of challenges to surveying people about their health care experiences and making the resulting information about quality easy to understand and use by others.
Also, low education and reading levels, plus age-related physical and cognitive declines, make it difficult for many Medicare beneficiaries to interpret such information. After pilot testing the new Medicare & You materials containing CAHPS information on quality, the Center for Medicare & Medicaid Services dropped the star charts altogether. It now includes only one quality measure (doctors who communicate well) in a bar graph in the printed booklet that beneficiaries receive. Interested individuals can get additional quality measures by calling 1-800-MEDICARE or using the Medicare Health Plan Compare feature on the Medicare web site (www.medicare.gov).[7,14,15]
Health-Plan Type | Private Insurance | Medicaid | Medicare |
---|---|---|---|
Looked at CAHPS report | 24–77 | 43 | 16a |
15–30 min. reading time (most common) | 15–44 | 38–46 | 37 |
Influenced plan choice "a lot" | 9–33 | 40 | 17 |
Influenced plan choice "a little" | 33–39 | 33–46 | 21 |
No influence on plan choice | 34–55 | 15–27 | 61 |
aThis percentage is from reference [8].
CAHPS will continue to be improved and expanded during a five-year follow-on study, CAHPS II, which is scheduled to begin in the summer of 2002. Leading the CAHPS II research teams are Harvard Medical School, RAND, and the American Institutes for Research. Westat will continue providing technical support. The goal for the next five years of research is to continue to expand CAHPS beyond health plans to the individual provider level, as well as to continue development of CAHPS instruments for other health care settings.
CAHPS survey data are also being pooled into a single resource—called the National CAHPS Benchmarking Database—for use by policymakers, researchers, health plans, and health plan purchasers.
The papers cited in this document are listed below. A selected, annotated bibliography of key CAHPS publications is available online.
The CAHPS Survey Users Network offers free of charge a range of technical support for organizations wishing to conduct a CAHPS survey as well as the CAHPS Survey and Reporting Kit. In addition to all CAHPS survey and reporting tools, the Kit contains detailed instructions for planning and conducting a CAHPS project, the CAHPS SAS analysis software to analyze results, a consumer-oriented video, and print report templates. The CAHPS Survey Users Network also provides online instructional workshops, meetings, and networking opportunities. For information on how to access the CAHPS Survey Users Network, go to www.ahrq.gov.
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