Women’s perceptions of medicaid managed care

Conference Women’s Perceptions of Medicaid Managed Care Patricia J. Venus, MA Regina Levin, MPH Thomas S. Rector, PhD Center for Health Care Policy and Evaluation United HealthCare* Minnetonka, Minnesota

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irtually all states have begun to enroll Medicaid beneficiaries in managed care in the belief that managed care approaches can improve the quality of health care services while controlling program costs.1 The number of Medicaid beneficiaries enrolled in managed care grew from 750,000, or 3%, of all beneficiaries in 1993 to 13.3 million, or 40%, of all beneficiaries in 1996.2,3 Medicaid beneficiaries enrolled in managed care are predominately low-income women and their children.4 The Medicaid population has presented several unique challenges for health plans, such as limited literacy, English proficiency, access to transportation, childcare, and telephone services,5 which require special efforts to deliver optimal health care. In addition, Medicaid beneficiaries have a greater likelihood to have health care needs than do low-income privately insured managed care enrollees.6 Research also suggests that people in poor health are more vulnerable to delivery system problems.7 Not only do the characteristics of the Medicaid population influence the delivery of managed care, but different approaches to managed health care may affect the experiences of Medicaid beneficiaries who utilize medical services. Recipients may need to select a primary physician from the health plan’s network. Primary care physicians may be assigned principal responsibility for coordinating care and approving and monitoring referral to specialists; however, managed care may give beneficiaries a greater choice of physicians by including both traditional and non-traditional providers in their networks. Managed care organizations might also place providers at full or partial financial risk for medical services through capitation. These organizational and financial structures are intended to reduce the need for inpatient utilization and inappropriate emergency department visits and to shift patients to more efficient providers while expanding choice of providers. There are concerns, however, that these approaches may create incentives for health plans and their contracting providers to underserve Medicaid members.8 To monitor the quality of care, federal and state agencies and accreditation organizations are increasingly requiring managed care organizations to assess and report their performance.3 As a result of the growth in Medicaid managed care, the Health Care Financing Administration (HCFA) issued Quality Assurance and Reform Initiatives in 1993 to ensure quality care for Medicaid beneficiaries.9 The National Committee for Quality Assurance (NCQA), a

*The opinions expressed in this article are those of the authors and do not necessarily reflect those of United HealthCare. © 1999 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/99/$20.00 PII S1049-3867(98)00050-4

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prominent managed care accreditation organization, issues accreditation standards that guide health plan efforts to monitor and improve clinical care and service to members.10 In 1996, NCQA began to require that health plans report process of care and outcome measures that exemplify some of the unique needs and concerns of the Medicaid population. In increasing numbers, states are requiring Medicaid managed care plans to report measures in the Health Plan Employer Data and Information Set (HEDIS) developed by NCQA.4 In 1999, HEDIS will include the Consumer Assessment of Health Plans (CAHPS 2.0) survey to capture the perspectives of Medicaid beneficiaries’ enrolled in managed care. In anticipation of the new standards, United HealthCare collected survey data from Medicaid beneficiaries enrolled in several of its affiliated health plans in 1997 using the initial version of CAHPS. These data are the basis of this report.

CONSUMER ASSESSMENT OF HEALTH PLANS (CAHPS) CAHPS was sponsored by the Agency for Health Care Policy and Research and developed by a consortium headed by Harvard University, the RAND Corporation, and the Research Triangle Institute. The overall goal of the project was to provide an integrated set of carefully tested, standardized questionnaires and report formats that could be used to collect and report reliable and meaningful information about the experiences of consumers enrolled in health plans.11 RAND was responsible for developing and testing survey items targeted toward Medicaid beneficiaries. Development of the adult Medicaid questionnaire was based on a review of the published literature, previously used consumer surveys, and the results of focus groups and cognitive interviews conducted with Medicaid beneficiaries in both English and Spanish.12 The CAHPS questionnaire elicits information on specific plan features such as access to specialists, patient-physician interactions, and customer service. Questions in the CAHPS 1.0 Adult Medicaid survey are listed as an Appendix. Respondents were asked to provide overall ratings of 1) their personal doctor or nurse, 2) the specialist physician they saw most often, 3) the health care they received, and 4) their health insurance plan using a 0 (worst) to 10 (best) point scale. They were also asked about the frequency of various experiences, such as how often care perceived as necessary was received (“never,” “sometimes,” “usually,” or “always”) or if a particular experience occurred, such as whether it was always easy to get a referral when needed (“yes” or “no”).

REPORT OBJECTIVES United HealthCare was one of the early adopters of CAHPS. Survey results are described to provide an early summary of the experiences and perceptions of female Medicaid beneficiaries enrolled in managed care organizations. For overall ratings, the developers of CAHPS recommend reporting data by grouping respondents based on the number of physician visits. The currently recommended classification scheme places members with three or more visits during a 6-month period into a “high-use” group and others into a “low-use” group.11 The presumed rationale behind this classification is that the high-use group has more experience with the health plan and, therefore, has the best opportunity to see how well it works. In addition, consumers want to know how well the delivery system will provide for them when they are sick.13 People in the high-use group might be expected to have poorer health status 82

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than the low-use group. Our analysis examined this presumption by comparing self-reported health status in the high- and low-use groups. Research has been conducted in managed care settings to examine the relationship between degree of health care utilization and consumer satisfaction with access to care and the quality of health care services.14 –17 Not all previous research found an association between use and satisfaction14 –16; however, none of the previous research focused on Medicaid beneficiaries, a population that may be more vulnerable to health plan methods to manage care. To further explore whether use of health services is related to consumer perceptions, the survey data were examined from adult female Medicaid respondents according to the recommended high-use and low-use group classification. To better understand the characteristics of high- and low-use groups, a variety of utilization variables were compared, in addition to physician visits, to determine if the extent of experience was markedly different across groups. Hypothetically, perceived difficulty getting care may result in low use among members who need health care. This concern was examined by comparing the reported frequency of not getting care when needed in the highand low-use groups.

METHODS Survey Sample The four plans that piloted the CAHPS questionnaire were structured as independent practice associations. Two of the health plans (A and B), with 15,000 –17,000 Medicaid members, had capitated financial arrangements with physicians. The other two plans (C and D), with 20,500 and 42,000 members, organized physicians as fee-for-service gatekeepers. Three of these health plans were located in states that mandated Medicaid beneficiaries to enroll in managed care; in one State (Plan D) enrollment in managed care was voluntary. All four health plans were affiliated with United HealthCare, a diversified health care management company that includes over 40 health plans nationwide with 5 million members, including 500,000 Medicaid enrollees. Members from these four plans were selected for the study population if they were 18 years of age or older and had been continuously enrolled from June through August 1997. The sample size for the CAHPS telephone survey was designed to achieve a 95% confidence interval on responses equal to 6 6 percentage points. Simple random samples ranging from 1,300 to 2,000 members were drawn from the Medicaid populations of each health plan. A computerized telephone number search was used to supplement and update phone numbers listed in the health plan enrollment data files. Fifty to ninety percent of the selected samples of Medicaid beneficiaries remained after members without known phone numbers were eliminated. After the survey process began, an additional 25%–50% of the health plan samples were not surveyed because of wrong or non-working numbers. Possible reasons for missing or inaccurate phone numbers include lack of phones, frequent residential changes among Medicaid beneficiaries, and incomplete or inaccurate enrollment data files.

Survey Process and Response Rates The survey was administered in late 1997 following the sampling and administration procedures recommended in the CAHPS Survey and Reporting Kit.11 Approximately 5 days before interviews were initiated, pre-notification letters were sent to members. Then professional, experienced interviewers

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called members and conducted the survey. Six attempts were made to contact each member. The average response rate across all four plans was 55% and ranged from 38% to 74%. Among contacted members, 1%–2% refused to participate in the survey in health plans A and D, whereas in health plans B and C 30%–34% refused.

Statistical Analysis Ratings on 0-to-10-point scales were summarized using median and quartile values for health plans and high- and low-use groups. Responses to other questions are presented as the percentages of members in various response categories. Distributions of ratings were compared across health plans using rank-sum statistical tests. Cochran-Mantel-Haenszel statistics stratified by health plan were used to compare high- and low-use groups. Data were analyzed using SAS software (SAS Institute, Cary, NC).

RESULTS Description of Respondents A total of 1,091 interviews were completed in the four health plans. Approximately 75% of the respondents were enrolled in Medicaid because they received Temporary Aid to Needy Families (TANF). Non-TANF beneficiaries were excluded from the remaining analyses because they were small in number; aged, blind, or disabled; or living in institutions and therefore likely to have different needs, experiences, and utilization patterns. Consequently, the analysis was based on 712 women who were TANF beneficiaries. Characteristics of these respondents are described in Table 1 by health plan. Most of the survey respondents in each health plan were enrolled for more than 1 year. There were notable differences in race across the four health plans. It is also noteworthy that the majority of women said they had at least a high school education. Plan B had a particularly low number of completed surveys, making it difficult to compare their results to the other plans with great confidence.

Overall Ratings Over 99% of respondents provided ratings of their health plan, and from 78% to 88% provided ratings of their health care. Ratings of personal physicians were provided by fewer surveyed members (70%, 44%, 74%, and 84% for Plans A to D, respectively), in part because the CAHPS survey only asked this question of respondents who had a person they thought of as their personal doctor or nurse. Similarly, only respondents who thought they needed a Table 1. RESPONDENT CHARACTERISTICS Health Plan

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Characteristics

A

B

C

D

Number of respondents Mean age (SD) Percentage of respondents High school graduate or more White African American Enrolled in plan 1 year or more

172 28(7)

94 30(8)

180 29(8)

266 31(8)

79 61 37 78

84 51 38 85

81 51 47 73

74 70 1 95

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Table 2. OVERALL RATINGS Health Plan A Dimensions

Personal doctor Specialist Health care Health plan

Rating*

B n

Rating

C n

Rating

D n

Rating

n

P Value

9 (8,10) 121

9 (8,10) 41

9 (8,10) 133

9 (8,10) 224

.13

10 (8,10) 47 8 (7,10) 151 8 (6,10) 171

9 (8,10) 24 8 (8,10) 76 8 (7,10) 94

9 (7,10) 51 9 (8,10) 140 9 (7,10) 178

9 (8,10) 74 9 (8,10) 216 9 (7,10) 265

.74 .02 .001

*Values are the 50th (25th, 75th) percentiles. The rating scale was from 0 (worst) to 10 (best) and the P value indicates if there were significant differences among the four health plans.

specialist in the last 6 months were asked to rate the specialist they saw most often. Data evaluating specialist care were available for only 27%, 20%, 52%, and 28% of the respondents. Since all members in the high-use group had three or more physician visits by definition, this subgroup may provide ratings of physicians based on actual recent experiences. Table 2 shows the overall ratings for the four health plans. In general, the majority of respondents gave high ratings to their personal doctor, specialist doctor, health care, and their health plan. At least 50% of the respondents in each health plan gave these dimensions of health care delivery a rating of 8 or higher on a scale of 0 (worst) to 10 (best). Twenty-five percent of the respondents in each health plan gave the best possible rating for each dimension. Fewer than 25% of members rated any of the four dimensions as a 5 or less. Ratings of personal doctors and specialists were not significantly different across the four health plans; however, overall ratings of health care and health plans did vary significantly. For example, members of Plan A rated both their health care and health plan significantly (P , .05) less favorably than members of Plan D. The median rating for Plan A was one point less on the 11-point scale than the median rating for Plan D.

Comparisons of High- and Low-Use Groups Utilization Consistent with definitions recommended by CAHPS, women included in the high-use group were respondents who stated that they had three or more physician visits in the last 6 months. Conversely, women in the low-use group were respondents who stated that they had less than three visits to a doctor’s office or clinic in the last 6 months. These self-reported classifications were not verified using claims or encounter data. Given the small sample sizes, data from all four health plans were aggregated to compare high- and low-use groups using an analysis stratified by health plan. Overall, 61% (n 5 430) of the respondents were in the low-use group. Twenty-nine percent of the low-use group had no visits to a doctor’s office or clinic during the past 6 months. Consistent with fewer physician visits, a smaller proportion of the low-use group used prescription medication (71% versus 96%; P , .001), were hospitalized (14% versus 28%, P , .001), or used emergency care (27% versus 42%; P , .001). Therefore, utilization of medical care was less frequent in the low-use group, although a substantial portion of the low-use group did receive the aforementioned health care services.

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Health Status The health status of the high-use group was significantly different than the low-use group (P , .001). Members in the high-use group were somewhat more likely than members in the low-use group to report a fair or poor health status (22% versus 10%); however, 43% of the high-use group stated they were in excellent or very good health, and 35% said their health was good. Although only 10% of the low-use group indicated they had fair or poor health status, 63% reported having a medical condition lasting more than 3 months that was treated with a prescription medication, compared to 85% of the high-use group. The survey did not assess the severity of the respondents’ medical conditions. The high-use group was more likely than the low-use group to be pregnant or have given birth in the last 6 months (20% versus 6%; P , .001). This observation might explain why some women had frequent physician visits but reported they had good health. Perceived Medical Care Needs The low-use group appeared to have less perceived need for medical services than the high-use group. For example, fewer members in the low-use group reported they tried to see a doctor or nurse for routine care (58% versus 81%; P , .001) or illness (42% versus 70%; P , .001), needed specialist care (22% versus 52%; P , .001) or tests or treatments (46% versus 70%; P , .001), or phoned their doctor for medical advice (48% versus 79%; P , .001). As shown in Table 3, however, among those reporting a need for health care services, members with fewer physician visits more frequently said they experienced problems getting help or advice when phoning a doctor’s office or clinic, getting tests and treatments, and seeing a specialist when they thought they needed these types of services. Approximately one third of respondents in both groups said they never had to see someone else when they wanted to see their personal doctor or nurse. Similar percentages of the low- and high-use groups reported that it was easy to find a personal doctor or nurse they were happy with (74% versus 79%). Despite the fact that the low-use group found it easy to find a personal doctor, low use appears to be a combination of low perceived need for care and perceived difficulty getting care when a need occurs.

Table 3. PERCEPTIONS OF GETTING NEEDED CARE IN HIGH- AND LOW-USE (PHYSICIAN VISITS) GROUPS Use Group Low %

How often did you get the medical help or advice you needed when you phoned the doctor’s office or clinic?* How often did you get the test or treatment you thought you needed?* How often did you see a specialist when you thought you needed one?* How often did you have to see someone else when you wanted to see your personal doctor or nurse?† *Percent of respondents answering “usually” or “always.” †Percent of respondents answering “never.”

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High n

%

n

P Value

40 173

66 186

.001

23

97

54 151

.001

8

36

31

87

.001

29 123

34

95

.13

Table 4. OVERALL RATINGS BY HIGH- AND LOW-USE (PHYSICIAN VISITS) GROUPS Use Group Low

High

Dimensions

Rating*

n

Personal doctor Specialist Health care Health plan

9 (8,10) 8 (7,10) 9 (8,10) 9 (7,10)

294 69 304 427

Rating

9 (8,10) 9 (8,10) 9 (7,10) 8 (7,10)

n

224 127 279 279

P Value

.44 .05 .84 .04

*Values are the 50th (25th, 75th) percentiles. The rating scale was from 0 (worst) to 10 (best).

Overall Ratings To examine the association of number of physician office visits with subjective evaluations of the health care delivery system, relationships between the highand low-use groups and overall ratings were tested. In general, overall ratings for personal doctors and health care were high and similar for the high- and low-use groups. (See Table 4.) Ratings of specialists were significantly different between low- and high-use groups with the low-use group tending to give less favorable ratings. As expected, only 16% of the low-use group rated specialist care compared to 45% of the high-use group. Over 99% of both the high- and low-use groups rated their health plan. The high-use group had lower overall ratings of their health plan than the low-use group. Although the difference was statistically significant, the median health plan rating of the high-use group was only one point lower (8 versus 9).

DISCUSSION The CAHPS survey was designed primarily to help consumers select health plans. It is believed that the experiences and perceptions of large numbers of health plan members can identify health plans that provide the most value to health care consumers.11 This report provides some of the first available data based on the CAHPS questionnaire completed by adult female Medicaid recipients. In addition, this report examined the use of physician visits as a criterion to differentiate perceptions of health plan performance among Medicaid beneficiaries. Previous research found that Medicaid beneficiaries enrolled in managed care had high levels of satisfaction.18 Most Medicaid respondents from the four managed care health plans in this study gave their physicians, health care, and health plans high overall ratings; however, there were differences among the four health plans evaluated. One health plan had significantly less favorable ratings of overall health care received and the overall health plan performance. These results suggest that the CAHPS data may be useful to differentiate health plans. There were differences between plans of similar magnitude that were not statistically different and these differences may have been due to random variation. Differences in the number of respondents per health plan make it difficult to compare health plans with the same degree of confidence in the ratings. Although statistically significant, the differences in this study of approximately one point on an 11-point scale were not large, and the importance of the observed difference to women choosing a health plan is not known. Furthermore, analyses are needed to understand the reasons for the observed differences in overall ratings. Overall ratings with responses to other CAHPS

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questions were not correlated, nor were relationships examined between health plan or member characteristics and differences in overall ratings. Although the majority of women gave their health plans high ratings, a portion (,25%) gave ratings of less than 5. Another study on perceptions of Medicaid beneficiaries found similar beneficiary dissatisfaction.18 Different factors may explain high and low ratings. Information from members that give low ratings may provide insight into ways that health care systems could improve to meet the needs of members. Additional analyses, and perhaps additional queries not currently in the CAHPS questionnaire, are needed to understand why some members gave low ratings. Larger sample sizes than were available in this study are needed to analyze the small subgroup that gives low ratings. The low-use group rated specialist care and health plans differently than the high-use group. The low-use group rated their specialists less favorably. The CAHPS questionnaire does not include questions to help illuminate reasons for respondents’ different perceptions of specialists. Interestingly, the low- and high-use groups rated personal doctors similarly. A higher percentage of the high-use group saw a specialist when they thought they needed one, which is noteworthy because respondents who thought they needed a specialist rated specialists even if they did not actually visit one. Perhaps members that have greater perceived needs for specialist care and get specialist care may be more likely to rate their specialists favorably. Earlier research found that members who felt they needed a referral to a specialist but did not get one had less favorable perceptions of physician competency and efficiency and general satisfaction.19 Perhaps members in the high-use group had more favorable perceptions because they were more likely to visit specialists and had an opportunity to form an opinion based on experience. The high-use group rated their health plans less favorably than the low-use group. Although not shown, responses to questions about experiences with the health plan were examined. Specifically, reported experiences with paperwork, handling of approvals and payments, and health plan customer service were analyzed. The high- and low-use groups had similar experiences. The reason the high-use group gave less favorable ratings than the low-use group is not apparent. Previous research does not consistently show that high use was associated with lower satisfaction with the health plan.20 Since the high-use group did have more favorable perceptions of specialists and less favorable ratings of health plans than the low-use group, data reported by use groups may provide unique insights; however, when ratings of health plans were compared using only the high-use group, the results were essentially the same as the comparisons shown in Table 2 that were based on both groups combined. Combining both use groups did not alter or contradict plan comparisons based only on the high-use group. There were no differences among health plans in ratings of specialists by the high-use group (data not shown); however, the smaller size of the high-use group made it more difficult to detect differences across health plans. The CAHPS survey indicated that many respondents in both the high- and low-use groups did not get the care they thought they needed. Although barriers to access to care were observed, as measured by responses to questions about “getting the care you need,” it is not clear that these women received substandard medical care. More analysis is needed to examine whether consumers who believe they did not get all of the care they needed are less likely to get health care that meets standards set forth in authoritative medical guidelines or whether they have differences in health outcomes. The appropriateness of limitations on care when there is a perceived need requires further investigation. Questions such as whether perceived needs for medical 88

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care are appropriate and whether managed care organizations inappropriately create barriers to needed care should be examined. Perceptions that needed care was not received were more prevalent in the low-use group than the high-use group. Indeed, perceived access barriers may partially explain the lower number of physician visits. The health status of the low- and high-use groups were not markedly different. Therefore, similar utilization rates would be expected unless perceptions of access barriers or utility of medical care were different. It is possible that the low-use group had less propensity to use medical care based on personal beliefs about medical care.21 Women who had positive experiences may have had a greater willingness to return for more health care services, whereas women who had negative experiences may have been reluctant to seek additional health care services.22 Perhaps the high-use group learned to navigate the managed care system and the low-use group needs more assistance dealing with managed care or better explanations of why desired care may not be necessary. Whatever the reasons, these data suggest that perceptions of members who did not get the care they thought they needed should be examined in more detail in the future. In summary, women’s perceptions of Medicaid managed care generally were quite favorable for the four health plans in this study. The CAHPS questionnaire did identify some differences between health plans and some potential opportunities for improving health care. More information is needed to understand differences in consumer perceptions and to determine the importance of observed differences to consumers. In this pilot study, it was difficult to interpret the data due to insufficient and potentially biased responses. These concerns need to be addressed. In 1999, health plans will be required to increase the CAHPS sample size, and attempts to increase responses rate will be made by using a combined mail and telephone survey administration method. Hopefully, with continued effort to improve and understand CAHPS data, women’s perceptions of managed care will become more valuable information with which to compare and improve health plan performance.

REFERENCES 1. U.S. Dept. of Health and Human Services, Health Care Financing Administration, Center for Medicaid and State Operations. Medicaid statistics: program and financial statistics, fiscal year 1996, HCFA Pub. No. 10129. Washington (DC): Health Care Financing Administration, 1998. 2. Scott KC, Simon L. Women’s health and managed care: promises and challenges. Womens Health Issues 1996;6:39 – 44. 3. U.S. Dept. of Health and Human Services, Health Care Financing and Administration, Office of Research and Demonstrations. Health care financing review: statistical supplement. Washington (DC): Health Care Financing Administration, 1997. 4. Landon BE, Tobias C, Epstein AM. Quality management by state Medicaid agencies converting to managed care: plans and current practices. JAMA 1998;279:211– 6. 5. Perkins J, Olson K, Rivera L, Skatrud J. Making the consumers’ voice heard in medicaid managed care: increasing participation, protection and satisfaction. Report on required and voluntary mechanisms. Los Angeles (CA): National Health Law Program, 1996. 6. Lillie-Blanton M, Lyons B. Managed care and low-income populations: recent state experiences. Health Aff (Millwood) 1998;17:238 – 47. 7. Gold M, Sparer M, Chu K. Medicaid managed care: lessons from five states. Health Aff (Millwood) 1996;15:153– 65. 8. Holahan J, Zuckerman S, Evans A, Rangarajan S. Medicaid managed care in thirteen states. Health Aff (Millwood) 1998;17:43– 63. 9. U.S. Dept. of Health and Human Services, Health Care Financing Administration,

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10.

11.

12.

13. 14.

15.

16. 17. 18. 19. 20. 21. 22.

Medicaid Bureau. A health care quality improvement program system for medicaid managed care. Washington (DC): Health Care Financing Administration, 1993. National Committee for Quality Assurance. 1998 surveyor guidelines for accreditation of managed care organizations. Washington (DC): National Committee for Quality Assurance, 1998. U.S. Dept. of Health and Human Services, Agency for Health Care Policy and Research. CAHPS 1.0: survey and reporting kit, AHCPR Pub. No. 97-0063. Rockville (MD): Agency for Health Care Policy and Research, 1997. Hays RD, Brown JA, Nederend S. Summary of RAND’s 1996 field test: results from the consumer assessment of health plans study, RAND Pub. No. DRU-1665AHCPR. Santa Monica (CA): RAND, 1997. Blendon RJ, Brodie M, Benson JM, et al. Understanding the managed care backlash. Health Aff (Millwood) 1998;17:80 –110. Zapka JG, Palmer HR, Hargraves LJ, Nerenz D, Frazier HS, Warner CJ. Relationships of patient satisfaction with experience of system performance and health status. J Ambulatory Care Manage, 1995;18:73– 83. Meng YY, Jatulis DE, McDonald JP, Legorreta AP. Satisfaction with access to and quality of health care among medicare enrollees in a health maintenance organization. West J Med, 1997;166:242–7. Jatulis DE, Bundek NI, Legorreta AP. Identifying predictors of satisfaction with access to medical care and quality of care. Am J Med Qual, 1997;12:11– 8. Fincham JE, Wertheimer AI. Predictors of patient satisfaction in a health maintenance organization. J Health Care Mark, 1986;6:5–11. Sisk JE, Gorman SA, Reisinger AL, Giled SA, DuMouchel WH, Hynes MM. Evaluation of medicaid managed care. JAMA, 1996;276:50 –5. Zapka JM. Assessment of member satisfaction in and HMO: understanding the interaction of variables and their implications. J Ambulatory Care Manage, 1979:29–45. Gelb BD, Gaskins JN, Hendrickson JG, Iszard JE. Does greater usage of a health plan reduce satisfaction? J Health Care Mark, 1991;11:68 –74. Andersen R. A behavioral model of families’ use of health services. Research Series No A25. Chicago: University of Chicago Press, 1968. Ware JE, Davies-Avery A, Stewart AL. The measurement and meaning of satisfaction. Health Med Care Serv Review, 1978;1:1–15.

APPENDIX Adult Medicaid Managed Care Questionnaire for CAHPS 1.0* I. OVERALL RATINGS Use any number on a scale from 0 to 10 where 0 is the worst personal doctor or nurse possible and 10 is the best personal doctor or nurse possible. How would you rate your personal doctor or nurse now? Use any number on a scale from 0 to 10 where 0 is the worst specialist possible and 10 is the best specialist possible. How would you rate the specialist? Use any number on a scale from 0 to 10 where 0 is the worst health care possible and 10 is the best health care possible. How would you rate all your health care? Use any number on a scale from 0 to 10 where 0 is the worst health insurance plan possible and 10 is the best health insurance plan possible. How would you rate your health insurance plan now? II. GETTING THE CARE THAT YOU NEED, WHEN YOU NEED IT A. Getting the care you need In the last 6 months, how often did you have to see someone else when you wanted to see your personal doctor or nurse? In the last 6 months, how often did you see a specialist when you thought you needed one?

*Reprinted from U.S. Dept. of Health and Human Services, Agency for Health Care Policy and Research. CAHPS 1.0 survey and reporting kit, AHCPR Pub. No. 97-0063. Rockville (MD): AHCCPR, 1997.

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III.

IV.

V.

VI.

VII.

In the last 6 months, how often did you get the medical help or advice you needed when you phoned the doctor’s office or clinic during the day Monday to Friday? In the last 6 months, how often did you get the tests or treatment you thought you needed? B. Getting the care without long waits In the last 6 months, how often did you get that medical help or advice during the day Monday to Friday without a long wait? In the last 6 months, when you tried to be seen for an illness or injury, how often did you see a doctor or other health professional as soon as you wanted? In the last 6 months, when you needed regular or routine health care, how often did you get an appointment as soon as you wanted? In the last 6 months, how often did you wait in the doctor’s office or clinic more than 30 minutes past your appointment time to see the person you went to see? DOCTORS AND MEDICAL CARE A. Easy to find a personal doctor you are happy with With the choices your health insurance plan gives you, was it easy to find a personal doctor or nurse you are happy with? B. Doctors who communicate well with patients In the last 6 months, how often did doctors or other health professionals listen carefully to you? In the last 6 months, how often did doctors or other health professionals show respect for what you had to say? In the last 6 months, how often were you involved as much as you wanted in these decisions about your health care? C. Doctors who spend enough time with patients and know their medical history In the last 6 months, how often did doctors or other health professionals spend enough time with you? In the last 6 months, how often did doctors or other health professionals know what you thought they should know about your medical history? D. Being encouraged to exercise or eat a healthy diet In the last 6 months, has a health professional or your health insurance plan encouraged you to exercise or eat a healthy diet? MEDICAL OFFICE STAFF A. Courtesy, respect, helpfulness of medical office staff In the last 6 months, how often did office staff at a doctor’s office or clinic treat you with courtesy and respect? In the last 6 months, how often were office staff at a doctor’s office or clinic as helpful as you thought they should be? THE HEALTH PLAN A. Reasonable paperwork, handling of approvals and payments In the last 6 months, how often did you have more forms to fill out for your health insurance plan than you thought was reasonable? In the last 6 months, how often did your health insurance plan deal with approvals or payments without taking a lot of your time and energy? B. Health plan customer service: efficiency and helpfulness In the last 6 months, how often were your calls to the health insurance plan’s customer service taken care of without a long wait? In the last 6 months, did you get all the information or other help you needed when you called the health insurance plan’s customer service? In the last 6 months, how often were the people at the health insurance plan’s customer service as helpful as you thought they should be? SPECIAL TOPICS THAT APPLY ONLY TO HMO & POS PLANS A. Easy to get referral to specialist In the last 6 months, was it always easy to get a referral when you needed one? SCREENERS AND DEMOGRAPHIC QUESTIONS Our records show that you are now covered by (health insurance plan name). Is this right? Is this the health insurance plan that you use for all or most of your health care? How many months or years in a row have you been covered by (health insurance plan name)?

VENUS ET AL: WOMEN’S PERCEPTIONS OF MEDICAID MANAGED CARE

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Since you joined the plan, have you tried to find a personal doctor or nurse for yourself? Do you have one person you think of as your personal doctor or nurse? In the last 6 months, did you try to see your personal doctor or nurse? In the last 6 months, have you thought you needed to see a specialist? In the last 6 months, in order to see a specialist did you need to get a referral, that is approval or permission, from your doctor? In the last 6 months, did you phone a doctor’s office or clinic during the day Monday to Friday to get medical help or advice for yourself? In the last 6 months, did you try to see a doctor or other health professional right away to get care for an illness or injury? In the last 6 months, did you try to make any appointments with a doctor or other health professional for regular or routine health care? In the last 6 months, how many times did you go for your own care to an emergency room? In the last 6 months (not counting times you went to an emergency room), how many times did you go for your own care to a doctor’s office or clinic? In the last 6 months, were any decisions made about your health care? In the last 6 months, did you think you needed any tests or treatment? In the last 6 months, was your health insurance plan asked to approve or pay for any health care for you? In the last 6 months, did you call your health insurance plan’s customer service to get help of any other kind? In the last 12 months, have you been a patient in a hospital overnight or longer? Not counting pregnancy, do you now have any medical conditions that have lasted for at least 3 months? In the last 12 months, have you seen a doctor or other health professional more than twice for any of these conditions? Have you been taking prescription medicine for at least 3 months for any of these conditions? In general, how would you rate your overall health now? What is your age now? Are you male or female? What is the highest grade or level of school that you have completed? Are you of Hispanic or Spanish family background? How would you describe your race? Did someone help you complete this survey? How did that person help you? In the last 6 months, how often have you had a hard time speaking with or understanding a doctor or other health professional because you spoke different languages? An interpreter is someone who repeats or signs what one person says in a language used by another person. In the last 6 months, did you need an interpreter to help you speak with doctors or other health professionals? In the last 6 months, when you needed an interpreter to help you speak with doctors or other health professionals, how often did you get one? Some states pay health plans to care for people covered by (Medicaid/state name for Medicaid). With these health plans, you may have to choose a doctor from the plan list, or go to a clinic or health care center on the plan list. Are you covered by a health plan like this? Did you choose your health plan or were you told which plan you were in? You can get information about plan services in writing, by telephone, or in person. Did you get any information about your health plan before you signed up for it? How much of the information that you were given before you signed up for the plan was correct? What language do you mainly speak at home?

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WOMEN’S HEALTH ISSUES VOL. 9, NO. 2 MARCH/APRIL 1999