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Understanding Variations in Patient Care from the Patient’s Viewpoint Integrated Patient Care Expert Advisory Panel Boston, MA ● February 13, 2015 Financial.

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Presentation on theme: "Understanding Variations in Patient Care from the Patient’s Viewpoint Integrated Patient Care Expert Advisory Panel Boston, MA ● February 13, 2015 Financial."— Presentation transcript:

1 Understanding Variations in Patient Care from the Patient’s Viewpoint Integrated Patient Care Expert Advisory Panel Boston, MA ● February 13, 2015 Financial support for this research was provided by The Commonwealth Fund and Kaiser Permanente Community Benefit; the Lucian Leape Foundation provided financial support for the advisory panel. Thanks to Ariadne Labs for hosting the inaugural advisory panel meeting.

2 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary & next steps Aim to understand and critically assess survey development and initial results and explore new opportunities

3 Meet the project team Harvard: Sara Singer, Ashley Fryer, Michaela Kerrissey, Maryaline Catillon, Juliana Stone UC Berkeley: Steve Shortell, Patty Ramsay Weill Cornell: Larry Casalino RAND: Mark Friedberg, Maria Orlando Edelen, Sam Hirshman Penn State: Jonathan Clark

4 Introductions of panel and guests Your background Activities related to integrating care or studying its impact in which you or your organization is involved

5 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary & next steps Aim to understand and critically assess survey development and initial results and explore new opportunities

6 PPIC national sample overview Original sample: 12,364 Medicare beneficiaries Number of medical groups represented: 150 Number excluded*: 412 Surveys received: 3226 Response rate: 27% Percent respondents who verified their association with the medical group: 84% A response rate of 27% was slightly lower than hoped, but on par with similar surveys and sufficient for analysis

7 Psychometric analysis of PPIC 2.1 responses We analyzed 3226 PPIC 2.1 responses – 1066 randomly drawn and reserved for CFA – Remaining 2160 responses entered into EFA We withheld items with low covariance coverage (i.e., those answered infrequently) from EFA Before conducting EFA, we adjusted each item score for “response tendency” (i.e., general optimism or pessimism) – Using residuals after accounting for LOT-R scores

8 EFA yielded a 5-factor solution Staff awareness of information about the patient 3 items, Cronbach alpha = 0.80 Provider communication with the patient 12 items, Cronbach alpha = 0.86 Provider knowledge about the patient 5 items, Cronbach alpha = 0.70 Integration post visit3 items, Cronbach alpha = 0.67 Integration with specialists2 items, correlation = 0.61

9 Staff awareness of information about the patient (3 items) In reference to staff in the index provider’s office: – In the last 6 months, how often did these other staff seem up-to-date about the care you were receiving from this provider? – In the last 6 months, how often did these other staff talk to you about the care you received from this provider? – In the last 6 months, how often did these other staff seem to know the important information about your medical history?

10 Provider communication with the patient (12 items) In the last 6 months, how often did this provider or someone in his or her office… – Talk with you about what to do if you have a bad reaction to your medicine? – Talk with you about how you were supposed to take your medicine? – [conditional on needing services at home] Help you get these services at home to take care of your health? – Help you identify the most important things for you to do for your health? – [conditional on presence of things that make it hard to take care of your health] Ask you about these things that make it hard for you to take care of your health? And Help you come up with a plan to help you deal with the things that make it hard for you to take care of your health? – Give you instructions about how to take care of your health? And In the last 6 months, how often did the instructions you received help you take care of your health? – Contact you between visits to see how you were doing?

11 Provider communication with the patient (12 items), continued In the last 6 months: – Did this provider talk with you about setting goals for your health? And Did the care you received from this provider help you meet your goals? – [conditional on receiving a prescription from a specialist] In general, how often does the provider named in Question 1 talk with you about the medicines prescribed by these specialists? – Before your most recent visit with this provider, did you get a reminder from this provider's office about the appointment? And Before your most recent visit with this provider, did you get instructions telling you what to expect or how to prepare for the visit? – How often did this provider ask about things in your work or life at home that affect your health? – [conditional on missing an appointment] When you missed an appointment with this provider, how often did someone from his or her office contact you to make a new appointment?

12 Provider knowledge about the patient (5 items) How would you rate this provider’s knowledge of your values and beliefs that are important to your health care? In general, how often does the provider named in Question 1 seem informed and up-to-date about the care you get from specialists? In general, how often do you have to remind the provider named in Question 1 about care you receive from specialists? In the last 6 months, how often did this provider seem to know the important information about your medical history? In the last 6 months, how often did you have to repeat information that you had already provided during the same visit?

13 Integration post visit (3 items) [conditional on having had a test] In the last 6 months: – When this provider or someone in his or her office ordered a blood test, x-ray, or other test for you, how often did this provider or someone from his or her office follow up to give you those results? – How often did you have to request your test results before you got them? – How often were your test results presented in a way that was easy to understand?

14 Integration with specialists (2 items) [conditional on having seen a specialist] In the last 6 months: – When you see this specialist, does he or she seem to know enough information about your medical history? – When you see this specialist, how often does this specialist seem to know all your test results from other providers?

15 Integration following a hospital stay (4 items) This scale included items not entered into factor analysis because few patients had hospital stays (low covariance coverage) [conditional on having had a hospital stay] After your most recent hospital stay: – Did the provider named in Question 1 or someone in his or her office contact you to see how you were doing? – Did the provider named in Question 1 or someone in his or her office contact you to check if you were able to follow instructions about any medicines you were prescribed? – Were you given instructions about caring for yourself at home? And, were the instructions you were given easy to understand? – After your most recent hospital stay, did the provider named in Question 1 seem to know important information about this hospital stay?

16 Orphan items Three items failed to load with any factor In the last 6 months: –If you had any trouble taking care of your health at home, would you know who to ask for help? –There are many reasons why people may not always be able to take their medicines as prescribed. How often were you able to take your medicine as prescribed? –How often did this provider cancel or change the date of an appointment?

17 Psychometric summary Final model demonstrates satisfactory goodness of fit according to standard measures And sufficient discriminant validity (factor correlations ranging from.214 to.458 versus internal consistencies > 0.61) MeasureExploratory sample Confirmatory sample Target Χ2 (df) (248) (262)N/A RMSEA <0.08 CFI >0.93 SRMR <0.08

18 Coordinated within care team Coordinated across care teams Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility Continuity: familiarity with patient over time Continuity: proactive and responsive action between visits Patient centeredness Shared responsibility Coordination between care teams and community resources PPIC 1.0 PPIC 2.0 

19 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay PPIC 2.1

20 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility PPIC 2.1 PPIC 2.0 

21 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility PPIC 2.1 PPIC 2.0 

22 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility PPIC 2.1 PPIC 2.0 

23 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility PPIC 2.1 PPIC 2.0 

24 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility PPIC 2.1 PPIC 2.0 

25 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility PPIC 2.1 PPIC 2.0 

26 PPIC journey Psychometrically-derived factors are generally consistent with the 11 functional domains of integrated care we hypothesized based on PPIC 2.0 Psychometric analysis also suggests that patients may not differentiate between knowledge and communication about medical and patient- centered issues – Items about provider knowledge of/communication about patients’ medical care loaded onto the same factors as items about provider knowledge of/communication about patients’ values and beliefs

27 Panel member reflections Any questions or clarifications? What is striking to you about these findings? Is there value in providing results according to functional domains in addition to psychometrically-derived factors?

28 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary & next steps Aim to understand and critically assess survey development and initial results and explore new opportunities

29 Analysis update Sample characteristics Levels of patient-perceived integration Relationship with organizational characteristics

30 Sample overview (reprise) Original sample: 12,364 Medicare beneficiaries Number of medical groups represented: 150 Number excluded*: 412 Surveys received: 3226 Response rate: 27% Percent respondents who verified their association with the medical group: 84% 1 1 Sample Characteristics A response rate of 27% was slightly lower than hoped, but on par with similar surveys and sufficient for analysis

31 Respondent demographics 1 1 Sample Characteristics Percent of respondents by demographic category Respondents tended to be older, female, with at least some college, white, low income, not living alone Younger than 75 Older than 75 Male Female No more than high school Older than 75 Less than $40K/year Older than 75 White At least some college Alone Non white More than $40K/year Not alone

32 Types of services received 1 1 Sample Characteristics Obtained sufficient responses from patients receiving relevant types of care Number of respondents by type of service received

33 Respondent health status Average of ~7 chronic conditions 93% had at least two chronic conditions 1 1 Sample Characteristics Number of respondents with each chronic condition Majority of respondents could be considered high need Health status overview

34 Organizational characteristics 1 1 Sample Characteristics LargeSmall Multi-specialty Primary care Hospital owned Not hospital owned High Low HighLow Though there is some imbalance, the distribution appears adequate for analysis Distribution of respondents across medical group characteristics

35 Percentage of responses in top box Integration post visit Provider knowledge about the patient Integration with specialists Integration following hospital stay Staff awareness about patient Provider communication with patient 2 2 Levels of patient perceived integration

36 Percentage of responses in top box Integration post visit Provider knowledge about the patient Integration with specialists Integration following hospital stay Staff awareness about patient Provider communication with patient 2 2 Levels of patient perceived integration Question 42: 7% said their provider or someone in the office always contacts them between visits to see how they are doing. Question 49: 34% said their provider always talked with them about medicines prescribed by their specialists. Question 29/30: 30% said their provider or someone in the office always asked about things that make it hard to take care of their health and helped them come up with a plan.

37 Percentage of responses in top box Integration post visit Provider knowledge about the patient Integration with specialists Integration following hospital stay Staff awareness about patient Provider communication with patient 2 2 Levels of patient perceived integration Question 22: 33% said other staff always talked to them about the care they received from their provider. Question 23: 50% said other staff always seemed to know important information about their medical history.

38 Percentage of responses in top box Integration post visit Provider knowledge about the patient Integration with specialists Integration following hospital stay Staff awareness about patient Provider communication with patient 2 2 Levels of patient perceived integration All 3 integration post visit items had top box percentages over 70%, and the highest was: Question 26: 79% said they never had to request their test results before they got them. Question 47: 58% said they never had to remind their provider about the care they received from specialists.

39 Percentage of responses in top box Integration post visit Provider knowledge about the patient Integration with specialists Integration following hospital stay Staff awareness about patient Provider communication with patient 2 2 Levels of patient perceived integration Question 52: 45% said their specialists always seemed to know their test results from other providers. Question 56: 41% said after their most recent hospital stay, their provider or someone in the office contacted them to check if they were able to follow instructions about any medicines that were prescribed.

40 Summary of findings on levels of patient-perceived integration Substantial variation in top box percentages across questions Some notably low levels of perceived integration in certain areas Several questions in “provider communication with patient” dimension had particularly low levels 2 2 Levels of patient perceived integration

41 Regressions exploring the relationship with medical group characteristics 3 3 Relationship with organizational characteristics We first analyzed a set of basic models for each psychometric dimension with only one medical group explanatory variable in each (30 models total) We then analyzed a set of complete models with all explanatory variables and multiple control variables (and standard errors clustered by practice) The complete models indicated some unexpected negative relationships with patient-perceived integration for CMPs. This led us to wonder whether the effect of CMPs depended on other variables. Step 1 Step 2 Step 3

42 Addition of interaction terms What did we do? Ran additional models for each integration dimension with interaction terms added for CMP capability with each of the other organizational characteristics What did we find? Introduction of interaction between CMP and hospital ownership resulted in a decrease in the negative relationship of CMP with integration for non hospital-owned practices 3 3 Relationship with organizational characteristics Preliminary models include the five organizational factors, controls, and an interaction term for CMP/hospital ownership

43 Preliminary models 3 3 Relationship with organizational characteristics Notes: ^ p<.1; * p<.05; **p<.01; ***p<.001 Control variables not shown Standard errors are heteroskedasticity robust and clustered by practice

44 Preliminary models 3 3 Relationship with organizational characteristics Notes: ^ p<.1; * p<.05; **p<.01; ***p<.001 Control variables not shown Standard errors are heteroskedasticity robust and clustered by practice

45 Key findings on the relationship with organizational characteristics Patients receiving care from multispecialty and hospital-owned groups more often perceived slightly higher levels of integration than those from primary care and non hospital-owned practices The integrative value of CMPs depends on the organizational context in which the activities are carried out, with a more positive relationship observed among non-hospital affiliated practices 3 3 Relationship with organizational characteristics

46 Panel member reflections Any questions or clarifications? What is striking to you about these findings?

47 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary & next steps Aim to understand and critically assess survey development and initial results and explore new opportunities

48 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary & next steps Aim to understand and critically assess survey development and initial results and explore new opportunities

49 [Slide for internal use only] Care integration at Atrius Health Patient: The people gathered here today are interested in patients’ experiences related to their health care. Can you tell us about the care you receive from your providers? How many caregivers are involved in your care? Provider: I’d like you to begin by considering your role as a physician at Atrius. We’re interested in understanding care integration from providers’ perspectives. What keeps you up at night? Manager: How are you changing practice structures and processes to provide reliably safe care for your high need, high cost patients and for patients like Mr. Gibson? Provider: What have these changes meant for you as a physician who cares for patients? Patient: Have you noticed any difference in the care you receive? What support do you still need to feel like your care is well- integrated? If you could change one thing about the care you receive, what would it be?

50 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary & next steps Aim to understand and critically assess survey development and initial results and explore new opportunities

51 Dissemination plans and opportunities Papers planned Website Papers in progress

52 Papers planned A paper about the psychometric journey of the PPIC survey and what it taught us about how patients think Capstone paper tentatively titled “The Patient Perceptions of Integrated Care survey: Establishing a National Evidence Base” – Proposed presentations at Academy of Management and Academy Health 1 1 Suggested journals, framing, emphasis?

53 Website under construction integratedpatientcare.org Website for information about and access to the PPIC survey and related research 2 2 What information is most useful and important?

54 Papers in progress “Achieving Care Integration from the Patients’ Perspective: Results from a Care Management Program” comparing perceptions of CMP patients to patients receiving standard care (Fryer et al.) “Patient Perceptions of Integrated Care and their Relationship to Utilization of Health Services” showing perceptions of more integrated care relate to lower utilization, especially in outpatient settings, but for some factors the inverse was true (Fryer et al.) “Translating the PPIC to measure integrated care in the Netherlands: Combining equivalence and contextualization approaches for optimal results” (Tietschert et al.) 3 3 Papers based on pilot data

55 Your suggestions What additional key questions can our data help answer? – Are there disparities in perceived integration based on demographic characteristics like income, education and race? – Are some patients more likely not to respond to this survey, and are there items to which patients are less likely to respond? What key audiences should we aim to reach and how best can we reach them?

56 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary & next steps Aim to understand and critically assess survey development and initial results and explore new opportunities

57 Related and future research Proposed new research Related research Opportunities under development

58 Proposed new research Qualitative investigation of 12 physician organizations in order to gain a more in-depth understanding of how physician organizations achieve care integration for patients with high costs and high needs Quantitative study combining data on patient- perceived integration with data on Medicare claims in order to examine the relationship between patient- perceived integration and clinical outcomes of care. – Collaboration with Steve Shortell and Patty Ramsay of UC Berkeley, Larry Casalino of Weill Cornell, and Loren Baker of Stanford 1 1 Both proposals were submitted to CMWF

59 Related research: VA integrated care study “Achieving Integrated Care for Patients with Multiple Chronic Conditions” is an Investigator Initiative Research grant that will – Study the relationship of patient experience of integrated care in a stratified random sample of VA medical centers – Compare patient experience to provider perceptions of relational coordination, to alterable organizational characteristics – Conduct qualitative assessment in select facilities to identify behavioral and process mechanisms underlying organizational characteristics Supported by the VA HSR&D, Mark Meterko PI 2 2

60 Related research: VA integrated maternity care study “Patterns and Experiences of VA Maternity Care Coordination for Women Veterans” is an IIR that will – Investigate prevailing approaches for pregnancy and maternity care delivery, including facilitators to maternity care coordination through provider interviews – Explore pregnant Veteran’s experience of integrated maternity care – Develop recommendations for VHA research, practice and policy Supported by the VA HSR&D, Kristin Mattocks, PI 2 2

61 Related research: Pediatric Integrated Care Survey (PICS) “Advancing care integration in child health” is developing and validating a survey measure of patient- and family-centered care integration with support from the Lucille Packard Children’s Foundation – Rich Antonelli PI and Sonia Ziniel Co-PI 2 2

62 Related research: Additional applications of PPIC survey WhatWhereWho Evaluation of the NHSScotlandReid and Hartung Evaluation of integrated careThe NetherlandsRuwaard and Tietschert Evaluation of the Programs for All-inclusive Care for the Elderly (PACE) USBonner (Northeastern) Development of a provider perceptions of integrated care survey New ZealandDerrett (U of Otago) 2 2

63 Opportunities under development Medicare Current Beneficiary Survey (MCBS) includes PPIC as of 2014, presenting an opportunity to study: – Level of expenditures, – Type of health insurance coverage, – Health status, and – Demographic category Exploring with Commonwealth Fund Scorecard team the potential for contributing measures of integration among high-cost, high-need beneficiaries Does fielding of the Qualified Health Plan (QHP) enrollee survey of experience with Healthcare.gov Marketplace plans offer an opportunity for comparative research? 3 3

64 Your suggestions What are the most important questions we can address through planned research? Toward what additional research opportunities should we strive?

65 Agenda Welcome PPIC survey development Survey findings Lunch Patient / provider-manager panel discussion Dissemination plans and opportunities Related research and future opportunities Summary and next steps

66 Have we achieved today’s aims? To understand and critically assess survey development and initial results To explore new opportunities

67 67 Thank you! Please send us your comments and suggestions:

68 Back up slides

69 MCBS, CWF Scorecards, and QHP enrollee survey Content and methodology

70 Medicare Current Beneficiary Survey

71 MCBS Overview Nationally representative survey of Medicare beneficiaries: -expenditures and sources of payment for all services, including copayments, deductibles, and non-covered services; -health insurance coverage and related coverages to sources of payment; -changes in health status and effects of program changes.

72 MCBS: initial content Demographics Health status and functioning Cost of care Preventive services Access to, satisfaction with, and usual source of care Health insurance Household or facility characteristics Survey weights Community/ Institutional timeline Event specific information: – Inpatient/Outpatient – Provider – Drug – LTC – SNF – Dental (source: CMS)

73 New / Health Reform-related Content Care coordination Patient activation Electronic health record use by provider of care Satisfaction, access to care, and usual source of care Knowledge and use of preventive services Mobility and Use of Transportation Services Premiums Out of pocket spending Enhanced race/ethnicity reporting Self-reported health outcomes (e.g., ADLs, health status, etc.)

74 MCBS Methodology Data Years Available1991-present PeriodicityAnnual Mode of CollectionComputer-assisted personal interviews (CAPI) in households and facilities. Proxy respondents may be used for institutionalized persons in poor health. Population CoveredNationally representative sample of aged, institutionalized, and disabled Medicare beneficiaries. MethodologyThe overlapping panel design of the survey allows each sample person to be interviewed three times a year for 4 years, whether he or she resides in the community or a facility or moves between the 2 settings, with oversampling among disabled persons under age 65 and among persons 80 years of age and older. Response Rates and Sample Size 16,000 beneficiaries. Each fall 1/3 of the sample is retired and new sample persons are included in the survey. response rates for initial interviews: mid- to high-80s; subsequent rounds in 95%.

75 MCBS Data Files Access to Care Point in time Always enrolled No survey-reported cost and utilization included No imputation Sample size =15,500 Cost and Use Entire calendar year Ever enrolled Include costs and utilization and event-level info. Imputation Sample size = 12,000 (source: CMS)

76 Commonwealth Fund Scorecards

77 CWF Scorecards 42 key indicators in 4 dimensions + 19 equity indicators Access and Affordability (6 indicators)rates of insurance coverage individuals’ out-of-pocket expenses cost-related barriers to receiving care Prevention and Treatment (16 indicators)measures of receiving preventive care and the quality of care in ambulatory, hospital, and LTC and postacute settings. Potentially Avoidable Hospital Use and Cost (9 indicators) avoidable hospital use estimates of per-person spending among Medicare beneficiaries cost of employer-sponsored insurance Healthy Lives (11 indicators)premature death health risk behaviors Equity (19 indicators)differences in performance associated with patients’ income level or race or ethnicity on the 4 other dimensions

78 CWF Scorecard Methodology Performance MetricsSame indicators over time. But since the 2009 Scorecard, several indicators have been dropped. Several new indicators have been added, including measures of premature death, out-of-pocket spending on medical care relative to income, and potentially avoidable emergency department use. Measuring Change over Time Time series for 34 of 42 indicators. Data SourcesIndicators draw from publicly available data sources, including government-sponsored surveys, registries, publicly reported quality indicators, vital statistics, mortality data, and administrative databases.

79 CWF Scorecard Data Sources BRFSS CAHPS (via AHRQ NationalHealthcare Quality Report) CCW (via CMS Geographic Variation Public Use File) CDC NVSS: Mortality Restricted Use File, WISQARS, WONDER CMS Hospital Compare CPS ASEC HCAHPS (via CMS Hospital Compare) HCUP (via AHRQ National Healthcare Quality Report) MDS (via CMS Nursing Home Compare) Medicare Claims (via CMS Home Health Compare) MedPAR, MDS MEPS NIS NSCH OASIS (via CMS Home HealthCompare) 5% Medicare enrolled in Part D 5% Medicare SAF

80 Qualified Health Plan Enrollee Experience Survey

81 QHP enrollee survey overview The QHP Enrollee Survey is a consumer experience survey that assesses enrollee experience with the QHPs offered through the Marketplaces. The QHP Enrollee Survey will be fielded nationally for the first time in early 2015 and will be administered by CMS-approved survey vendors using a standardized protocol to facilitate QHP comparison both within and across Marketplaces.

82 QHP enrollee survey content The QHP Enrollee Survey expands on the CAHPS Health Plan Survey 5.0 incorporating: -existing CAHPS supplemental items -new survey items Access to care Access to information Care coordination Cost Cultural competence Doctor communication Health promotion Plan administration Prevention Shared decision-making Specialized services

83 QHP enrollee survey methodology SamplingAt the product level (HMO, PPO, etc.) offered by a particular issuer in a particular state. QHPs with at least 500 enrollees are required to conduct the survey. Eligible MembersAdults (18+) enrolled at least 6 months with no more than one 30-day break in enrollment. Disenrollees will be included. Sample SizeHHS will require a sample size of 1,000 members per sampling unit, anticipating a response rate of 30% and 300 completed surveys. Survey ToolThe survey tool is based on Medicaid CAHPS 5.0 with an array of additional and supplemental questions. There are currently a total of 76 questions for the beta test phase. MethodologyHHS anticipates a mixed mode methodology with mail, phone and web protocols. TimelineCMS will not publically report the results of the 2015 survey administration; however, State Exchanges may have the option to publicly report the 2015 results. CMS will begin to publicly report results using the scores from 2016.

84 Back up: Regression variables Dependent variables (psychometric dimensions) 1.Staff awareness of information about the patient 2.Provider communication with patient 3.Integration post visit 4.Provider knowledge about patient 5.Integration with specialists 6.Integration following hospital stay Explanatory variables (organizational characteristics) 1.Size (large v. small) 2.Type (multispecialty v. primary care) 3.Ownership (hospital v. not) 4.Tech sophistication (high v. low) 5.Care management processes (high v. low) Control variables Provider characteristics Primary care provider (v specialist) Individual characteristics Age 75 or older (v younger) Gender Male (v female) Education No college (v more) Ethnicity Hispanic (v non-hispanic) Race non-white (v white) Income less than $40K (v more) No. people in household 1 (v not living alone) Individual health and psychological characteristics Number of chronic conditions Depression Expectation of health in next 6 months Fair or Poor (v better) Problems with care scale of 0-12** Assistance needed scale of 0-12*** One or more friends or relatives helped with any of the tasks in Q69 Yes (v no) Q70 Life orientation test-revised on scale of 0-24****

85 Staff awareness of information about the patient Integration with specialists Provider knowledge about the patient Integration post visit Provider communication with the patient Integration following a hospital stay Information flow to your primary provider Information flow to other providers in your primary provider’s office Information flow to your specialist Information flow post hospitalization Coordination with home and community resources Continuous familiarity with patient over time Proactive action before visits Post-visit information flow to the patient Responsive independent of visits Patient Centeredness Shared responsibility PPIC 2.1 PPIC 2.0 


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