UCSF Fresno Family and Community Medicine Dept. Controlling for Race and Ethnicity: A Comparison of California HMO CAHPS Scores to National Benchmarks John Zweifler MD, MPH Susan Hughes, MS Rebeca Lopez, BS UCSF Fresno Family and Community Medicine Dept. May 2008

Background Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey developed in 1995 Enrollee’s perspective of health plan quality Increasing role as quality indicator in state and national enrollee guides California HMOs consistently rank lower than national HMOs Only one of California’s sixteen commercial HMOs in top 20% of US News & World Report

Impact of Racial and Ethnic Diversity on California CAHPS Scores CAHPS survey results case-mix adjusted for age, gender, and self-reported health status Racial and ethnic disparities in survey responses are well documented California’s diverse demographics may significantly impact its CAHPS scores In 2000 census, 35% Hispanic/Latino, 12% Asian, and 7% black In 2005 California ranked 2nd in nation for % population Asian

Methods California 2005 CAHPS 3.0 survey responses compared to 2005 National CAHPS Benchmark Database (NCBD) Limited to adults in commercial HMO or PPO plans Did not include Medicaid, Healthy Families, or Medicare respondents Six questions from the CAHPS database were analyzed Logistic regression analysis done

Hypothesis Lower scores California HMOs have received on CAHPS surveys result from racial and ethnic differences in patient satisfaction scores higher concentration of Asian/PIs and Hispanics in California

Results 9,952 California respondents 54% White 11% Asian/PI 20% Hispanic 67% HMO 56% in plan > 5 yrs 27% High school 17% Excellent health 113,320 other US respondents 77% White 3% Asian/PI 7% Hispanic 48% HMO 47% in plan > 5 yrs 29% High school 18% Excellent health

Odds Ratio for California CAHPS responses by race/ethnicity compared to whites* Rate MD Rate plan Rate care Courtesy Understand Respect White 1.00 Black 1.56 1.53 1.39 1.28 1.22 1.47 Asian/PI 0.81 0.97 0.78 0.48 0.73 Hispanic 1.11 1.15 0.89 1.02 1.14 *controlling for age, gender, insurance type, time in plan, education, and general health rating with significant results bolded

Including Race/Ethnicity No Race/Ethnicity Odds Ratio for California compared to Nation with and without race/ethnicity* Characteristic Including Race/Ethnicity No Race/Ethnicity MD rating 0.93 0.94 Plan rating 1.09 1.11 Care rating 0.87 0.85 Courtesy 0.79 Understand 0.92 0.90 Respect 0.89 *controlling for age, gender, insurance type, time in plan, education, and general health rating

Results California adults reports of satisfaction on CAHPS differed from the rest of nation More likely to rate care lower More likely to rate their health plan itself higher More likely to rate their doctor and their interactions lower California scores relative to nation did not change after controlling for race/ethnicity

Results Consistent differences in CAHPS scores between racial and ethnic groups in both California and the nation Blacks more likely to rate their doctor, their plan, and their care higher than Whites Asians more likely to rate their care, courtesy, understand, and respect lower than Whites Hispanics more likely to rate their plan higher than Whites

Possible Explanations A higher percentage of Californians are enrolled in managed care plans Comfortable with managed care Rate health plans themselves higher Lower scores for doctors and care may reflect problems with how enrollees receive health care services In California, several hundred large medical groups contract with health plans in a “delegated model” to provide the bulk of managed care Distinction between HMOs and medical groups may insulate HMOs but not doctors from frustrations enrollees may encounter in their care

Possible Explanations Discordance between physicians and patients Unable to assess with CAHPS data Health care in California may be worse On objective measures of quality such as the Health Plan Employer Data and Information Set (HEDIS®), California health plans have scores comparable to health plans across the nation

Conclusions California health plan enrollees rate their care lower than health plan enrollees in rest of nation Disparities between California and the rest of the nation persist after controlling for race and ethnicity Consistent within most racial and ethnic populations Further investigation warranted

Conclusions Stratifying member satisfaction by race/ethnicity highlighted important differences in CAHPS ratings between different racial and ethnic groups in both California and the nation At the same time, reporting on disparities in geographic regions and within health plans would raise awareness and increase accountability for reducing racial and ethnic disparities.

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