1 Consumer Knowledge of Health Insurance Plans and Affordability of Care: An Emergency Department Survey in Three Diverse Communities Massachusetts Center for Health Information Analysis August 14, 2013

2 Research Team Principal Investigator Danny McCormick, MD, MPH Co-Investigators Rachel Nardin, MD Assaad Sayeh, MD Leah Zallman, MD, MPH

3 Background l Goals of Chapter 58 and 224: improve affordability, access and quality of care l Despite MA reform, rate of uninsurance remains high in some communities n Everett: 16% n Revere: 15% l Affordability continues to be a barrier for both uninsured and the insured

4 Background l Knowledge of insurance products may influence care seeking yet plan knowledge and informational needs are not well understood l Prior population-based surveys on affordability and plan knowledge: n May have under-sampled populations at highest risk—immigrants, non-English speakers and poor n Have not analyzed according to insurance type l Understanding these has relevance for ACA

5 Research Objectives In disadvantaged populations and across insurance types: l What is truly affordable for consumers? l Do consumers understand their health plans and the insurance options available to them? l To what extent do consumers experience gaps in or changes to their insurance coverage? l What level of cost-sharing is associated with avoidance of medical care?

6 Methods Overview l Phase I: Develop, pilot and administer a consumer survey to patients seen in three socioeconomically diverse communities. n Examine by demographic and insurance characteristics l Phase II: Conduct semi-structured, qualitative interviews (N=10-12) to explore key issues in depth.

7 Setting: 3 EDs of Cambridge Health Alliance Whidden Hospital Somerville Hospital Cambridge Hospital

8 Study Population l > 230 MA communities n travel to overcome access-to-care barriers. l Age <65: n 57% state payment sources (36% Medicaid, 5% Comm Care, 16% HSN), 3% uninsured and 40% privately insured. l Allows sample enriched with policy relevant groups.

9 Study Sample l 1290 patients l Equal numbers of Uninsured, CommCare, MassHealth, HSN and private insurance l Ages 18 to 64 l English, Spanish, Portuguese and Haitian Creole l Not intoxicated, delirious, or severely ill

10 Survey l Face to face interview l Four domains: n Knowledge/Access to information n Insurance “churn” n Affordability n Tipping points l Demographic information l Insurance verified, not self report

11 Generalizability l 3 socioeconomically and racially/ethnically diverse communities l Individuals actually needing care l Trade-off between policy relevant populations and generalizability to the state as a whole

12 Progress l Study staff hired l Developed, piloted and started survey l Completed ~75 surveys l Qualitative interviews will begin late August 12

13 Policy Implications As the Commonwealth of Massachusetts prepares for changes to insurance products under ACA, we hope to provide better information on affordability, knowledge needs, tipping points and churning for disadvantaged populations that are highly affected by these changes but may be underrepresented in state-wide population based surveys. 13

14 Discussion l Questions?

15 Sample questions: Knowledge l Knowledge: “Under your current insurance, do you n Have a premium/deductible/copay for medication/copay to see doctor/coninsurance?” n Amount of that premium/deductible/…etc. n Compared to g l Consequences: n “Has uncertainty about what is covered and how much you have to pay for services ever caused you to delay or to not get any medical care?”

16 Sample questions: Sources and Quality of Information l “At the time you applied for or were considering a health plan, did you try to get information... n through the Health Connector or MassHealth helpline?” n through the Health Connector or plan websites?” n from a person at health center or other organization?” n Helpfulness of these sources l “It was difficult to figure out how to apply for your current insurance.” l “It was difficult to complete the application process.”

17 Sample questions: Quality and Understanding of Information l When signing up for insurance... n Had information needed to make a good decision n Had information in primary language n Were able to get questions answered n Was hard to understand the information l “Have your out-of-pocket costs on your current plan ended up being as you expected?”

18 Sample questions: Affordability: General l “Your plan is affordable for you.” l Concerned about paying premiums l Among uninsured n Lost coverage due to cost n Could not find affordable plan

19 Affordability: Delayed or Forgone Care l Any l Specialist care l Regular doctor l Preventive care l Tests l Medications l Mental or emotional care l Dental l Vision l Home services such as visiting nurses,

20 Affordability: Medical Debt l Unpaid medical bills and amount l Gone into debt l Contacted by bill collector l Consequences n Resulted in difficulty paying for other bills