1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. Questions?