1. Has Health Plan Quality Measurement Improved Quality of Care among Medicare Managed Care Enrollees? Presented by Kate Bundorf Coauthors: Laurence Baker and Kavita Choudhry Academy Health Annual Research Meeting June 6, 2004

2. Background Objectives of health care provider “report cards” –Allow consumers to make tradeoffs between cost and quality when choosing health plans –Improve quality of care Medicare and quality measurement and reporting –HCFA publicly released the first hospital mortality rankings in 1986. –Current initiatives include: Nursing Homes Home Health Care Managed Care Plans Are these report cards effective?

3. Do Consumers Use Report Cards? Consumers would like comparative information about health care provider quality. Report cards rarely affect consumer decision making (Marshall et. al 2000; Schauffler 2001). Some more recent studies of health plan report cards suggest that they do affect consumer choices (Chernew et al 2001; Scanlon et. al. 2002; Beaulieu 2002; Wedig and Tai-Seale 2002).

4. Have report cards improved quality of care? Hospital Report Cards –Divergence between consumers and providers in evidence of use (Marshall et. al 2000; Schauffler 2001). –Early studies demonstrated improvements in quality of care associated with availability of report cards (Hannan 1994). –More rigorous analysis found that report cards had unintended effects on patient treatments and outcomes (Dranove et. al. 2002). Health Plan Report Cards –Performance has improved dramatically among participating health plans (NCQA 1999; 2000; 2001; 2002; Lied 2001). –The extent to which health plans in a market participate in quality measurement is associated with increases in utilization of some but not all performance indicators (Bundorf and Baker 2004).

5. Research Question Does health plan participation in standardized performance measurement and reporting improve quality of care among enrollees in Medicare Managed Care plans?

6. Health Plan Performance Measurement in Medicare In 1996, HCFA contracted with NCQA to develop HEDIS measures for Medicare managed care plans. HCFA began requiring plans to submit Medicare HEDIS data as of January 1997. In 1998, CMS launched www.Medicare.gov.www.Medicare.gov In 1999, HEDIS measures became available on the site.

7. Study Design Did utilization of measured services increase more rapidly among Medicare managed care enrollees than other beneficiaries after the implementation of mandatory quality reporting?

8. Data Source Medicare Current Beneficiary Survey (1994- 2000) –Annual survey of approximately 12,000 Medicare beneficiaries conducted by CMS –Study sample includes non-institutionalized, non-rural Medicare beneficiaries enrolled in either Medicare risk plans or traditional FFS

9. Study Variables -Dependent Performance IndicatorsControl Indicators Mammogram within last yearPap Smear within last year Flu Shot within the last yearPneumonia Shot within last year

10. Model Estimation where i indexes individuals, m indexes counties, t indexes years (1994- 2000) Y is a binary indicator of utilization of service H is an indicator of enrollment in a Medicare managed care plan I is an indicator of whether mandatory quality reporting had been implemented during the time period X is a vector of individual characteristics (age, sex, # of reported chronic condition, self-reported health status, health and healthcare behaviors, supplemental insurance status, education, and marital status) A is a vector of county fixed effects Z is a vector of year fixed effects

11. Utilization of performance indicators among managed care enrollees

12. …compared to utilization among non- managed care enrollees

13. Utilization of control indicators

14. Results from multivariate models

15. Summary of Results Rates of utilization of HEDIS performance indicators increased among Medicare managed care enrollees after the implementation of health plan quality reporting. Rates of utilization of HEDIS performance indicators also increased among Medicare FFS enrollees who were not directly affected by the program. The implementation of health plan quality measurement did not increase utilization of performance indicators among Medicare managed care enrollees relative to FFS enrollees.

16. Potential Interpretations The implementation of mandatory health plan quality measurement and reporting… –did not increase utilization of performance measures among Medicare managed care enrollees, or –increased utilization of performance measures among Medicare managed care enrollees but the estimate is biased downward by selection of Medicare beneficiaries into Medicare managed care plans, or –increased utilization of performance measures among Medicare managed care enrollees as well as FFS beneficiaries.

17. Implications Potential effects of selection and spillovers need to be examined. Health plan performance measurement may not be an effective way to increase utilization of preventive services. Different quality measures may be more effective in improving quality of care.