THE INFLUENCE OF COMMUNITY CONTEXT ON HEALTH PLAN DECISIONS: A MULTI-METHOD ASSESSMENT OF COMMUNITY EFFECTS
Open Access
- Author:
- Calkins, Christopher Alan
- Graduate Program:
- Health Policy and Administration
- Degree:
- Doctor of Philosophy
- Document Type:
- Dissertation
- Date of Defense:
- December 21, 2007
- Committee Members:
- Joseph J Vasey, Committee Chair/Co-Chair
Marianne Messersmith Hillemeier, Committee Member
Michael R Meacham, Committee Member
Mona M Counts, Committee Member - Keywords:
- consumer choice
decision making
health plan choice
social networking
information seeking - Abstract:
- The expansion of quality report cards and other information in the marketplace has increased the need for consumers to gather, interpret and synthesize complex information in advance of choosing a health plan. A growing body of research on consumer choice in healthcare has identified factors that influence plan choice including the impact of ever-increasing amounts of quality information. The literature has also raised serious questions about consumers’ capacity to manage the amount and complexity of plan information available to them in the marketplace. Many of these questions have yet to be explored fully. There is a gap in the literature on how consumers move through the process of gathering, assimilating and using information to choose a health plan. Understanding this process is critical for crafting effective information presentation and dissemination approaches. This dissertation is comprised of three studies each employing a different methodological approach to elucidate the consumer decision making process. The first study used a case-study approach to explore community level factors that support information gathering and decision making. Key informants in three rural communities were interviewed about information resources, dissemination approaches, and consumers’ information awareness. The second study evaluated the scholarly literature from several research perspectives to suggest factors that might be used to measure the influence of community variables on health plan decisions. The third study modeled these factors to determine their influence on health plan choice. This is the first study to empirically test the relationship between community context variables and health plan choice. In the community case studies key informants in three rural communities were interviewed about information resources, dissemination approaches, and consumers’ information awareness. The result of these studies was a general consensus that consumers lack the knowledge necessary to make a fully informed choice. While a variety of approaches to meeting information needs have been adopted in the three communities, none of the interviewees felt that consumers’ information needs were consistently and adequately met. The case studies helped identify community level factors that support information gathering and comprehension for consumers. The conclusion from the first study was that community context does play a role in helping consumers gather, interpret and understand complex information in order to make a health plan choice. Policy implications include the need to undertake broad public information efforts if the expectation that consumers can make truly informed health decisions is to be met. The second study examined the research on decision-making, information-seeking and social networks to synthesize the research and suggest a research agenda for examining the effect of community context on health plan choice. PubMed, Medline and PsychINFO databases were searched for articles on decision-making, information seeking and social network effects. The literature makes clear that there is a fundamental tension between the amount and type of information consumers say they want and what they can effectively comprehend. Several of the factors that consumers say would be helpful to them are complicated and difficult to present and interpret. Effectively communicating the information mandated by the Balanced Budget Act (BBA) and the Medicare Improvement and Modernization Act (MMA) to Medicare beneficiaries without overwhelming them continues to be a significant challenge. In addition, the development of national, regional and disease-specific benchmarks has added complexity without improving comprehension. The literature also makes clear that some consumers have more difficulty than others in managing the complexity of information in the decision making process. They may prefer to count on the assistance of their doctor or may rely on family members, friends, employers or others to make the plan choice for them. It is also important to note that many of these information agents face the same challenges as the consumers they are trying to assist. Policy implications from the second study include the need to further refine public reporting of health plan information to enable consumers at a variety of literacy levels to access and understand the information. Further, technology enables disease-specific reporting across providers and plans; however, consensus is necessary to develop consistent measures to foster consumer comparisons. Finally, public programs should evaluate the distribution channels currently used to disseminate health plan information and consider approaches that target both the consumer and those who serve as information resources for the consumer. The third study examined the effect of adding community context variables to an established model of health plan choice. Data from a survey of 1,200 rural Pennsylvania residents were used to develop models of plan choice and the probability of changing plan type. Estimates were derived using binary logistic regression. Separate models were estimated for plan change using rare event logit techniques. Adding community context variables significantly improves the predictive power of both choice models and plan change. Individuals in poorer health have a strong preference for Fee For Service (FFS) models. Those who have a household member who requires frequent care have a strong preference for FFS plans. Consumers are sensitive to restrictions on provider choice, specifically restrictions on physicians and hospitals. These results suggest that adding community context variables to models of plan choice would improve our understanding of consumers’ plan choices. The increasing health care related burden on public budgets is unsustainable. States are experimenting with a number of models to lessen the financial impact of health care expenditures on their budgets while increasing access to basic health care. If public plans and employers are going to use managed care models to contain costs and improve the care of individuals with chronic health needs then a broad information campaign to educate consumers about the prevention and chronic care management benefits of managed care models will need to be undertaken. This dissertation contributes to the literature by increasing our understanding of the decision making process used by consumers in increasingly complex healthcare environments. As policy and market changes increase demands on consumers to effectively negotiate the health plan decision making process, the supply of effective information sources and dissemination efforts must keep pace. Because the implications of failure for personal and community health and individual and collective wealth are so great, the onus of creating a truly informed consumer is shared by consumers, providers and policy makers. The challenge for health plans, consumer advocates and policy-makers is to develop and implement effective communication efforts and disseminate them through the distribution channels that consumers use as information resources for health care related decisions.