Mountain Health Choices Beneficiary Report

 Mountain Health Choices Beneficiary Report A Report to the West Virginia Bureau for Medical Services
Bureau of Business and Economic Research
College of Business and Economics
Post Office Box 6025
West Virginia University
Morgantown, WV 26506
(304) 293-7829
Tami Gurley-Calvez, Ph.D. (PI)
tami.calvez@mail.wvu.edu
Paula Fitzgerald Bone, Ph.D.
paula.bone@mail.wvu.edu
Adam Pellillo
adam.pellillo@mail.wvu.edu
Christopher Plein, Ph.D.
lplein@wvu.edu
Michael Walsh, Ph.D.
Michael.walsh@mail.wvu.edu
Issued July 2009
Updated January 2010
This research was funded by a grant from the West Virginia Department of Health and Human Resources,
Bureau for Medical Services.
Table of Contents I. EXECUTIVE SUMMARY ................................................................................................................................ 4 A. Overall Results .................................................................................................................................. 4 B. Survey Results ................................................................................................................................... 4 C. Administrative Data .......................................................................................................................... 5 II. MOUNTAIN HEALTH CHOICES ...................................................................................................................... 7 A. Implementation History .................................................................................................................... 8 III. BENEFICIARY SURVEY ............................................................................................................................... 10 A. Method ........................................................................................................................................... 10 IV. BENEFICIARY SURVEY MEASURES AND RESULTS ............................................................................................ 13 A. Demographics ................................................................................................................................. 14 B. Experience with Medicaid ............................................................................................................... 16 C. Health Literacy and Medicaid Awareness ....................................................................................... 18 D. Perceived Benefits of and Barriers to Mountain Health Choices ................................................... 24 E. Information Sources for Mountain Health Choices ........................................................................ 31 F. Lifestyle and Health Status.............................................................................................................. 34 G. Mountain Health Choices Outcomes .............................................................................................. 39 H. Future Planned Behavior ................................................................................................................ 42 I. Access to Health Care ..................................................................................................................... 45 J. Past Health Insurance ..................................................................................................................... 46 K. General Psychological Constructs ................................................................................................... 47 L. Open‐ended Responses .................................................................................................................. 50 V. BENEFICIARY SURVEY: ANALYSIS OF WEIGHTED DATA ................................................................................... 56 A. Participation .................................................................................................................................... 56 B. Transportation Problems ................................................................................................................ 57 1
C. Health‐Related Behaviors: Exercise and Tobacco ........................................................................... 59 D. Education, Marital Status and Outlook ........................................................................................... 61 E. Changes in Health ........................................................................................................................... 63 F. Average Body Mass Index (BMI) ..................................................................................................... 64 G. Health Service Use .......................................................................................................................... 65 H. Experience with Medicaid and MHC ............................................................................................... 68 I. Other Experience with the Health Sector ....................................................................................... 70 VI. MOUNTAIN HEALTH CHOICES ADMINISTRATIVE DATA ANALYSIS ..................................................................... 72 A. Initial Summary Statistics ................................................................................................................ 73 B. ............................................................................................................................................................. 74 Health Care Utilization ............................................................................................................................ 74 C. July 2008 Cross Section of the Administrative Dataset .................................................................. 77 D. Health Care Utilization for the Cross Section .................................................................................. 79 E. Themes from the Administrative Data ........................................................................................... 82 F. Preliminary Regression Results ....................................................................................................... 83 1. Specification – Selection into the Enhanced Plan ....................................................................... 83 2. Results – Selection into the Enhanced Plan ................................................................................ 85 3. Specification – Effects of MHC on Service Utilization ................................................................. 86 4. Results – Effects of MHC on Service Utilization .......................................................................... 87 VII. Mountain Health Choices Health Improvement Plans Analysis ......................................................... 88 VIII. CONCLUSION .......................................................................................................................................... 91 I. APPENDICES. .......................................................................................................................................... 92 A. Appendix I: Eligibility Criteria .......................................................................................................... 92 B. Appendix II: Overview of Services Available for Adults .................................................................. 93 C. Appendix III: Overview of Services Available for Children .............................................................. 94 2
D. Appendix IV: Member Responsibility Agreement ........................................................................... 95 E. Appendix V: Health Improvement Plan .......................................................................................... 97 F. Appendix VI: Adult Questionnaire .................................................................................................. 99 G. Appendix VII: Child Questionnaire ................................................................................................ 113 H. Appendix VIII: Survey Sampling and Weighting ............................................................................ 127 I. Appendix IX: Overall Survey Results ............................................................................................. 130 J. Appendix X: Adult v. Child Survey Results .................................................................................... 145 K. Appendix XI: Enhanced Plan v. Basic Plan Survey Results ............................................................ 161 X. BIBLIOGRAPHY .......................................................................................................................................... 176 3
I.
EXECUTIVE SUMMARY Mountain Health Choices (MHC), the West Virginia Medicaid redesign program targeted
towards a healthy population of adults and children, began rollout in Spring 2007. The goal of
this evaluation is to provide a comprehensive snapshot of the redesign in order to answer initial
questions and identify areas of focus for future research. Herein, we analyze the Mountain
Health Choices program, examining MHC members’ knowled-ge, attitudes, and behaviors with
respect to their health care and the MHC program in general. This evaluation uses survey data
from a stratified random sample of Medicaid members as well as administrative data on
eligibility, medical claims, and prescription drugs. Taken together, these data provide insights
into the characteristics of Mountain Health Choices members, their attitudes and awareness
regarding their health and plan choices (Basic Plan or Enhanced Plan), and their behavioral
outcomes.
A. Overall Results •
•
•
Adults on the Enhanced Plan tend to have worse self-reported health and higher numbers of
doctor visits and prescriptions per month than those adults who select the Basic Plan. This
result is robust across datasets and methodologies.
The differences between children enrolled in the Basic Plan and children enrolled in the
Enhanced Plan are mainly in the attitudes, outlook, and engagement levels of their parents.
Differences in health status and health care service utilization for children, as reported by
their parents/guardians, are much smaller.
Prescription use, namely using more than four prescriptions per month, appears to be one of
the main determinants of Enhanced Plan participation, especially for adults.
B. Survey Results A mail survey was completed by 1,073 Medicaid members (or if the member was a child,
his/her parent/guardian), which represents an overall response rate of 26.8% out of the 4000
members sent a survey. The sample was stratified by age (adult vs. child) and the plan selected
(Basic vs. Enhanced). We assessed eleven broad areas of study ranging from members’
experiences with Medicaid to the perceived benefits and barriers of the MHC program. The top
line findings include:
•
•
•
MHC members are generally satisfied with their respective plans, with an average rating of
4.03, in which 4 indicates “satisfied.” Most respondents indicated that their current Medicaid
plan is either better (24.0%) or about the same (44.0%) as the previous plan. In the openended response section, over 100 respondents expressed gratitude for their Medicaid plan.
The planning horizon of MHC members is long, as the majority of members (66.6%) expect
to use Medicaid for three or more years.
The survey respondents scored well overall on a test of health literacy by demonstrating the
ability to correctly interpret the West Virginia Department of Health and Human Resources
chart entitled “Medicaid Benefits at a Glance.” However, only about 10% of the respondents
were familiar with the term “Medical Home.”
4
•
•
•
•
•
•
•
•
Despite the general ability to interpret health information correctly, there is significant
confusion about the Mountain Health Choices program and enrollment process.
Approximately one-quarter of respondents were unaware that two Mountain Health Choices
plans existed, and another quarter knew of two plans, but were unsure as to in which plan
they had enrolled. Respondents also expressed confusion in the open-ended responses.
Several sources of information were identified as helpful to members and their
parents/guardians. Information received in the mail and from doctors, pharmacists and case
workers were the highest rated sources.
The survey data show clear differences between the four groups within the Mountain Health
Choices population. While there are relatively few differences between children enrolled in
the Basic Plan and children enrolled in the Enhanced Plan, it is clear that adult members are
different than child members. Additionally, adults in the Enhanced Plan clearly differ from
others in the Mountain Health Choices population.
o Specifically, parents/guardians who completed the child survey are more satisfied
with their child’s Medicaid plan, are more conscientiousness, have completed more
years of education, and have a more positive outlook than adult members completing
the survey about their own, as opposed to their child’s, experiences with MHC. They
reported their children to be in good health. Enhanced Plan members more actively
use information from a variety of sources, are more knowledgeable about Mountain
Health Choices, and are less likely to have transportation problems than Basic Plan
members. Adults in the Enhanced Plan have the most negative future outlook, with
the worst self-reported health. Adults in the Enhanced Plan also tend to have a higher
incidence of obesity given their BMI calculations. These members were likewise
significantly more interested in the Enhanced Plan benefits of four prescriptions per
month and weight management.
Barriers, such as no time to visit the doctor to complete a member agreement or too much
time or paperwork involved in making a decision, do not appear to discourage participation.
Of the various additional benefits offered by the Enhanced Plan, having more than four
prescriptions per month is most highly valued by the survey participants.
MHC members on average feel that they are following the behavioral guidelines in the
Member Agreement.
Weighting the survey data to be representative of the population does not alter the above
results.
Weighted survey data indicate that adults in the Enhanced Plan have more education,
exercise less, are less optimistic, and are more likely to have had a negative change in their
health status within the past six months than adults in the Basic Plan.
C. Administrative Data The MHC administrative data is composed of medical claims and prescription drug data for
all MHC members. In all, there are almost six million person-month observations for all months
and years for which data were supplied. It is important to note this data is for all MHC members
as opposed to a sample, as in the case of survey data. • Adults in the Enhanced Plan tend to be four years older than those in the Basic Plan on
average and there are no substantial differences in average age for children.
5
•
•
•
•
•
•
Health care utilization, measured as the number of doctor visits per month and number of
prescriptions per month, follows a clear pattern with the highest use in the winter months and
the lowest use in the summer months.
Almost one of five adults on the Enhanced Plan averaged two or more doctor visits per
month while the number was about one out of ten for adults on the Basic Plan. There were
not significant differences for children on the Enhanced and Basic Plans.
Adults in the Enhanced Plan filled nearly 150% more prescriptions in July 2008 than their
counterparts in the Basic Plan and visited the doctor more than twice as often.
Children in the Enhanced Plan averaged about 60% more doctors’ visits and prescriptions in
July 2008 than those in the Basic Plan.
Regression analysis confirms that adults with higher past utilization of health services are
more likely to select the Enhanced Plan. The effect is much smaller for children and pertains
only to prescription use.
There is suggestive evidence that MHC leads to more doctor visits and prescriptions for
adults but decreases child doctor visits and has no effect on child prescriptions. However
magnitudes of the effects are so small that they are of little if any practical significance.
More research needs to be conducted in this area.
6
Medicaid Beneficiary Report The West Virginia Department of Health and Human Resources, Bureau for Medical
Services, began the implementation of a new Medicaid program, Mountain Health Choices
(MHC), in March 2007. This report provides information for the continued implementation of
the program as well as an initial evaluation from a beneficiary perspective. The goal of this work
is to provide a comprehensive snapshot of MHC in order to answer initial questions and identify
areas of focus for future research. We begin with a brief history of Mountain Health Choices,
followed by a detailed discussion of the results from a survey of MHC members. We then turn to
the analysis of weighted survey results.
Next, we detail key findings from Medicaid
administrative data, providing both initial summary statistics and preliminary regression results.
Information from completed Health Improvement Plans in the pilot counties is then presented.
By assessing the above material, we shall present an overview of the Mountain Health Choices
program from an evaluative perspective.
II. MOUNTAIN HEALTH CHOICES Mountain Health Choices, the Medicaid redesign program in West Virginia, was
launched after the passage of the Federal Deficit Reduction Act of 2005, which allowed states to
implement alternative benefit packages, through a State Plan Amendment, for a particular subset
of Medicaid members, primarily healthy adults and children. This Medicaid reform transferred
certain Medicaid coverage groups from the traditional coverage to Mountain Health Choices,
including Aid to Families with Dependent Children (AFDC) Medicaid recipients, deemed AFDC
7
recipients, transitional Medicaid recipients, and qualified children and poverty-level children
meeting certain age and income criteria. See Appendix I for Eligibility Criteria.
A. Implementation History The Mountain Health Choices program was implemented using a phased approach on a
county-by-county basis, with the initial rollout in Clay, Lincoln and Upsur counties beginning in
March 2007. A second wave of 16 counties (September 2007), a third wave of 21 counties
(October 2007), a fourth wave of 9 counties (November 2007), and a final wave of 2 counties
(January 2008) followed thereafter. Presently, all but four counties have implemented the
Mountain Health Choices program for eligible populations. Sixty days prior to their
redetermination dates, Mountain Health Choices eligible members in the roll-out counties were
sent a package of information by Automated Health including an explanation of benefits, a copy
of the Member Agreement, a Health Improvement Plan, and a pamphlet instructing members to
call their health care provider for a ‘well-visit’ and to sign up for a specific Mountain Health
Choices plan. Automated Health Systems (the enrollment broker contracted by the WV Bureau
for Medical Services) sent follow-up postcards to Mountain Health Choices members and
likewise made outreach phone calls, yet some members may not have been contacted given the
transitory nature of the population. Additionally, a $103,527.10 media campaign focusing on
radio, newspaper and outdoor advertising, ran from September 1, 2007 to November 30, 2007.
Mountain Health Choices members remained under traditional coverage until the
beginning of the month of their redetermination, at which time members were placed into the
Basic Plan and given the option to select the Enhanced Plan by completing the necessary
8
agreements within 90 days.1 Each plan offers a package of health care benefits, with the Basic
Plan limiting benefits on average vis-à-vis the traditional Medicaid plan and the Enhanced Plan
offering more benefits on average than the traditional plan. Appendices II and III provide an
overview of the services covered under each plan. In order to enroll in the Enhanced Plan,
Mountain Health Choices members must sign a Member Responsibility Agreement (Appendix
IV) and develop a Health Improvement Plan (Appendix V) with a physician in their medical
home (i.e., the primary care provider who manages their care). The member agreement for
Mountain Health Choices specifies the actions that must be taken by Enhanced Plan members
with regard to their health care behaviors (e.g., read all information provided by the doctor). The
Health Improvement Plan is developed collaboratively by the member and his/her primary care
provider and specifies health care and education services (e.g., tests for high blood pressure or
diabetes education) that the member is to receive within the next year.
From the date of redetermination, members had a period of 90 days to submit these
documents to Automated Health and thereby enroll in the Enhanced Plan. If they did not choose
to enroll in the Enhanced Plan or failed to do so within the 90 day period, they were enrolled into
the Basic Plan. These Mountain Health Choices members remain in their respective plans for
one year. As of July 2009, 13.8 percent of MHC members (22,225 members) were enrolled in
the Enhanced Plan. Enrollment was higher for children, 14.1 percent, than for adults, 10.9
percent.
The goal of this document is to evaluate the Mountain Health Choices program. We
approach this evaluation in several ways, and will begin with a detailed look at the program from
the perspective of MHC members themselves. We contribute to the existing studies with a large
1
It is possible that a member could have enrolled in the Enhanced Plan before being assigned to the Basic Plan if
their agreements were submitted prior to the beginning of their redetermination month.
9
primary data collection effort, administrative data analysis, and a broad set of questions.2 An
evaluation from the perspective of Medicaid health care providers is under separate cover and is
titled, Medicaid Provider Report.
III. BENEFICIARY SURVEY The beneficiary survey was designed to collect information that is important in policy
and implementation decisions but difficult or impossible to glean from administrative data. The
survey addresses why members choose the Enhanced Plan and identifies the main perceived
barriers and benefits. Questions also gauge members’ attitudes about health and Medicaid as
well as their awareness of MHC. Respondents were asked to identify which information sources
were most helpful in learning about MHC and deciding between the Enhanced Plan and the
Basic Plan. Further, information was collected on demographics, health access, and lifestyle
factors not available in administrative data. Given the central role of the Medical Home concept
in Medicaid redesign, questions were also included to assess how closely members’ experiences
align with key aspects of medical home.3 We were also able to investigate whether these issues
differ between children and adult members and Enhanced and Basic Plan participants.
A. Method Data was collected for this evaluation by mailing printed surveys to respondents’ homes.
There were two versions of the questionnaire: one version for adult beneficiaries (Appendix VI)
and a second version directed to the parents/guardians of child beneficiaries (Appendix VII).
2
Previous studies include Families USA (2008) , Direct Action Welfare Group Inc. (2008), andHendryx, et al.
(2009).
3
Early drafts of the survey also included questions about incentives that might induce participation in the Enhanced
Plan or healthier behaviors. However, these questions were left for the future until the Healthy Rewards aspect of
Medicaid redesign is developed more fully.
10
Since a parent/guardian may have more than one child, the mailing envelope, the cover letter,
and the questionnaire identified the focal child for the study (for example, “About your child,
Tami,” [see Appendix VII]).
A stratified random sample of 4,000 Mountain Health Choices eligible members was
mailed one of the versions of the survey. Two stratifying variables were used: whether the
member was a child or adult, and whether the member was enrolled in the Basic Plan or
Enhanced Plan. Children and adults were sampled proportionally to their ratio in the Medicaid
administrative database, resulting in 85% of those selected in the sample being children and 15%
adult. Thus, based on our total survey sample of four thousand, 600 surveys were sent to adult
members and 3,400 were sent to the parents/guardians of child members. At the time we mailed
the surveys, approximately 10% of Mountain Health Choices members were enrolled in the
Enhanced Plan. To ensure adequate responses from this population, a disproportionate sample
was used in which Enhanced Plan members were oversampled. Thus, for adults, we sampled
50% (300 members) from the Enhanced Plan and 50% percent from the Basic Plan. Because the
child sample is much larger than the adult sample, we used a factor of 3 when oversampling
children in the Enhanced Plan. Thus, we mailed out 1,050 surveys for children in the Enhanced
Plan and 2,350 to those in the Basic Plan. Details of the sampling plan are presented in Appendix
VIII.
Many strategies were used to increase the response rate (c.f., Dillman 2000). First, the
questionnaire was carefully designed and pretested to increase readability and visual appeal.
Second, all surveys were mailed with a $2 bill enclosed. Third, the cover letter was phrased so
as to enlist the respondent’s help. Fourth, respondents who completed the survey were informed
they would be included in a drawing for $500 worth of gift cards. Fifth, respondents were given
11
the option to call a toll-free number and complete the survey over the phone. Finally, a followup postcard was sent to nonrespondents to encourage them to complete their survey and to
remind them of the random drawing. This card also provided the toll-free number which the
recipient could call to obtain another copy of the questionnaire. These procedures resulted in
1073 usable responses, for an overall response rate of 26.8%. About 21% of the Basic adult and
child members completed the survey. The response rate for those in the Enhanced Plan was
higher, with 38% of the adults and 39.1% of the child members responding.
Survey layout and pre-testing methodology were based on recommendations by Dillman
(2000).
There were eleven broad categories of questions: (1) demographics, (2) experience
with Medicaid, (3) health literacy, (4) perceived benefits and barriers, (5) information sources,
(6) lifestyle and health status, (7) outcomes, (8) planned future behavior, (9) access to health
care, (10) past health insurance, and (11) psychological constructs. Each is described in detail
below. Generally, the questions used in the adult survey are equivalent to those used in the child
survey; substantive differences are identified below.
The questionnaires presented in the
Appendices VI and VII are identical to those mailed to respondents with the exception that the
question numbering has been changed in order to facilitate communication in this document.
Herein, when a specific question is addressed, we will identify the question on both the adult and
child survey. For example, the first question on the adult survey asks about the frequency of
problems encountered when transporting the Medicaid member to his/her primary care physician
and is identified as “A1.” The equivalent question in the children’s questionnaire is the first
question in the children’s questionnaire and is identified as “C1.”
12
For data collected in the child’s survey, it is important to note that the Medicaid member
is the child and the respondent is the child’s parent/guardian; however, for the adult survey, the
respondent and the Medicaid member refer to the same individual.
The overall results (percentages or means) for each question are presented in Appendix
IX. Appendix X provides the same information broken down by whether the Medicaid member
is an adult or child. When there are statistically significant differences between these two
groups, relationship strength is identified using either phi or eta2, each of which can range from
0.0 to 1.0. Small values of phi and eta2 (less than 0.02) indicate that differences between the two
groups are unlikely to be of practical significance. In social science, phi and eta2 of greater than
0.10 could be considered large. Appendix XI provides the results broken down by whether the
Medicaid member is enrolled in the Basic Plan or the Enhanced Plan and uses the same
conventions. Importantly, we used the Medicaid administrative data available at the time the
survey was mailed to determine if a member was enrolled in the Basic Plan or Enhanced Plan.
IV. BENEFICIARY SURVEY MEASURES AND RESULTS We now turn to the major areas of interest measured in the surveys. Eleven interest
categories were identified as potential drivers of a respondent’s choice of health plan as well as
potential outcomes after their selections.4
4
Readers may occasionally notice slight differences in the percentages reported in Appendices D and E and those
presented in tables. These discrepancies result due to the impact of missing data which changes the denominator
used in computing percentages.
13
A. Demographics BMS Administrative Data were used to determine age and gender. Respondents were
asked to provide their marital status (A12, C10) and educational level (A16, C11). As the table
below indicates, the average age of adult was 32.9 and 36.1 for Basic and Enhanced members,
respectively. The average child’s age was 7.7 and 8.3 for Basic Plan and Enhanced Plan
members, respectively. While children members were roughly 50% females and 50% males,
adult respondents were overwhelmingly female. A greater percentage of Enhanced Plan
members tended to be married compared to Basic Plan members; children in the Enhanced Plan
were more likely than children in the Basic Plan to have married parents/guardians. In terms of
education, about 75% of adult members have at least a high school degree or GED with no
significant difference between Basic and Enhanced Plan members. On the other hand,
respondents for children in the Enhanced Plan tend to be better educated compared to Basic Plan
members.
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Demographics
Adult
Measure
Average Age
Gender
Female
Male
Marital status Married
Single
Divorced
Separated
Widowed
Don't Know
Education
8th or Less
Some HS
HS or GED
Some College
Bachelor's
More than Bachelor's
Basic Enhanced (n=63)
(n=114)
32.9
36.1
85.70%
86.80%
14.30%
13.20%
25.40%
35.10%
28.60%
22.80%
39.70%
30.70%
6.30%
6.10%
0.00%
4.40%
25.40%
23.70%
9.50%
6.10%
14.30%
16.70%
54.00%
49.10%
17.50%
22.80%
3.20%
0.90%
1.60%
2.60%
Child
Basic Enhanced (n=485)
(n=411)
7.7
8.3
51.80%
50.90%
48.20%
49.10%
43.70%
54.70%
29.10%
17.80%
17.70%
19.50%
7.00%
3.20%
2.10%
2.70%
22.10%
21.90%
4.10%
3.90%
17.50%
8.30%
40.40%
46.50%
32.60%
32.60%
3.30%
5.60%
1.00%
1.20% All respondents provided information on the number of children in their home under the
age of 18, and the ages of their children (A5, A6, C6, C7) using fill-in-the-blank questions
patterned after those used by Dilger et. al (2004). On average, MHC members have 2.2 children
under the age of 18 living with them. This number does not change substantively for adult vs.
child members nor between the Enhanced Plan and the Basic Plan.5
5
The information presented is self‐reported. Individuals without children are not eligible for MHC; yet, a small percentage report no children in their home. However, it is possible that some of the respondents’ home situations may have changed between their enrollment and the time they completed the questionnaire, others may have misinterpreted the question and excluded the child who was the focus of the study. 15
Measure
Number of children in home
Presence of Children
Adult
Child
Basic Enhanced Basic Enhanced (n=63)
(n=114)
(n=485)
(n=411)
0
1
2
3
4
5
6
7
0.00%
30.20%
41.30%
15.90%
9.50%
1.60%
0.00%
1.60%
1.80%
46.50%
35.10%
9.60%
1.80%
4.40%
0.90%
0.00%
4.10%
20.40%
31.30%
21.60%
9.30%
3.10%
0.60%
0.40%
5.40%
24.10%
31.90%
20.00%
7.80%
3.20%
0.50%
0.20% B. Experience with Medicaid A series of questions were asked about past and current events and future plans relating
to health and Medicaid. This survey was mailed to only those individuals in our most recent
eligibility file and respondents were asked whether they hold a medical card (yes/no item; A19,
C19). Respondents indicated whether a specific medical event (e.g., illness or injury) was the
catalyst for the members’ current enrollment (A20, C20). Expectations for the length of time the
member expects to receive Medicaid was measured on a five-point scale patterned after that used
by Dilger et. al (2004) and anchored with “not more than a year” and “more than nine years,”
(A21, C21).
Ninety-seven percent of the members had a current medical card, with child members
(97.8%) being more likely to have a current medical card than adult members (94.4%). The vast
majority of members (95.4%) did not have a critical event (illness or injury) that prompted their
enrollment; however, adults were much more likely than children to enroll due to a critical event.
Indeed, 18% of adult enrollments versus only 2% of child enrollments were precipitated by an
illness or injury. Generally, members expect to be using Medicaid for many years; the most
16
common response was “more than nine years” (28.2%) and the majority expects to use Medicaid
for three or more years (66.6%). Adults intend to use Medicaid for a shorter time period, with
almost half (47.7%) expecting to use Medicaid less than three years. Enhanced Plan and Basic
Plan members did not differ on any of these questions.
Experience with Medicaid
Adult
Child
Basic Enhance
Basic Enhanced Measure
(n=63) d (n=114) (n=485)
(n=411)
Have Medicaid yes
93.70%
94.70%
96.10%
98.10%
card?
no
6.30%
5.30%
3.10%
1.20%
Why enrolled? Was Sick
7.90%
14.00%
1.60%
1.00%
Got Hurt
6.30%
5.30%
0.60%
0.70%
Neither
84.10%
77.20%
97.30%
97.30%
How long do Year or Less
11.10%
12.30%
7.20%
8.50%
you expect to 1‐2 Years
41.30%
22.80%
20.00%
18.70%
be on 3‐5 Years
14.30%
20.20%
23.10%
22.40%
Medicaid?
6‐8 Years
3.20%
5.30%
14.60%
12.20%
More than 9 Years
17.50%
25.40%
24.50%
26.50% Respondents also stated their satisfaction level with the member’s current Medicaid plan,
caseworkers, and primary care provider using a five-point “very dissatisfied” to “very satisfied”
scale (A18, C18). Respondents were satisfied (average = 4.03, in which 4 indicates “satisfied”)
with their current Medicaid plan, but were less satisfied with their caseworkers (3.51). They
were also satisfied with their primary care physician (4.31). Children’s parents/guardians are
more satisfied with their Medicaid plan than adult members, as were members in the Enhanced
Plan. It should be noted that membership in the Enhanced Plan for adults had a stronger positive
impact on satisfaction with the plan, than it does for parent/guardians of child members. Other
differences were minor.
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Satisfaction Measure
Satisfied w/ Medicaid plan
Satisfied w/ caseworker
Satisfied w/ doctor
Very Dissatisfied
Dissatisfied
Neither
Satisfied
Very Satisfied
Very Dissatisfied
Dissatisfied
Neither
Satisfied
Very Satisfied
Very Dissatisfied
Dissatisfied
Neither
Satisfied
Very Satisfied
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
7.90%
2.60%
3.10%
2.40%
19.00%
6.10%
5.80%
1.50%
9.50%
12.30%
6.80%
7.10%
47.60%
50.90%
56.30%
50.10%
12.70%
25.40%
26.80%
38.70%
12.70%
9.60%
7.80%
5.60%
15.90%
12.30%
12.80%
9.00%
20.60%
13.20%
21.20%
19.50%
42.90%
43.00%
40.60%
43.80%
6.30%
18.40%
15.30%
20.90%
1.60%
0.90%
1.60%
3.20%
6.30%
3.50%
3.30%
3.40%
11.10%
6.10%
6.40%
4.60%
46.00%
42.10%
40.40%
31.40%
28.60%
45.60%
47.20%
57.40% C. Health Literacy and Medicaid Awareness Health literacy is the consumer’s ability to understand and use medical information (U.S.
Department of Health and Human Services 2000). Several measures of health literacy are
included herein, the first being the respondent’s ability to interpret materials supplied at the time
of enrollment. Each respondent was provided the West Virginia Department of Health & Human
Resources Mountain Health Choices chart entitled “Medicaid Benefits at a Glance.” Either the
adult or children’s version of this chart was used depending on whether the Medicaid member
was an adult or child. Respondents first answered an open-ended question which asked them to
identify the main point of the chart (A35, C35). Then, a list of seven services tied to either the
adult’s or children’s plan was presented.
Based on the chart, respondents indicated that the
services were provided by “neither,” “only the Basic Plan,” “only the Enhanced Plan,” or “both
plans.” They were also provided a “don’t know” option (A36, C36). In the adult survey, two
18
services (emergency dental and primary care office visits) are covered under both plans, one
service (inpatient hospital rehabilitation) is not covered by either plan, and the remaining four
services are covered only under the Enhanced Plan. For the children’s survey, podiatry services
and weight management services are covered only under the Enhanced Plan, chiropractic
services are not covered by either plan, and the remaining four services are offered by both plans.
Answers were recorded such that each correct answer received one point, then the number of
correct answers were summed. “Don’t know” responses were considered incorrect. Thus, the
health literacy chart score could range from 0 (none correct) to 7 (all correct).
As seen in the following table, the respondents were highly literate with 74% to 81%
(depending on the group and plan) getting a score of perfect or only one of the seven wrong.
Number Correct
0
1
2
3
4
5
6
7
Health Literacy
Adult
Child
Basic Enhance
Basic Enhanced (n=63) d (n=114) (n=485)
(n=411)
11.10%
8.80%
12.00%
7.80%
0.00%
1.80%
1.00%
0.50%
1.60%
1.80%
1.60%
1.20%
0.00%
0.90%
1.20%
1.00%
0.00%
2.60%
1.90%
2.20%
6.30%
7.00%
7.60%
5.80%
12.70%
15.80%
20.00%
19.00%
68.30%
61.40%
54.60%
62.50% A total of 899 (83.7% of total sample) survey respondents completed the open ended
question, “What is the purpose of this chart?” The responses were coded as either a correct or
incorrect response to the question. In general, any response that described the chart as
summarizing or containing information regarding the two Mountain Health Choice plans or a
chart to help a person decide which plan to enroll in was judged correct. An example of a
“correct” answer was this response from a survey participant: “To show what is/is not covered
19
by the two plans.” The responses judged “incorrect” were either statements like “I don’t know”
or statements not directly related to the question, such as this response from a respondent: “There
[sic] okay, but our children should have all the benefits we can give them” which would suggest
a misinterpretation of the survey question. Of the 899 responses, 852 (94.8%) were judged
correct—indicating high levels of literacy.
As part of measuring health literacy, emotional and cognitive confusion was measured.
Emotional confusion, the negative emotions which arise when a consumer is confused (c.f.,
Mitchell, Walsh and Yamin 2005), was measured by respondents indicating how they felt (e.g.,
relaxed, confidence, unsure, confused and frustrated) while reading the chart using a four-point
“not at all” to “totally” scale. This scale was patterned after Mitchell, Walsh and Yamin (2005;
A37, C37). After reverse coding the unsure, confused and frustrated items, the four-item scale
showed excellent reliability (α=.84) and was averaged together after being coded so that higher
numbers mean more positive emotions. The overall average of 2.89 (out of 4) suggests that
members generally experienced positive emotions while examining the chart.
Emotional Confusion
(1= Negative emotion; 5= Positive emotion)
5
4
3
5 item average
2
1
Adult basic
Adult enhanced
Child basic
Child enhanced
20
Cognitive confusion occurs when the consumer realizes s/he is confused and lacks clarity
in his/her thoughts (c.f., Mitchell and Papvassiliou 1999) and was measured using two four-point
“strongly disagree” to “strongly agree” scales. Respondents stated whether the chart information
was easy to follow and whether it was confusing (A38a&b, C38a&b). These questions were
patterned after those suggested by Block and Keller (1997), Walsh, Hennig-Thurau and Mitchell
(2007) and Schweizer, Kotuc and Wagner (2006). Respondents agreed that the chart was easy to
follow (3.44 out of 4) and disagreed that the chart was confusing (1.92 out of 4). There were no
significant differences between the groups (adult/child and Basic/Enhanced) in terms of finding
the charts confusing or difficult to understand.
Measure
info easy
info confusing
Strongly Disagree
Disagree
Agree
Strongly Agree
Don't Know
Strongly Disagree
Disagree
Agree
Strongly Agree
Don't Know
Cognitive Confusion
Adult
Basic (n=63)
Enhanced (n=114)
3.20%
2.80%
4.80%
1.90%
37.10%
45.40%
50.00%
48.10%
4.80%
1.90%
38.70%
41.50%
41.90%
45.30%
9.70%
10.40%
4.80%
1.90%
4.80%
0.90%
Child
Basic (n=485)
Enhanced (n=411)
1.50%
1.50%
5.00%
3.50%
46.40%
48.40%
44.10%
40.60%
3.00%
6.00%
38.30%
39.20%
41.90%
42.80%
11.00%
10.60%
3.40%
2.60%
5.40%
4.90%
A primary component of Mountain Health Choices program is the use of Medical Homes.
Thus, respondents were asked if they had ever heard the term “Medical Home,” and if so, to
describe the term in their own words (A24, C24). Overall, relatively few (10.2%) of the
respondents had heard of this term. Compared to Basic Plan members, more members in the
Enhanced Plan had heard of this term although absolute levels remain low (15.0% of Enhanced
Plan members). If respondents answered “yes” to the Medical Home question, they were asked
21
in their own words to describe a Medical Home and given space on the survey form to record
their responses. A total of 89 survey participants wrote something in response to the question.
The responses were evaluated and coded as either a correct definition of a Medical Home or an
incorrect definition. An example of a response that was coded “correct” is: “The primary care
doctor who is our first-point of contact for Medical questions, problems, and check-ups. Where
they keep the medical records.” A response that was coded “incorrect” is: “Where a home health
nurse comes to your home and gives medical care to someone who could not otherwise see a
doctor, because of their physical inability.” Of the 89 respondents who wrote something, 75 or
84.2% defined the term correctly.
Awareness of Term "Medical Home"
(% Ever Heard) 18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Adult basic
Adult enhanced
Child basic
Child enhanced
Awareness of some key elements in the Enhanced Plan was measured.
First,
respondents were asked if they had ever seen a Health Improvement Plan and, if so, what they
thought of it (A32, A33, C32, and C33). Relatively few respondents had heard of a Health
Improvement Plan (9.2%) although a slightly higher number of Enhanced Plan members had
heard of the term (Basic=5.8%, Enhanced=12.8%). Following this, respondents were asked to
22
complete an open ended question, “”If yes, what do you think of the Health Improvement Plan?”
A total of 92 respondents replied to the question. Of the total responses, 45 respondents wrote a
positive comment regarding Health Improvement Plans. An example of a positive response was
“I think it is a great thing for my child.” There were 10 responses of a negative nature. An
example of this type of response was “I did not like it. I should be able to do what I want without
people telling me what to do with my health.” The remaining comments (37) covered a wide
range of topics from discussions of procedure (“Was harder for my dr's [sic] office to figure it
out than it was for me. My son's doctor has still not sent theirs in”) to general attitudinal
statements not specific to Health Improvement Plans (“My child does not need extra benefits”).
Awareness of different components of the Enhanced Plan was measured including the use
of a medical home in which one doctor is in charge of the member’s health (A31e, C31e) and
broader coverage of medical services in the Enhanced Plan (A31f ; C31f). Enhanced Plan
members were no more likely than Basic Plan members to agree that one doctor is to be in
charge. Additionally, both Basic Plan and Enhanced Plan members feel equally likely that they
will lose benefits depending on which Mountain Health Choices plan they select. There is no
significant difference in adult versus child member scores.
Respondents were asked their status in either the Basic or Enhanced Plan (A39, C39) and
they were given a range of options from being completely unaware that two plans exist to having
actively selected either the Basic Plan or Enhanced Plan. Recall that throughout this report,
when data is provided regarding differences between Basic Plan members and Enhanced Plan
members, membership is based on the Medicaid administrative data classification as of the end
of September 2008. Thus, discrepancies between the information provided in this question by
the respondent and the classifications used herein can be used as a measure of health literacy.
23
Given this, the data indicate a significant percentage of Basic Plan and Enhanced Plan members
do not understand their health plan status. For example, if there was perfect understanding of
their health plan status, nearly 100% of Basic plan members should have selected either “decided
Basic” or “did not choose” (allowing for a small number of actual changes in status in October
and early November). Yet, only 28% of adult Basic Plan members assigned themselves into one
of these categories. Error occurs within the Enhanced Plan members as well, as only 61.1% state
that they have seen their physician and signed a Health Improvement Plan. Approximately onequarter of respondents were unaware that two Mountain Health Choices plans existed (26.8%),
and another quarter knew of two plans, but were unsure as to which plan they were enrolled
(24.2%). Parents/guardians of MHC members were less likely to know two plans existed and less
likely to have signed a Health Improvement Plan than adult members. Additionally, Basic Plan
members were less likely to know of two plans and more likely to be in the decision process.
Self Reported Plan Status
Adult
Child
Basic Enhanced Basic Enhanced Status
(n=63)
(n=114)
(n=485)
(n=411)
Not aware of 2 plans
33.30%
5.30%
43.10%
12.70%
Not sure which plan I am in
25.40%
19.30%
24.50%
25.10%
Currently deciding
15.90%
5.30%
13.40%
4.90%
Waiting to sign HIP
19.00%
9.60%
16.50%
11.20%
Signed HIP
6.30%
65.80%
7.60%
59.90%
Decided Basic
6.30%
0.00%
5.60%
2.40%
Did not choose
22.20%
4.40%
22.10%
4.60% D. Perceived Benefits of and Barriers to Mountain Health Choices A battery of four-point “strongly agree” to “strongly disagree” questions was used to tap
the respondent’s perceived benefits and barriers to enrolling in the Enhanced Plan. Many
potential barriers were rated by the respondents (see A31, A34 and C31, C34). Several sets of
24
questions focused on different concepts. For example, five questions asked about the perceived
value of the Enhanced Plan (31b, 31c, 31h, 31k and 34c in both surveys) with statements such as
“I do not need any of the benefits under the Enhanced Plan” and “The Basic Plan and the
Enhanced Plan are about the same.” Another set of four questions focused on the perceived
hassle involved in joining the Enhanced Plan (31j, 31l, 34a, 34d in both surveys) and included
questions such as “I’m too busy to spend time looking over different Medicaid plans,” and
“There’s too much paperwork with the Enhanced Plan.” Other items explored the respondent’s
fear of penalties (A31a, A31i; C31a, C31i), level of confusion (A31g, C31g), and feelings that
the Enhanced Plan will be taken away (A34e, C34e) and changes in Medicaid lead to the
respondent being in a worse position (A34b, C34b). Complete results by group (children and
adult members) and type of plan (Basic and Enhanced) are detailed in the table below. Since
data across groups and plans were similar, the results were averaged to simplify the presentation
of the information and detailed in the following chart. With regard to these sets of questions,
only a few substantive differences stand out, adults and those in the Enhanced Plan usually need
more than four prescriptions at a time (A31d, C31d) and are less likely to agree that they will be
just as healthy in the Basic as the Enhanced Plan (A31l, C31l).
25
Barriers to enrollment
Adult
Child
Enhanced Basic Enhanced Basic (n=63) (n=114) (n=485) (n=411)
Barrier
Don't need the benefits
Not worth the paperwork
Strongly Disagree
27.00%
59.60% 18.80%
35.00%
Disagree
28.60%
21.10% 27.20%
33.60%
Agree
4.80%
4.40%
6.80%
3.60%
Strongly Agree
0.00%
2.60%
2.10%
1.20%
Don't Know
36.50%
11.40% 37.70%
22.10%
Strongly Disagree
11.11%
22.81%
3.30%
15.82%
Disagree
28.57%
43.86% 27.63%
41.12%
Agree
11.11%
4.39%
7.63%
9.49%
0.00%
5.26%
2.27%
1.95%
Strongly Agree
Benefits aren't great
Don't Know
46.03%
20.18% 51.55%
27.49%
Strongly Disagree
12.70%
31.60%
8.00%
19.70%
Disagree
33.30%
33.30% 31.30%
39.20%
Agree
12.70%
Strongly Agree
Will be just as healthy
Plans are the same
1.80%
6.80%
2.10%
2.70%
36.50%
20.20% 42.90%
27.50%
Strongly Disagree
19.00%
36.80%
7.60%
18.20%
Disagree
17.50%
28.10% 16.50%
26.50%
Agree
15.90%
10.50% 21.40%
16.80%
4.80%
0.00%
5.20%
3.90%
Don't Know
41.30%
21.90% 41.90%
31.40%
Strongly Disagree
17.50%
25.40%
5.80%
15.60%
Disagree
23.80%
43.00% 21.40%
34.10%
Agree
17.50%
13.20% 17.90%
16.50%
Strongly Agree
Don't Know
Don’t like member agreement Strongly Disagree
Disagree
Too busy to select plan
7.80%
Don't Know
Strongly Agree
3.20%
9.60%
3.20%
36.50%
4.80%
22.20%
0.90%
0.80%
1.00%
14.90% 47.00%
29.20%
16.70%
3.30%
11.20%
32.50% 24.30%
34.30%
Agree
9.50%
11.40%
7.00%
8.50%
Strongly Agree
0.00%
2.60%
2.70%
4.10%
Don't Know
60.30%
34.20% 54.00%
37.70%
Strongly Disagree
22.20%
28.90% 14.00%
22.10%
Disagree
28.60%
39.50% 40.20%
46.50%
Agree
14.30%
13.20% 12.00%
11.70%
Strongly Agree
Don't Know
4.80%
23.80%
4.40%
4.10%
11.40% 22.90%
2.90%
11.90% 26
Adult
Barrier
No time to visit doctor
Basic 14.30%
32.50% 11.50%
29.70%
Disagree
28.60%
40.40% 30.30%
42.30%
Agree
22.20%
8.80% 12.80%
5.80%
4.10%
1.00%
Don't Know
30.20%
11.40% 32.40%
17.00%
Strongly Disagree
11.10%
22.80%
3.30%
15.80%
Disagree
28.60%
43.90% 27.60%
41.10%
Agree
11.10%
4.40%
7.60%
9.50%
0.00%
5.30%
2.30%
1.90%
20.20% 51.50%
27.50%
15.80%
5.80%
14.10%
23.40%
Strongly Agree
Don't Know
I worry about the penalties
Will lose benefits if unable to obey member agreement
Strongly Disagree
Agree
25.40%
36.00% 23.70%
23.60%
Strongly Agree
12.70%
15.80%
7.60%
11.40%
Don't Know
38.10%
14.00% 38.10%
23.80%
Strongly Disagree
1.59%
7.89%
3.51%
4.14%
Disagree
9.52%
9.65% 14.43%
9.49%
Strongly Disagree
25.40%
9.52%
53.97%
3.20%
32.46% 15.88%
26.28%
22.81%
7.22%
15.57%
24.56% 51.34%
40.63%
4.30%
5.80%
Disagree
17.50%
32.50% 23.50%
29.00%
Agree
33.30%
25.40% 28.70%
32.40%
11.40%
Strongly Agree
17.50%
14.90% 10.90%
12.90%
Don't Know
27.00%
11.40% 24.70%
15.30%
Strongly Disagree
Disagree
7.90%
9.60%
3.10%
8.80%
6.30%
24.60% 13.80%
22.40%
Agree
28.60%
23.70% 13.80%
17.00%
Strongly Agree
11.10%
Don't Know
44.40%
Strongly Disagree
7.90%
9.60%
7.00%
5.10%
28.10% 54.80%
42.10%
16.70%
9.70%
19.50%
47.00%
Disagree
15.90%
43.00% 35.70%
Agree
30.20%
14.00%
9.90%
4.60%
3.20%
2.60%
4.10%
1.90%
Strongly Agree
Need more than four prescriptions
6.30%
14.90% 16.50%
Don't Know
I end up worse off
46.00%
4.40%
12.70%
Strongly Agree
New benefits will be taken away
0.00%
Disagree
Agree
Information was confusing
Basic Enhanced
Strongly Disagree
Strongly Agree
Too much paperwork
Child
Enhanced
Don't Know
39.70%
21.10% 32.60%
24.30%
Strongly Disagree
19.05%
11.40% 20.00%
19.22%
Disagree
34.92%
11.40% 37.32%
40.39%
Agree
11.11%
24.56% 10.93%
14.11%
Strongly Agree
17.46%
44.74%
Don't Know
15.87%
8.25%
5.26% 17.53%
9.49%
13.14% 27
Respondents tended to disagree that it was a hassle to join the Enhanced Plan (1.94 as
average of 4 items in which 2=disagree), and agree that the Enhanced Plan had greater value (3.2
as average of five items in which 3=agree). They appear to be only somewhat concerned
regarding penalties, as the average scores on this questions hover between disagree and agree
(i.e., 2.54 and 2.64). The same holds for confusion with Mountain Health Choices (mean=2.67)
and concern that the extra benefits in the Enhanced Plan will soon be taken away (mean=2.51).
Respondents disagreed that changes in Medicaid result in things being worse for the Medicaid
member (mean=2.02).
Barriers: Hassle
(1=Strongly Disagree; 4= Strongly Agree)
4
3
2
1
Don’t like member Too busy to select agreement
plan
No time to visit doctor
Too much paperwork
28
Barriers: Value
(1=Strongly Disagree; 4= Strongly Agree)
4
3
2
1
Don't need the Not worth the Benefits aren't Will be just as Plans are the benefits
paperwork
great
healthy
same
Barriers: Fears
(1=Strongly Disagree; 4= Strongly Agree)
4
3
2
1
I worry about the penalties
Will lose Information New benefits I end up worse benefits if was confusing will be taken off
unable to obey away
member agreement
Members who were enrolled in the Basic Plan were asked how much of a factor the
ability to make a doctor’s appointment to complete a Health Improvement Plan (“I couldn’t get
an appointment to complete the Health Improvement Plan with my doctor,” and “My doctor’s
office hours conflicted with my schedule,”) had on their plan choice using a two-point “not a
factor,” “was a factor” scale (A44, C44). About 16% of members in the Basic Plan cited these
aspects of health care as factors.
29
Measure
Could not get an appointment to complete HIP
Doctor office hours conflicted with my schedule
HIP/Doctor Barriers
Adult
Child
Basic Enhanced Basic Enhanced (n=63)
(n=114)
(n=485)
(n=411)
Was a factor
11.10%
7.00%
8.90%
2.70%
Was a factor
4.80%
5.30%
9.10%
4.10% Another set of questions addressed the perceived value of the wellness benefits offered in
the Enhanced Plan. MHC members were asked to rate the importance of having more than four
prescriptions covered, help losing weight, diabetes education and nutritional counseling on a
four-point “not important” to “very important” scale (A27b-e, C27a-d). Adult members were
also asked how important it was to have help to quit smoking—another Mountain Health Choice
Enhanced Plan benefit (A27a).
The results are summarized on the chart below.
Having more than four prescriptions
covered was rated the highest in terms of importance, averaging 3.34 on a 4-point scale, while
help losing weight was the least important (1.97 out of 4). However, the most noteworthy
differences between groups is that, compared to children, adult members rated help in losing
weight as important, particularly adult members on the Enhanced Plan. Additionally, adult
members in the Enhanced Plan placed more importance on coverage of more than four
prescriptions than other members.
30
Importance of Benefits
(1=not important; 4=very important)
4
3
2
1
Adult Basic
Adult Enhanced
Child Basic
Child Enhanced
E. Information Sources for Mountain Health Choices Respondents evaluated nine different information sources (e.g., mailed information,
internet, doctor, media) on a three-point “not helpful” to “very helpful” scale each with an
option that the respondent “did not receive info” (A28, C28). They then indicated which source
was the most important (A28k, C28k).
The results are summarized in the chart below.
Generally, respondents considered
information obtained from the mail to be the most helpful, with 35.3% indicating that the mailing
was “very helpful.” Second to this was information from doctors (23.2% “very helpful”). All
other information sources (pharmacists, internet, community groups, friends and family, media,
phone calls and case workers) were viewed as not particularly helpful. In addition to individual
ratings of information sources, respondents were asked to indicate one source as the most
important. By a 4 to 1 margin, respondents indicated information from the mail to be more
important than any other source (52.8% mailing vs. next highest rating of 13.2% from doctors).
31
Doctors and caseworkers were second and third, respectively with the exception of children
members in the Basic Plan where caseworkers were ranked second and doctors third.
Pharmacists proved to be a more important source of information for adult members.
Rating of information source
Adult
Souce
From mail
From pharmacist
From internet
From community groups
From friends & family
From media
From phone call about Mountain Health Choices
From caseworkers
From doctor
From other source
Basic (n=63)
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
Did Not Receive
Not Helpful
Somewhat Helpful
Very Helpful
23.80%
6.30%
38.10%
23.80%
34.90%
4.80%
15.90%
6.30%
50.80%
4.80%
1.60%
0.00%
55.60%
1.60%
1.60%
0.00%
39.70%
3.20%
11.10%
3.20%
49.20%
3.20%
3.20%
1.60%
44.40%
1.60%
4.80%
6.30%
31.70%
9.50%
9.50%
9.50%
34.90%
3.20%
12.70%
9.50%
38.10%
3.20%
3.20%
4.80%
Child
Enhanced (n=114)
6.10%
6.10%
43.00%
40.40%
42.10%
1.80%
8.80%
9.60%
51.80%
3.50%
5.30%
4.40%
51.80%
3.50%
7.00%
1.80%
46.50%
2.60%
10.50%
4.40%
50.00%
3.50%
7.90%
1.80%
39.50%
1.80%
12.30%
9.60%
32.50%
9.60%
14.00%
13.20%
25.40%
7.90%
14.00%
21.10%
41.20%
5.30%
5.30%
4.40%
Basic (n=485)
20.20%
6.60%
37.90%
27.20%
51.80%
2.10%
7.40%
3.90%
56.50%
2.50%
3.50%
2.10%
57.30%
3.10%
2.70%
0.80%
53.20%
1.60%
5.80%
4.30%
56.10%
3.70%
4.10%
1.40%
52.80%
2.70%
6.40%
3.70%
44.90%
3.90%
13.80%
7.40%
45.80%
1.00%
11.30%
9.10%
50.70%
1.40%
4.50%
2.10%
Enhanced (n=411)
8.00%
5.60%
40.10%
38.20%
44.50%
3.20%
4.90%
7.80%
51.10%
3.40%
1.70%
2.70%
52.80%
3.40%
1.00%
1.50%
48.40%
3.40%
4.90%
3.40%
48.70%
3.90%
3.90%
2.20%
42.30%
4.60%
6.80%
8.50%
34.10%
5.60%
13.40%
10.00%
28.20%
2.40%
14.80%
22.90%
42.30%
4.40%
1.70%
2.90% 32
Members in the Enhanced Plan rated many information sources higher than those in the
Basic Plan: mailings, pharmacists, phone calls, caseworkers, and doctors. This result is not
surprising since Enhanced Plan respondents went through an active selection process. Thus, it is
logical to assume these individuals probably turned to various information sources in their
decision process and would consider these sources of information to be of greater value than
Basic Plan participants, who may have defaulted into their plan as opposed to making an active
choice.
Respondents were provided a picture of the primary Mountain Health Choices mailing
envelop and asked if they recalled seeing this (A29, C29), and if so, how much of its contents
they read on a four-point scale ranging from “none” to reading “almost all of the contents” (A30,
C30). The majority of respondents recalled receiving the mailing (58.5%). Parents/guardians of
children members in the Enhanced Plan were most likely to recall the mailing (74.7%) while
parent/guardians of children members in the Basic Plan had much lower recall (41.2%). For
adult members, 51.8% of those in the Basic Plan recalled seeing the mailing compared to 64.0%
in the Enhanced Plan. In terms of readership of the mailing material, as detailed in the chart
below, roughly 70% of Enhanced Plan members read all the contents. Readership by Basic Plan
members was significantly less (44%-56%).
Basic (n=25)
Did Not Read Any Skimmed
Read Half
Read All
Adult
Enhanced (n=84)
8.00%
44.00%
4.00%
44.00%
4.80%
14.30%
10.70%
70.20%
Child
Basic Enhanced (n=256)
(n=411)
3.90%
27.70%
11.70%
56.60%
3.10%
18.50%
7.10%
71.30%
33
F. Lifestyle and Health Status A series of questions were asked regarding the respondent’s current health as well as
individual behaviors such as the tendency to exercise and use of tobacco. The MHC members’
exercise behavior was measured on a six-point scale ranging from “daily” to “never” (A4, C4).
Most members exercise daily (58.3%) with children much more likely to exercise daily than
adults. Additionally, members in the Basic Plan were more likely to exercise daily than those in
the Enhanced Plan.
Measure
Exercise Daily
3‐5 per wk
Once per Week
Few Times per Month
Less than one per Month
Never
Exercise Activity
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
39.70%
21.90%
66.00%
60.10%
14.30%
17.50%
20.20%
24.30%
15.90%
15.80%
4.10%
6.30%
17.50%
24.60%
3.70%
3.60%
3.20%
9.50%
8.80%
10.50%
0.80%
3.70%
1.50%
2.70% Only adult members were asked to indicate whether they had used any tobacco products
in the last thirty days (A8a), and, if so, how many cigarettes or how often they use other tobacco
products (A8b, A8c, A8d; measure recommended by Tworek 2008). Sixty-one percent of adult
members used tobacco products within the past 30 days. Members smoked up to 60 cigarettes a
day, averaging just over 16 cigarettes. Approximately 7% used snuff and 6% used other forms
of tobacco.
34
Tobacco Usage
Measure
Use Tobacco
Cigarette
Use Snuff
Other tobacco
Yes
No
0‐10
11‐20
21‐30
31‐40
41+
Adult
Basic Enhance
(n=63) d (n=114)
58.70%
62.30%
41.30%
37.70%
25.40%
23.90%
28.60%
26.40%
54.00%
50.30%
3.20%
4.40%
0.00%
0.90%
4.80%
6.10%
3.20%
5.30% To develop a proxy for overall health, the Body Mass Index (BMI) of each Mountain
Health Choices member was calculated. The member’s height (A15a, C16a) and weight (A15b,
C16b) were measured in fill-in-the blank format and then converted to BMI. It should be noted
that BMI estimates calculated in this manner have a systematic bias downward, as many
individuals report being taller than they actually are and weighing less than they actually do
(Shields, Gorber and Tremblay 2008). The average MHC member’s BMI was 22.88, with
11.6% overweight (BMI between 25.0 and 29.9) and 13.5% obese (BMI greater than 30). Adults
choosing the Enhanced Plan had an average BMI indicating obesity (31.7), while adults in the
Basic Plan had an average BMI indicating that they, as a group, are overweight (26.72). The
average child’s BMI, regardless of plan was approximately 21, indicating a healthy weight.
Measure
BMI
Body Mass Index
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
<24.99
45.16%
52.08%
79.33%
77.50%
25‐29.99
25.81%
47.92%
11.89%
12.19%
29.03%
0.00%
8.79%
10.31% >30.0
35
In terms of the current health of the Medicaid member, respondents were asked to
indicate recent changes in their overall health, as well as their physical and mental health.
Changes in the Medicaid member’s overall health within the last six months were measured on a
three-point “improved,” “same,” or “worse” scale (A10, C13). Both the member’s current
physical health (A11, C14) and current mental/emotional health (A14, C15) were measured on
five-point “excellent” to “poor” scales. These two items were averaged to provide a second
overall health measure (α=0.79).
The majority (78.2%) of Medicaid members’ health has remained the same over the past
six months; however, adults are much more likely to have experienced a decline, as were
members of the Enhanced Plan. The average overall health rating was 3.84, reflecting “good” to
“very good” health. Reported health for adults was much poorer (overall, as well as physical and
emotional) than for children. Indeed, the general pattern of results suggests that children,
regardless of plan, are reported to be in better health than adults, and that the adults choosing the
Enhanced Plan are in significantly worse health than those in the Basic Plan. 36
Measure
Health Change
Physical Health
Psychic Health
Health Status
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
Improved
12.70%
7.00%
16.30%
13.40%
Same
65.10%
53.50%
81.90%
82.70%
Worse
22.20%
38.60%
1.90%
2.90%
Excellent
4.80%
1.80%
44.30%
39.20%
Very Good
20.60%
8.80%
32.40%
37.70%
Good
38.10%
28.90%
17.50%
17.50%
Fair
27.00%
38.60%
4.90%
4.90%
Poor
9.50%
21.10%
0.80%
0.00%
Excellent
12.70%
7.90%
43.50%
43.60%
Very Good
14.30%
7.90%
26.80%
28.50%
Good
30.20%
24.60%
20.40%
19.50%
Fair
27.00%
42.10%
7.20%
6.30%
Poor
15.90%
17.50%
1.20%
0.70% Finally, a series of questions regarding attitudes towards and adherence to good health
practices as identified in the Mountain Health Choices Member Agreement, such as regular
check-ups, using the emergency room only for emergencies, and completing all medications,
were measures on five-point, “strongly disagree” to “strongly agree” scales (A17h,i, k, m-q,
C17h,i, k, m-q).
Respondents tended to agree that they use emergency rooms only for
emergencies (4.16 out of 5) and disagree that they receive better care in emergency rooms than at
other health-care facilities (2.20 out of 5). Respondents felt that they read the information
provided by the physician, call the doctor’s office when they cannot make an appointment, show
up to appointments on time, take all of their medications, and do their best to be healthy (all
means greater than 4.1), all of which are components of the Responsibility Agreement. Answers
did not differ in a substantive manner between members in the Enhanced and Basic Plan.
Indeed, the only noteworthy difference in responses to the items reflecting the responsibility
agreement dealt with regular checkups; adult members on the Basic Plan were much less likely
to have regular checkups than other members.
37
Measure
ER for emer‐
gencies only
ER care better
Go for reg. check ups
Read all health info
Call to cancel appts.
Try to stay healthy
Take meds
Show up on time for appts.
Responsibility Agreement Compliance
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
Strongly Disagree
3.20%
1.80%
1.90%
0.70%
Disagree
0.00%
3.50%
6.20%
3.40%
Neither 9.50%
6.10%
6.80%
6.10%
Agree
57.10%
43.00%
52.20%
48.70%
Strongly Agree
30.20%
42.10%
32.40%
40.10%
Strongly Disagree
14.30%
24.60%
20.80%
27.00%
Disagree
31.70%
39.50%
42.10%
43.30%
Neither 41.30%
25.40%
28.00%
22.90%
Agree
11.10%
5.30%
5.40%
3.90%
Strongly Agree
0.00%
3.50%
2.30%
1.70%
Strongly Disagree
4.80%
2.60%
1.60%
1.00%
Disagree
22.20%
3.50%
4.10%
1.20%
Neither 12.70%
6.10%
6.40%
2.20%
Agree
41.30%
50.90%
41.00%
44.00%
Strongly Agree
17.50%
35.10%
45.40%
50.10%
Strongly Disagree
3.20%
1.80%
0.60%
0.20%
Disagree
3.20%
7.00%
2.30%
3.60%
Neither
20.60%
13.20%
8.50%
7.30%
Agree
54.00%
56.10%
52.60%
55.20%
Strongly Agree
19.00%
20.20%
34.80%
32.60%
Strongly Disagree
1.60%
0.00%
0.40%
0.70%
Disagree
3.20%
0.00%
2.30%
1.20%
Neither
20.60%
4.40%
7.40%
5.40%
Agree
42.90%
58.80%
53.00%
48.70%
Strongly Agree
30.20%
34.20%
36.30%
42.80%
Strongly Disagree
1.60%
1.80%
0.40%
0.50%
Disagree
3.20%
7.00%
0.00%
0.50%
Neither
20.60%
19.30%
0.60%
0.50%
Agree
54.00%
51.80%
34.60%
38.20%
Strongly Agree
20.60%
16.70%
63.50%
59.60%
Strongly Disagree
0.00%
1.80%
0.60%
0.70%
Disagree
6.30%
0.90%
0.00%
0.00%
Neither
7.90%
7.90%
0.80%
1.20%
Agree
44.40%
43.90%
31.80%
37.20%
Strongly Agree
41.30%
42.10%
65.80%
59.40%
Strongly Disagree
0.00%
1.80%
0.20%
0.70%
Disagree
3.20%
0.00%
2.30%
0.50%
Neither
3.20%
5.30%
6.60%
3.40%
Agree
52.40%
45.60%
37.10%
39.70%
Strongly Agree
39.70%
46.50%
53.00%
54.50% 38
G. Mountain Health Choices Outcomes Many behavioral and attitudinal outcomes were addressed in this survey. Behavioral
changes were measured by asking whether members had engaged in a behavior “less,” “more,”
or “the same,” with respect to the amount of physical activity (exercising and watching
television; A41a, A41g, C41b, C41c), eating habits (consuming fried foods, or fruits and
vegetables; A41b, A41e, C41a, C41d) and, for adults, tobacco use (A41c) and prescription
compliance (A41f). These questions also allowed respondents to indicate that the Medicaid
member never engaged in the activity. Across all groups, MHC members are reported to eat less
fried food (26.8%), eat more fruit and vegetables (27.6%), and increase their level of exercise
(19.6%). For the remaining outcomes, respondents reported members watched less television
(16.3%), remembered to take their prescriptions more often (23.4% of the adults) and smoked
fewer cigarettes (12.4% of adults). Snuff usage was below minimum reporting standards. Adults
in the Enhanced Plan reported increases in the positive health behaviors of eating fewer fried
foods, smoking less tobacco and remembering to take prescriptions than did those in the Basic
Plan. Adults were more likely than children to reduce exercise. Healthy Outcomes (% of Total Sample)
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
39
Healthy Outcomes (% of Total Sample)
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Respondents were also asked to compare their current Mountain Health Choices plan
(either Basic or Enhanced) to their previous Medicaid plan by indicating that it is “better,”
“about the same,” or “worse” (A42, C42). An option was also provided that the member was
new to Medicaid and had no experience with Medicaid prior to Mountain Health Choices.
Additionally, respondents indicated their level of agreement, using a five-point “strongly
disagree” to “strongly agree” scale, that their health plan would allow them to receive more
support from their doctor, help the Medicaid member be healthy, and improve the Medicaid
member’s health in the future (A43a-c, C43a-c).
Most respondents indicated that the member’s current Medicaid plan is either better
(24.0%) or about the same (44.0%) as the previous plan. Only 3.5% of respondents felt the
current Medicaid plan is worse. Those that selected the Enhanced Plan are satisfied with their
decisions. For adults, 46% of Basic Plan members and 80% of Enhanced Plan members rated
their plan the same or better than their previous plan. For children, 56.8% of Basic Plan members
and 80.7% of Enhanced Plan members rated their plan better than their previous plan. Likewise,
40
Enhanced Plan members tend to rate their plan has having more support from their doctor and
making them healthier than Basic Plan members. The majority of Enhanced Plan members
selected their plan to be healthier.
Post Decision Attitudes
Adult
Child
Basic Enhance
Basic Enhance
Measure
(n=63) d (n=114) (n=485) d (n=411)
current better
Yes
11.11%
50.88%
11.34%
33.33%
current same
Yes
34.92%
29.82%
45.57%
47.45%
current worse
Yes
11.11%
7.02%
3.71%
1.22%
no prior medicaid Yes
11.11%
4.39%
5.77%
5.11%
More doc support Strongly Disagree
1.59%
5.26%
3.92%
5.84%
Disagree
11.11%
10.53%
8.45%
12.90%
Neither Agree or Disagree
52.38%
49.12%
37.94%
41.12%
Agree
6.35%
21.05%
11.75%
19.46%
Strongly Agree
1.59%
5.26%
3.30%
5.60%
Plans makes me healthy
Strongly Disagree
1.59%
2.63%
1.86%
2.43%
Disagree
7.94%
5.26%
3.92%
4.14%
Neither Agree or Disagree
34.92%
28.07%
19.79%
26.28%
Agree
23.81%
39.47%
29.69%
38.20%
Strongly Agree
4.76%
16.67%
10.93%
15.82%
Picked plan to be more healthy
Strongly Disagree
6.35%
0.88%
1.03%
1.95%
Disagree
4.76%
2.63%
2.47%
0.73%
Neither Agree or Disagree
34.92%
24.56%
22.47%
18.00%
Agree
17.46%
43.86%
22.89%
40.15%
Strongly Agree
11.11%
21.05%
15.46%
25.79% Finally, respondents provided their degree of agreement with the statement “I was
surprised to hear from my doctor that certain services are no longer covered” using the four-point
“strongly disagree” to “strongly agree” scale in order to determine if members have encountered
a reduction in previously covered services since the change to Mountain Health Choices (A34h,
C34h). While many respondents replied, “did not know,” among adult members, there was some
41
agreement to this statement (Basic: 34.9% agree/strongly agree; Enhanced: 41.2% agree/strongly
agree). This finding did not extend to children members.
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
Surprised services no longer covered
Strongly Disagree
Disagree
Agree
Strongly Agree
Don't Know
1.60%
6.30%
19.00%
15.90%
52.40%
6.10%
13.20%
30.70%
10.50%
34.20%
1.60%
11.50%
16.30%
7.80%
53.60%
5.60%
20.40%
17.00%
7.10%
44.00% H. Future Planned Behavior Adult members were given a list of wellness-related benefits offered on the Health
Improvement Plan and asked which, if any, they planned to have completed within the next year.
These included mammograms, glucose screenings, and cholesterol testing, among others.
Respondents used a “yes,” “no,” “don’t know,” or “not applicable” scale (A26a-l). Using the
same response scale, parents/guardians of children enrolled in Mountain Health Choices
indicated whether they expected their child to receive weight loss, nutritional education,
cholesterol screening, childhood vaccines, or diabetes education within the next year (C26a-e).
Several items were evaluated by both adult and child members: weight loss, nutritional
education, lipid screening, and diabetes education.
Many MHC members plan to have a pap test (68.8% of adults), childhood vaccines
(49.5% of children), tests for high blood pressure (45.5% of adults), and adult vaccines (37.8%
of adults). Few are planning colonoscopies, prostate exams, or diabetes education (all less than
10% of the relevant population). Adult members expressed greater interest in weight loss
(40.9%) and cholesterol screening (47.3%) than child members. Enhanced members expressed
42
greater interest in glucose screening, and testing for high blood pressure, than Basic members.
Adults in the Enhanced Plan were more likely to anticipate getting their blood pressure and
cholesterol tested than those in the Basic Plan.
Planned Future Behavior
(% Yes)
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Adult Enhanced
Quitting smoking
Test for high …
Prostate Exam
Colonoscopy
Pap Test
Glucose …
Mammogram
Vaccine (Adult)
Diabetes Eduction
Vaccine …
Lipid Screening
Nutritional Ed.
Weight Loss
Adult Basic
Child Basic
Child Enhanced
43
Measure
Weight Loss
Nutritional Ed.
Lipid Screening
Vaccine (Childhood)
Vaccine (Adult)
Diabetes Education
Mammogram
Glucose Screening
Pap Test
Future Planned Behavior
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
Yes
28.60%
43.00%
8.50%
6.80%
No
39.70%
26.30%
56.70%
55.20%
N/A
7.90%
7.00%
15.90%
16.30%
Don't Know
15.90%
16.70%
15.50%
18.00%
Yes
15.90%
22.80%
20.80%
18.20%
No
41.30%
39.50%
36.90%
40.40%
N/A
11.10%
8.80%
14.20%
13.40%
Don't Know
25.40%
23.70%
22.10%
21.90%
Yes
25.40%
54.40%
10.30%
11.70%
No
44.40%
20.20%
44.50%
42.60%
N/A
4.80%
2.60%
17.50%
14.10%
Don't Know
17.50%
16.70%
22.70%
26.50%
Yes
n/a
n/a
48.90%
46.70%
No
n/a
n/a
19.80%
17.80%
N/A
n/a
n/a
12.20%
10.70%
Don't Know
n/a
n/a
16.50%
20.90%
Yes
28.60%
38.60%
n/a
n/a
No
33.30%
29.80%
n/a
n/a
N/A
7.90%
5.30%
n/a
n/a
Don't Know
23.80%
18.40%
n/a
n/a
Yes
9.50%
12.30%
7.60%
7.80%
No
49.20%
40.40%
46.80%
45.50%
N/A
9.50%
12.30%
19.20%
16.30%
Don't Know
25.40%
21.90%
22.30%
26.30%
Yes
28.60%
42.10%
n/a
n/a
No
33.30%
28.90%
n/a
n/a
N/A
7.90%
10.50%
n/a
n/a
Don't Know
25.40%
15.80%
n/a
n/a
Yes
22.20%
47.40%
n/a
n/a
No
38.10%
21.10%
n/a
n/a
N/A
3.20%
5.30%
n/a
n/a
Don't Know
27.00%
21.90%
n/a
n/a
Yes
60.30%
69.30%
n/a
n/a
No
11.10%
11.40%
n/a
n/a
N/A
12.70%
6.10%
n/a
n/a
Don't Know
12.70%
8.80%
n/a
n/a
44
Future Planned Behavior (Cont.)
Adult
Child
Basic Enhance
Basic Enhance
Measure
(n=63) d (n=114) (n=485) d (n=411)
Colonoscopy
Yes
6.30%
8.80%
n/a
n/a
No
55.60%
51.80%
n/a
n/a
N/A
14.30%
9.60%
n/a
n/a
Don't Know
17.50%
23.70%
n/a
n/a
Prostate Exam Yes
1.60%
6.10%
n/a
n/a
No
49.20%
53.50%
n/a
n/a
N/A
23.80%
23.70%
n/a
n/a
Don't Know
17.50%
11.40%
n/a
n/a
Test for high blood pressure Yes
25.40%
52.60%
n/a
n/a
No
41.30%
23.70%
n/a
n/a
N/A
6.30%
3.50%
n/a
n/a
Don't Know
20.60%
14.90%
n/a
n/a
Quitting smoking
Yes
25.40%
25.40%
n/a
n/a
No
34.90%
36.80%
n/a
n/a
N/A
15.90%
20.20%
n/a
n/a
Don't Know
20.60%
11.40%
n/a
n/a
I. Access to Health Care Respondents were asked if they have transportation problems getting to their primary
care doctor’s office. Access to a Medicaid member’s primary care doctor’s office was measured
on a four-point scale ranging from “almost never” to “almost always” (A1, C1). Travel time to
the MHC members’ primary care doctor’s office and to the nearest emergency room was
measured using fill-in-the-blank questions segregated into hours (A2a, A3a, C2a, C3a) and
minutes (A2b, A3b, C2b, C3b).
All responses were converted to minutes for analysis.
Respondents’ thoughts regarding the difficulty of getting an appointment with the doctor’s office
were assessed by their agreement with the statements that the doctor’s “hours do not work with
my schedule” and “it is hard to get a doctor’s appointment” (A17 j, A17l, C17j, C17).
45
The majority of respondents (77.4%) almost never have a problem finding transportation
to the doctors. However, adult members and members in the Basic Plan are more likely to
experience a problem more than half the time they need to visit a doctor’s office.
Parents/guardians of children in the Basic Plan were also more likely to have transportation
problems than children in the Enhanced Plan. The average travel time to the doctor’s office and
to the nearest emergency room is approximately 30 minutes for MHC members. Based on
respondent’s low level of agreement (mean agreement scores less than 2.2 out of 5) they find it
difficult to obtain an appointment with the doctor which works into their schedule, these issues
do not appear to be limiting member’s access to health care.
Access to Health Care
35
30
25
20
15
Avg. Minutes to Dr. office
10
Avg. Minutes to ER
5
0
Adult Basic
Adult Child Basic Child Basic
Enhanced
J. Past Health Insurance The MHC members’ experience with other health insurers was measured with a yes/no
question (A22, C22). If the respondents answered “yes,” they were directed to a follow-up
question (A23, C23) to indicate the type of insurance (employer-based, covered under another
individual’s plan, purchased private insurance or “other”). For the child’s survey, a “CHIPs”
46
option was included as an answer option. Only 21.3% of respondents had health insurance prior
to Medicaid. More Enhanced Plan members, compared to Basic Plan members, tended to have
medical insurance prior to enrolling in Medicaid (24.5% and 18.7%, respectively). Of those who
had prior insurance, the most common response (35.8%) was that the member had previously
used health insurance provided through employment, particularly among the adult Enhanced
Plan members. Many were also previously covered by someone else’s plan (28.8%). Twentyseven percent of the children were covered by the CHIPs program prior to being covered by
Medicaid.
Of those 257 members with prior insurance, only
4.3% (11 respondents) had
purchased private insurance.
Measure
Have medical insurance prior Yes
If yes…
From employer
Purchased
On someone's plan
CHIP
Other
Adult
Child
Basic Enhance
Basic Enhance
(n=63) d (n=114) (n=485) d (n=411)
14.30%
3.20%
0.00%
7.90%
n/a
4.80%
22.80%
14.00%
0.90%
7.00%
n/a
1.80%
19.00%
7.00%
0.80%
6.20%
7.40%
2.50%
24.80%
9.70%
1.50%
7.50%
7.30%
2.40% K. General Psychological Constructs Past research has identified a number of personality and psychological concepts that can
influence individual behavior. As a potential explanation for an individual’s choice of health care
plans, a number of these psychological constructs were included in the survey. This information
is gathered not as an end in itself but to see whether it correlates with or predicts health care
decisions. Each is discussed briefly below and summarized in the following chart.
47
Psychological Measures
5
4
3
2
Adult Basic
1
Adult Enhanced
Child Basic
Child Enhanced
Health locus of control deals with whether the individual feels that s/he controls his/her
health (an internal locus of control) or whether external factors outside of the individual’s power
control health. Two five-point “strongly disagree” to “strongly agree” items, based on work by
Wallston, Wallston and DeVellis (1978), were used to measure the respondent’s health locus of
control: “A healthy lifestyle can make you healthy,” and “No matter what I do, if I’m going to
get sick, I will get sick,” (A17c, A17g, C17c C17g). The former item taps an internal locus of
control, whereas the latter taps an external locus of control. Respondents were more likely to
have an external locus of control (mean=4.15) than an internal locus of control (mean=2.89).
This personality factor did not differ between members on the Enhanced Plan or Basic Plan.
Adult members were slightly more likely to have an external locus of control and slightly less
likely to have an internal locus, than were the parents/guardians of child members.
Protection motivation taps a person’s drive to protect his/her health (Moorman and
Matulich 1993). Respondents indicated how much they agreed with the statements, “I don’t
worry about health risks until they become a problem for me or for someone close to me,” and
48
“There are too many things that can hurt you these days to worry about them all,” using a fivepoint “strongly disagree” to “strongly agree” scale adapted from Moorman and Matulich 1993
(A17a, A17b, C17a, C17b). These two items were reverse coded so that higher numbers mean
greater protection motivation and then averaged for an overall score (α=0.67). Respondents’
protection motivation was somewhat neutral (average = 3.29 out of 5). Parents/guardians of
child members are more motivated to protect health than are adult members, but there are no
differences between those on the Enhanced Plan or Basic Plan.
Conscientiousness is an underlying personality trait which deals with the respondent’s
propensity to be precise and organized (Mowen 1999). Two items, adapted from Mowen (1999),
measured this trait. Respondents, using the five-point scale, indicated how much they agreed
with the statements, “I am organized,” and “I like to keep things in order,” (A17e, A17f, C17e,
C17f).
These two items were averaged and coded so higher numbers mean greater
conscientiousness (α= 0.80). Respondents tend to agree they are conscientious (3.89 out of 5).
Parents/guardians of child members are more conscientious than adult members, but again, there
are not differences between those on the Enhanced Plan or Basic plan.
Future outlook was measured with three questions previously used by Dilger et. al
(2004). The first was a three-point item in which respondents indicated which statement was true
for them: the best part of their life is ”now,” “in the future,” or has “already happened,” (A9,
C9). A second question asked how the respondent viewed his/her future, on a five-point scale
ranging from “excellent” to “very poor” with the option of “not sure” in which “not sure” was
coded as missing (A13, C12). Finally, respondents indicated on a five-point scale how much
they agreed with the statement, “I have total confidence in my ability to provide for my family in
the future” (A17d, C17d). The first item did not correlate strongly with the others, so it is treated
49
separately. The latter two items were coded such that higher numbers indicate a more positive
future outlook and were averaged (α=.66).
Only 15.1% of respondents felt that the best part of their life was in the past, while 39.1%
feel that the best is in the future. The most common response was that the best of life is right
now (45.7%). These responses differed strongly between adult members, many of whom felt the
future would be better, yet a significant proportion (23.1%) felt the best was behind them.
Parents/guardians of child members were more likely to feel that the present is the best part of
their lives. It appears that parents/guardians of child MHC members are more positive in their
outlook than adult members. Moreover, adult members on the Enhanced Plan have the most
negative outlook of all.
L. Open­ended Responses Two open-ended responses elicited a large variety of responses and thus are given
particular attention. After the respondent answered the questions regarding which plan the
Medicaid member was in (A39, C39), respondents were asked why they chose that plan.
Additionally, the back page of the questionnaire asked if the respondent had any final comments
about Medicaid, Mountain Health Choices, or their health care in general. Verbatim answers
from each of these two questions were coded into N6 Qualitative Software and analyzed for
themes.
The most common responses to “Why did you choose your health plan?” dealt with the
breadth of coverage in the plans, the feeling that many members did not actively make a choice,
specific reasons for making a choice, and levels of uncertainty or confusion about the member’s
health plan.
50
Many stated that they chose their plan because of the services provided, making
statements such as, “…the Enhanced Plan offers more coverage that I may need or could use in
the future.” Indeed, this individual’s comment shows both sides of the “more coverage” coin.
First, some members suffer from an illness which they feel is better covered under the Enhanced
Plan, making statements such as, “At the time I needed some of the benefits that were not
covered on the basic Medicaid.” Specific medical conditions, such as asthma, diabetes, allergies,
and pregnancy6, were named. Often, respondents simply stated the Medicaid member has a
“medical problem.” A second group of respondents was concerned about the future and making
sure that if there is a medical event in the future, they are covered. “I chose the Enhanced plan
because no one knows what the future holds,” and “To make sure she would be taken care of
should any medical problems arise," exemplify this proactive attitude.
Respondents also often stated that they did not make a choice. Indeed, when asked why
they chose their plan, the answer was, “I didn’t.” Others clarified this response, stating the
DHHR or their caseworker made the choice, while many used the vague term “they” when
attributing the choice to others. Additionally, it appears that some doctors are encouraging
choice, as reflected in the statements, "Honestly, I didn't think the Enhanced Plan was necessary.
Our physician insists all her patients have it," and “I let the Dr. choose the plan.”
Respondents also identified specific reasons for choosing their plan. More than fifty
respondents stated a need for more than four prescriptions and many mentioned additional
coverage of contacts and vision services in the Enhanced Plan. Very few stated their desire for
6
Once BMS is notified that a woman is pregnant, she is removed from MHC and enrolled into the traditional Medicaid plan. Respondents indicating that they were seeking pregnancy benefits may not have yet informed BMS of the pregnancy or may be indicating by this answer that they are aware that the pregnancy changed their Medicaid plan. 51
help with tobacco cessation (only one respondent) or weight loss (less than ten respondents) was
a reason for their choice.
Finally, sixty to seventy of the respondents expressed uncertainty or confusion in at least
one of several ways. First, a number of these respondents could not provide a reason beyond
“Don’t know” or “Unsure” about why they chose one plan over the other. Others were uncertain
about which plan the Medicaid member was currently a part of (“Not sure what one she has,”) or
unaware that two plans were offered ("I didn't know there were 2 plans available”). Finally,
many were confused by information directly related to the plans (“…I don't understand the
plans,” “I am extremely confused with my son's health plan”).
Respondents were also given the opportunity to make any comments using the back
cover of the survey. Responses clustered into several groups: those expressing gratitude for the
Medicaid program and for asking their opinions (via this survey), those lodging complaints about
various aspects of their health care, those indicating confusion regarding Mountain Health
Choices or suggestions for improvements, and those asking specific questions about their health
care plan and needs. While the comments were consistent with responses to the multiple choice
questions, this unstructured opened-ended question provides insights into the “top of mind”
concerns and attitudes of Mountain Health Choice members.
Approximately 150 respondents (13-14% of all survey participants) expressed
appreciation for Medicaid. General positive comments about Medicaid included statements such
as, “I think it’s a great program and is very helpful in my life…” from an adult in the Enhanced
Plan, “Medicaid is a good plan. I appreciate having it,” from an adult in the Basic Plan,
“Medicaid helps me out a whole lot…” from a parent/guardian of a child in the Enhanced Plan,
52
and “I’ve been very fortunate to have this coverage since we do not have health insurance,” from
a parent/guardian of a child in the Basic Plan.
While there were a variety of complaints, no apparent dominant complaint exists. Some
complained about physician availability, generally focusing on either the lack of a specialist in
the local area, difficulty coordinating doctor visits when a team of doctors is needed or difficulty
in traveling the distance needed for the specialist. Others reported problems getting prescriptions
filled, making statements such as “I would like to know why I always have so much trouble
filling my meds.” Several on the Basic Plan are concerned about needing more prescriptions and
being defaulted into the Basic Plan. An example of these comments is, "I feel my health is
getting worse because of the plan that was picked for me, I can't get more than 4 prescriptions a
month w/out paying for them. I did not know I had to pick by a deadline, therefore someone
chose the plan for me."
About thirty respondents (2-3% of total survey participants) were clearly dissatisfied by
some aspect of Medicaid, describing the Basic Plan as a “way to cheat some people from
previous benefits,” or stating, “I think its ridiculous to make an appt. just to fill out paperwork. I
will be glad to sign papers whenever our next trip may be. Till then-why waste state dollars?”
regarding the Enhanced plan. Concerning Medicaid in general, one respondent stated, “I hate all
the red tape. You have to go around your elbow to get to your thumb.”
Dental coverage for adult regular dental and children’s braces was the most commonly
cited area for additional coverage, with about 30 mentions (2-3% of total survey participants).
About half that many suggested greater vision coverage.
53
Just over 30 respondents indicated some level of confusion, illustrated by statements such
as, “I really don't understand anything of any of it,” and “I really don't get this Mountain Health
Care. Does this mean the Medicaid care will be different?” Others added that, when confused,
they have difficulty finding answers saying, “Most things are confusing--caseworkers are nearly
impossible to contact to get questions answered,” and “The information I received was confusing
and the doctor’s office didn't understand it either.”
As shown above, several stated that their physicians did not understand what to do about
Mountain Health Choices, “The pediatrics office knew nothing about it and refused to sign
anything nor fax the paperwork in.” Some respondents felt too much work/hassle is required by
Medicaid making statements such as “Every 3 months I am filling out more papers to keep my
insurance, NO insurance does this,” and “Prior authorization required to see a specialist is
ridiculous if your doctor referred you to them.” A handful questioned the usefulness of the
wellness visit and paperwork (HIP and Responsibility Agreement) required for the Enhanced
Plan, with comments such as “I think children’s health care isn't going to change because of a
piece of paper 'agreement'.”
A few respondents explained why they actively chose the Basic Plan. For example, one
respondent wrote, “I picked basic. He just went to the doctor when I received this information +
survey + 3 years services are covered under the basic plan. I have no transportation so I see no
reason to take him back to doctor for no reason.”
Suggestions regarding how Medicaid can be improved were also made. Respondents
offered ideas such as: (1) allowing Basic members to switch to the Enhanced Plan prior to
redetermination, (2) improving person-to-person interaction with DHHR, such as using trained
54
councilors to help members choose a plan and making it easier to contact caseworkers, (3) using
an explicit opt-out and opt-in system so that it is clear that a Basic Plan member has actively
made the choice, (4) including a return envelope with the appropriate address on it when the
member must return information to Medicaid, and (5) including a checklist of steps the member
needs to take in the health packets.
Finally, many respondents had specific questions for which they requested answers.
While the research team is not qualified to address these specific questions and is bound to
confidentiality as to who responded to the survey, we recommend that some effort be made to
contact these individuals. We are happy to send a post card drafted by BMS to these respondents
which will explain how they can get their questions addressed.
The results from the member survey provides an in-depth look at the MHC members who
completed the survey.
One unknown with every investigation is whether, and how, the
individuals who did not complete the survey differ from those who did respond. One way of
investigating this question is to use weighted survey data. This analysis follows.
55
V.
BENEFICIARY SURVEY: ANALYSIS OF WEIGHTED DATA The results presented above are unweighted survey responses, which are sufficient for
identifying differences between Enhanced and Basic and child and adult respondents. Weighted
data is necessary to assess whether these results are representative of the MHC population. The
survey sample was pulled from a cross-section of administrative data pulled at the end of
September 2008. After matching the survey sample and responses back to the cross-section of
administrative data, survey responses were weighted to MHC population accounting for our
oversampling of Enhanced Plan members and higher survey response rates for Enhanced Plan
(see Appendix VIII for more details). Results from the weighted data were largely qualitatively
similar to those from the unweighted data. For brevity, the full set of weighted results are not
included in this section. Instead the section highlights some overarching themes and topics
germane to the evaluation as a whole. One of the most notable results is that adults who select
the Enhanced Plan are less healthy than adults who choose the Basic Plan, based on a myriad of
measures. There are no such stark differences amongst Enhanced and Basic children. Instead, it
is the outlook and attitudes of their parents/guardians that determine plan selection. More
discussion of this selection mechanism is included in the Preliminary Regression Results section.
A. Participation As shown below, Enhanced Plan respondents are estimated to account for about 17% of
MHC members when the weights are applied, suggesting that the survey weighting significantly
improves but does not completely address the oversampling and higher response rates of
56
Enhanced Plan members.7 The vast majority, or about 88%, of the weighted Enhanced Plan
respondents are children.
Breakdown of Mountain Health Choices Members
2%
15%
11%
Basic Adult
Basic Child
Enhanced Adult
Enhanced Child
72%
B. Transportation Problems Based on weighted data, the average time to the doctor or ER is slightly higher for
children enrolled in the Basic Plan and adults enrolled in the Enhanced Plan. On average,
members enrolled in the Enhanced Plan reported having fewer difficulties finding transportation
than those members enrolled in the Basic Plan, with adults reporting more difficulties than
parents/guardians of children enrolled in Mountain Health Choices.
Most parents/guardians
reported no problems with transportation. Problems are more common for Basic enrollees as
about 25% experienced a problem during at least one out of every four trips, whereas only 12%
of Enhanced members had similar problems. Members that live further away from the doctor or
ER understandably have more transportation problems than those that live closer; however,
7
About one-third (33.75 percent) of surveys were mailed to Enhanced Plan members who accounted for 49 percent
of the completed surveys. See Appendix VIII for more information on sampling and response rates.
57
given the high percentages of all respondents claiming that they do not have a transportation
problem, there do not appear to be any pervasive impediments to going to the doctor or ER.
58
C. Health­Related Behaviors: Exercise and Tobacco As shown below, adults enrolled in the Enhanced Plan are far less likely to exercise daily
(21.2%) than those enrolled in the Basic Plan (41.1%). Children enrolled in the Enhanced Plan
(63.2%) also exercise slightly less than those enrolled in the Basic Plan (67.6%).
Mountain Health Choices Members Exercise
80%
70%
60%
50%
40%
30%
20%
10%
0%
Daily
3‐5 per week Once per A few times Less than week
per month
once per month
Basic Adult
Enhanced Adult
Basic Child
Never
Enhanced Child
Overall, about 60% of adults enrolled in Mountain Health Choices are tobacco users.
Adult members enrolled in the Enhanced Plan are slightly more likely to be tobacco users than
those members enrolled in the Basic Plan (63.2% versus 58.6%, respectively). Tobacco use
differed by reported education levels, with members reporting tobacco use having fewer years of
education on average.
59
Tobacco Use Amongst Adult Members
Do Not Use Tobacco Use Tobacco 41%
59%
60
80%
60%
40%
Basic Adults
Average Cigarettes per Enhanced day
20%
0%
Use Do Not Tobacco
Use Tobacco
20
Adults
Of those members that used tobacco
products in the last 30 days, MHC members
smoke an average of 15.2 cigarettes.
Enhanced adult members smoke about 1.5
15
cigarettes per day more than Basic Plan
10
members on average. Tobacco usage
5
among
0
Basic Adult
Enhanced Adult
MHC
members
is
therefore
significantly higher than tobacco usage
among the general population.
D. Education, Marital Status and Outlook Members enrolled in the Enhanced Plan have a slightly higher education level on average
than those enrolled in the Basic Plan. Enhanced Plan members are more likely to have a high
school diploma or GED, some college, and a bachelor’s degree or more. About 20% of Basic
Plan members have not completed a high school education.
61
Education Level
50%
40%
30%
20%
10%
0%
8th Gradeor Some HS
Less
HS or GED
Basic
Some College
Bachelor's More than a Degree
Bachelor's
Enhanced
Enhanced Plan enrollees are more likely to be married (and divorced) than Basic Plan
enrollees. Basic Plan enrollees are more likely to be single or never married.
Member Marital Status
60%
50%
40%
30%
20%
10%
0%
Married
Single
Divorced
Basic
Separated
Widowed
Enhanced
When asked whether the best of their life was in the future, now, or in the past, members
enrolled in the Basic Plan were more optimistic for the future than those enrolled in the
Enhanced Plan. Basic Plan adult members were more optimistic than Enhanced Plan adult
62
members and parents/guardians of Basic Plan child members were more optimistic than their
Enhanced Plan counterparts.
However, parents/guardians of children enrolled in Mountain
Health Choices were more likely to report satisfaction with the present, whereas adult members
are more likely to claim that the best of their lives will be in the future.
When asked to rate their view of the future from “excellent” to “very poor,” adults on the
Basic Plan were far more optimistic than those on the Enhanced Plan. Over 20% of adults on the
Enhanced Plan indicated that they thought their future prospects are "very poor” compared to
12% enrolled in the Basic Plan.
E. Changes in Health Overall, 25.2% of adults claimed that their health had changed for the worse in the past
six months. The difference between adults enrolled in the Enhanced Plan and adults enrolled in
the Basic Plan is striking, with 22.6% of Basic Plan members reporting a negative change in their
health status versus 37.5% of Enhanced Plan members. In contrast to the results for adult
members, parents/guardians reported that their children's health was about the same (82.2%)
with about 15.8% reporting improved health. Thus, adults enrolled in the Enhanced Plan have
significantly worse physical and psychological health than their counterparts in the Basic Plan
and are more likely to have experienced a decline in health over time.
63
Member Health Over Time
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Basic Adult
Enhanced Adult
Improved
Basic Child
About the Same
Enhanced Child
Worse
Adults on the Basic Plan also have far better self-reported psychological health than those
on the Enhanced Plan. No such difference was found for children. These results indicate that,
adults with psychological or physical health conditions are more likely to enroll in the Enhanced
Plan over the Basic Plan.
F. Average Body Mass Index (BMI) To develop a proxy for overall health, we collected the height and weight of MHC
members through survey data and then calculated the Body Mass Index (BMI) arising from these
figures. Based on reported height and weight, 35.9% of Mountain Health Choices members are
within the normal BMI range. About 20% are defined as 'severely underweight' and almost 12%
qualify as 'obese'. The BMI range for the population is between 7 and 63. Around two percent
of members have BMIs greater than 40. Note that, as above with the unweighted survey data,
BMI estimates calculated via survey data have a systematic bias downward, as many individuals
report being taller than they actually are and weighing less than they actually do.
64
Average BMI
35
The BMI for adults in the Enhanced Plan is much
higher than the BMI for adults enrolled in the
30
Basic Plan, with averages of 31.4 and 26.8,
25
respectively. Children, on average, have roughly
20
the same BMI between the Basic Plan and
15
Enhanced Plan.
10
5
0
Basic Enhanced Basic Enhanced Adult
Adult
Child
Child
G. Health Service Use The unlimited prescription coverage under the Enhanced Plan was quite important for
adults enrolled in the Enhanced Plan.
Nearly 80% indicated that having more than four
prescriptions covered was “very important” compared to about 50% of adults enrolled in the
Basic Plan. The results indicate that the possibility of needing more than four prescriptions
likely had a significant role in driving enrollment into the Enhanced Plan for adults. Conversely,
the results for child members do not indicate a distinctive pattern.
65
Importance of Prescriptions
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Basic Adult
Not Important
Enhanced Adult
Somewhat Important
Basic Child
Important
Enhanced Child
Very Important
Results presented below also indicate that adults enrolled in the Enhanced Plan place
more importance on receiving help to lose weight. In addition, adults on the Enhanced Plan were
far more likely to respond “yes” to whether they would need a glucose screening or a test for
high blood pressure in the next year.
Importance of Help in Losing Weight
70%
60%
50%
40%
30%
20%
10%
0%
Basic Adult
Not Important
Enhanced Adult
Somewhat Important
Basic Child
Important
Enhanced Child
Very Important
66
Glucose Screenings
0.5
0.4
0.3
0.2
0.1
0
Yes
No
Basic Adult
N/A
Don't Know
Enhanced Adult
Test for High Blood Pressure
0.6
0.5
0.4
0.3
0.2
0.1
0
Yes
No
Basic Adult
N/A
Don't Know
Enhanced Adult
Taken together, these results indicate that adults in the Enhanced Plan are relatively less
healthy than their counterparts in the Basic Plan. While one may interpret the above result as a
preventative measure (i.e. getting glucose screenings to stave off diabetes), the survey results
indicate that adults in the Enhanced Plan actually have a lower health risk prevention motivation
67
than Basic adults. Thus the above result should imply that the reason for glucose screenings is
not necessarily as a preventative measure but as a byproduct of poor health.
H. Experience with Medicaid and MHC Respondents were asked to rate their satisfaction with Medicaid, their welfare
caseworkers, and doctors on a five-point scale, with 5 indicating “very satisfied” and 1 indicating
“very dissatisfied” (a value of 3 indicates neither satisfied or unsatisfied). Satisfaction with
Medicaid was higher for those in the Enhanced Plan and highest for the parents/guardians of
children in the Enhanced Plan. Satisfaction rates were lower on average for welfare caseworkers
and highest for doctors.
Beneficiary Satisfaction
5
4.5
4
3.5
3
2.5
2
1.5
1
Basic Adult
Enhanced Adult
Medicaid
Basic Child
Case Worker
Enhanced Child
Doctor
Understanding a member’s planning horizon might also offer insight into whether the
costs of completing the process to enroll in the Enhanced Plan will be offset by future benefits.
Consistent with the idea that short planning horizons increase the likelihood of choosing the
68
Basic Plan, adults on the Basic Plan expected to spend the least amount of time on Medicaid.
Parents/guardians of children enrolled in the Enhanced Plan expect them to be on Medicaid for
quite some time but the differences with Basic Plan members were not as definitive as those for
adults.
Expected Time in Mountain Health Choices
50%
40%
30%
20%
10%
0%
Less than one year
Basic Adult
1‐2 years
3‐5 years
Enhanced Adult
Basic Child
6‐8 years
More than 8 years
Enhanced Child
In terms of information regarding MHC, the mail was unquestionably the most important
source. Of those that reported receiving the MHC information packet in the mail, 58.7%
reported reading about all of the information. Information from the doctor was rated second in
importance.
69
Information Sources
From Mail
From Pharmacist From Internet
From Community Groups
From Family or Friends
From Media
From Phone
From Caseworker
From Doctor
From Other Source
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Did Not Receive Information
Not Helpful
Somewhat Helpful
Very Helpful
I. Other Experience with the Health Sector Around 260 members indicated they had a different type of health insurance prior to
being covered by Medicaid. Of these members, around 61% indicated that they had previously
received health insurance from their employer or from someone else’s coverage. About 30% of
Mountain Health Choices members reported that their child was enrolled in WV CHIP prior to
being covered by Medicaid.
70
Prior Insurance Type
Other
From someone else's coverage
Self‐purchased
From employer
WV CHIP
0%
5%
10%
15%
25%
30%
35%
Less that 10% of Mountain Health
Knowledge of 'Medical Home'
Choices members indicated that
they had heard of the term ‘Medical
7%
Yes
93%
20%
No
Home’ and even fewer could
correctly explain the concept of a
Medical Home.
71
VI. MOUNTAIN HEALTH CHOICES ADMINISTRATIVE DATA ANALYSIS Administrative data have several key advantages over survey data.
Most notably,
administrative data include the entire population of MHC eligible members, not a sample subject
to response bias, and administrative data are observed, not self-reported outcome. This second
point can be crucial in areas such as health service utilization where survey respondents’
perceived use might be different from actual patterns. The ability to analyze similar questions
using both survey and administrative data provides the ideal situation for reaching solid
conclusions if results from both sources suggest the same outcomes.
The administrative data used in this section was pulled at the end of February 2009. The
data begin in January 2005 and end in December 2008. The data included start and end dates for
all enrollment periods on Medicaid as well as in which plan the member was enrolled. Medical
claim data and prescription data were merged onto the eligibility file. After restructuring the
data for analysis, keeping only those who were ever eligible for MHC, and removing duplicate
observations, the data include almost 200,000 members over the time period. We exclude
members in the four counties that have not implemented MHC. In all, there are almost six
million person-month observations for all months and years for which we have data.8 For
example, starting in January 2005, there are 95,415 observations for those eventually eligible for
MHC.9 In the most recent month for which we have accurate medical data, July 2008, there are
8
N= 5,988,249 observations across all months (48) in the administrative database.
Throughout this report, those adults enrolled in the Enhanced Plan, for example, are referred to as ‘Enhanced
Adults’ and those children enrolled in the Basic Plan, for example, are likewise referred to as ‘Basic Children’.
9
72
156,172 total observations, with those eligible for the Mountain Health Choices program
accounting for 126,671 of those observations.
This last distinction is an important one as it illustrates that we are distinguishing countylevel rollout from member eligibility for MHC. This is because members currently enrolled in
the program do not get assigned to the MHC Basic Plan until the first day of their
redetermination month. We define “eligible” as the first redetermination month after rollout in
the member’s county. For adults, we calculate redetermination every six months and for children
it is on an annual basis. For new members or those that start a Medicaid enrollment period after
rollout in their county, they are “eligible” for MHC the month that they are enrolled in Medicaid.
A. Initial Summary Statistics The summary results from the full administrative database are almost identical to those
from the cross-section of data (both weighted and unweighted) discussed above. The distribution
of the full Mountain Health Choices population with respect to age is quite similar to that of the
cross section, as evinced in the graphs below (age is on the horizontal axis and the total number
of members is on the vertical axis). The average age of a child on MHC is 7.5 and 7.7, for the
Basic and Enhanced Plans, respectively. The average age of an adult on the Basic Plan and
Enhanced Plan is 31.7 and 35.8, respectively. Adults on the Enhanced Plan are four years older
on average than those on the Basic Plan. The full adult population is predominantly female
(82.4%). For children in Mountain Health Choices, gender is equally distributed. With regard
to the age structure of the Mountain Health Choices population, 86% are child members and 14%
are adults. Adult Enhanced Plan members are more likely to be women (82%) than those in the
Basic Plan (76%). 73
Mountain Health Choices Adults
Mountain Health Choices Children
For All Months
For All Months
12000
90000
10000
80000
70000
8000
60000
6000
50000
40000
4000
30000
20000
2000
10000
0
0
19 24 29 34 39 44 49 54 59 64
BASIC ADULT
ENHANCED ADULT
0
2
4
BASIC CHILD
6
8 10 12 14 16 18
ENHANCED CHILD
B.
Health Care Utilization In considering health care utilization for the full population, the following graphs
emphasize the ‘health care cycle’ in which doctor visits and prescriptions per month are
relatively high in the winter and relatively low in the summer. For doctor visits, the more the
other colors (one or more doctor visits) intrude into the blue space (no doctor visits), the more
MHC members are utilizing doctor visits. Rollout of the Mountain Health Choices program
ostensibly does not appear to have affected this cycle, with no major changes in health care
utilization seen in the graphical analysis.10 However, regression analysis is necessary to fully
understand whether the Mountain Health Choices program has affected health care utilization. 10
The graph represents doctor visits across time for the full population, Mountain Health Choices and Traditional
Plan Included.
74
Doctor Visits
Jul‐08
Jan‐08
Jul‐07
Jan‐07
Jul‐06
Jan‐06
Jul‐05
Jan‐05
0%
20%
40%
0
1
60%
2
3
4
80%
100%
5 or more
Adult Enhanced members had more doctor visits per month on average than their Basic
Plan counterparts. Almost 19 percent of Enhanced Adults had two or more doctor visits,
compared with nearly 12 percent of Basic Adults. These statistics further indicate a relatively
less healthy Enhanced Plan group of adults. Consistent with earlier findings, there is not a large
difference between the average number of doctor visits for children in the different MHC Plans. Average Doctor Visits
Enhanced Child
Basic Child
Enhanced Adult
Basic Adult
Average
0%
10%
20%
30%
0
1
40%
2
50%
3
4
60%
70%
80%
90%
100%
5
75
Another way to gauge the frequency of
Differences in Doctor Visits
doctor visits by group is to ask what percentage of
those who went to the doctor on 5 or more days per
5
4
month are in the Enhanced Plan. As noted in the
3
graph to the right, adults in the Enhanced Plan
2
account for the majority of those with 5 or more
0
1
0%
doctor visits. Children in the Enhanced Plan also
have more doctor visits on average than those in the
Basic Plan.
50%
100%
Average
Basic Adult
Enhanced Adult
Basic Child
Enhanced Child
Prescription utilization follows a similar cyclical trend for the full population. The graph
below indicates that prescriptions likewise spike in the winter season and fall during the summer.
Prescriptions Jul‐08
Jan‐08
Jul‐07
Jan‐07
Jul‐06
Jan‐06
Jul‐05
Jan‐05
0%
10%
20%
30%
0
40%
1
2
50%
3
4
60%
70%
80%
90%
100%
5 or more
76
C. July 2008 Cross Section of the Administrative Dataset Because of the delay in processing of medical information, data from October through
December 2008 were problematic for doctor visits. We selected July 2008 for a cross-section for
a more in-depth analysis of medical and prescription use data because it provides a baseline for
service use--July represents the low-point in the ‘health cycle’ or cyclical trend of health service
utilization.
Thus, the results presented below are not an average of the cycle but the lowest
point thereof, so members’ use of health services will be less than an average of the calendar
year. The July 2008 cross-section contains 156,172 observations, of which 126,671 are Mountain
Health Choices eligible. For the analysis, we will omit observations for the traditional plan
(those who have yet to become eligible for MHC) unless otherwise noted and focus on assessing
Mountain Health Choices members’ health service usage.
Mountain Health Choices Population
July 2008 Cross Section
12000
10000
Mountain Health Choices Population July 2008 Cross Section Frequency
Percentage Basic Adult 18,088
14.28% Enhanced Adult 1,163
0.92% Basic Child 100,475
79.32% Enhanced Child 6,945
5.48% Sum 126,671
1 8000
6000
4000
2000
0
0 10 20 30 40 50 60
BASIC ADULT
ENHANCED ADULT
BASIC CHILD
ENHANCED CHILD
77
Enhanced and Basic Plan participation numbers as well as age distributions are presented
above and below. Rates of Enhanced Plan participation are lower than noted earlier because July
2008 is earlier in the implementation period. As emphasized above, the summary statistics
results from the cross section are quite similar to those from the full administrative database.
The distribution of the cross sectional Mountain Health Choices population, as displayed the
graphs below, elucidates this similarity.
Mountain Health Choices Adults
Mountain Health Choices Children
July 2008 Cross Section
July 2008 Cross Section
1000
12,000
900
10,000
800
700
8,000
600
500
6,000
400
4,000
300
200
2,000
100
0
0
19
34
BASIC ADULT
49
64
ENHANCED ADULT
0
2
4
BASIC CHILD
6
8 10 12 14 16 18
ENHANCED CHILD
78
In the cross section, the average age of a child on the Basic Plan and Enhanced Plan is 7.7
and 7.0, respectively. This differs slightly from the results of the full population. This difference
may be explained by the fact that the Mountain Health Choices program effectively rolled out in
the state by the beginning of 2008 and parents/guardians of newborn children may have opted to
select the Enhanced Plan for their child. The average age of an adult on the Basic Plan and
Enhanced Plan is 31.8 and 35.4, respectively, which is almost identical to the statistics from the
full population. The cross sectional adult population is still predominantly female, with 78.8%
female and 21.1% male. For children in the cross section, the distribution is still about equally
split (49.5% female and 50.5% male). With regard to the age structure of the cross sectional
population, 84.4% of the members are children and 15.6% of the members are adults. Again,
adults in the Enhanced Plan are more likely to be women (81.2%) than those enrolled in the
Basic Plan (77.1%).
D. Health Care Utilization for the Cross Section In the cross section, there are significant differences in the utilization of doctor visits and
prescriptions per month between groups. These differences are especially pronounced with
respect to Basic and Enhanced adult members. For example, adults on the Enhanced Plan had
4.5 prescriptions on average in the cross section, compared to the adults on the Basic Plan, who
had on average 1.8 prescriptions. This implies that Enhanced Adults, on average, filled 149%
more prescriptions than those adults enrolled in the Basic Plan. Adults on the Enhanced Plan
also comprised the highest percentage of the groups with regard to filling prescriptions, as
presented in the graph below (composition of the number of prescriptions by Mountain Health
Choices plan in the cross section). 79
Prescriptions
5 or more
4
3
2
1
0
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Basic Adult
Enhanced Adult
Basic Child
Enhanced Child
Adults in the Enhanced Plan likewise visited the doctor more often than adults enrolled in
the Basic Plan, comprising 60% of all Mountain Health Choices members visiting the doctor
more than five times in the month of July 2008. Below is the graph of the composition of doctor
visits by Mountain Health Choices plan for the cross section.
Doctor Visits
5 or more
4
3
2
1
0
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Basic Adult
Enhanced Adult
Basic Child
Enhanced Child
80
The differences in health care utilization are further emphasized below. In the crosssection, the average number of doctor visits for an adult on the Basic Plan and an adult on the
Enhanced Plan is 0.74 and 1.39, respectively. The average number of doctor visits for a child on
the Basic Plan and a child on the Enhanced Plan is 0.36 and 0.58, respectively, thus Mountain
Health Choices members on the Enhanced Plan overall tend to go to the doctor more often. This
is not necessarily unexpected as the HIP must be filled out with the member’s doctor. The same
result holds for the number of prescriptions for the cross section, implying that those members on
the Enhanced Plan have a higher utilization rate of prescription drugs than those members on the
Basic Plan. The average number of prescriptions for an adult on the Basic Plan and an adult on
the Enhanced Plan, as emphasized above, is 1.8 and 4.5, respectively. The average number of
prescriptions for a child on the Basic Plan and a child on the Enhanced Plan is 0.41 and 0.68,
respectively. Doctor Visits
Enhanced Child
Basic Child
Enhanced Adult
Basic Adult
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
0
1
2
3
4
5 or more
81
Prescriptions
Enhanced Child
Basic Child
Enhanced Adult
Basic Adult
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
0
1
2
3
4
5 or more
E. Themes from the Administrative Data Initial analysis of the administrative data reveals a health care utilization cycle for
Medicaid and Mountain Health Choices members, with higher untilization rates in the winter
months and lower rates in the summer months. There do not appear to be any substantive
changes in this cycle after the rollout of the Mountain Health Choices program and this theme is
further explored in the preliminary regression results below. One of the key findings in the
analysis is the difference in health care utilization between adults on the Enhanced and Basic
Plans, with the former having higher rates of health care utilization than the latter, especially
with regard to prescriptions per month. This may provide a key insight as to why adults in
Mountain Health Chocies enroll in the Enhanced Plan—use of more than four prescriptions per
month. This is also supported by the survey results as many adults reported one of the reasons
they enrolled in the Enhanced Plan was the ability to fill more than four prescriptions per month.
82
F. Preliminary Regression Results Regression analysis is the next step in evaluating whether the patterns observed in the
survey and administrative data analysis are causal. We use regression techniques to explain
selection into the Enhanced Plan and whether service use is different amongst Enhanced Plan
and Basic Plan members after enrollment in MHC. Results provide preliminary answers to two
basic questions: 1) Do members who use more health services (and presumably experience
worse health) select the Enhanced Plan? and 2) Does participation in the Enhanced Plan lead to
more service use? As is evident, the two questions are closely related requiring careful attention
to specification of the regression equation to avoid problems of endogeniety, or in other words,
to avoid a circular relationship between the dependent and independent variables. The regression
analysis is conducted on the full set of administrative data.11
1.
Specification – Selection into the Enhanced Plan We estimate the probability that a member will enroll in the Enhanced Plan separately for
children and adults as both the survey and administrative data indicate that there might be
important differences across groups. Enhanced Plan enrollment is estimated as a function of past
medical and prescription service use, age, and controls for time:
Pr y
1
Pr
0
where:
where
is our variable of interest. It takes on a value of one for the months that the person is
enrolled in the Enhanced Plan and a value of zero if they are in the Basic Plan (i.e. their county
11
Regression analysis of combined survey and administrative data is also possible and will be explored in future
research. This report focuses on the administrative data because it is expected to have more explanatory power
because: 1) It is a panel, not a cross-section, and it contains the entire MHC population pre and post-MHC
implementation and 2) Sample sizes are about 200 times larger.
83
has experienced rollout and are a new enrollee or have come up for redetermination after the
rollout date). The variables included in “x” are past medical and prescription use, age and age
squared. Past medical and prescription use are defined as the number of doctor visits and
prescriptions in the twelve months proceding the analysis month. For example, if the analysis
month is December 2007, then the medical and prescription data are taken from November 2006
through November 2007. Essentially the data are “lagged” for two purposes. First, the variables
establish whether prior use is associated with Plan choice. Second, using lagged values mitigates
endogeneity concerns or the possibility that the choice of Plan leads to service utilization and not
visa versa.
T is a set of dummy variables indicating the year and month. These controls account for
the cyclical nature of service utilization (e.g., service use is higher in winter months) and for any
factors that might be occurring at the state level, such as a particularly bad flu season. The last
term,
, is an individual and time-specific random effect. This element is of particular interest
because administrative data are limited in the amount of demographic and attitudinal data they
contain. This term captures the effects of characteristics that are unique to the MHC member
that we are unable to control for directly.
Intuitively, the above equations state that we are estimating the probability that the
enhanced variable will take a value of one (the member will enroll in the Enhanced Plan) based
on an underlying process
. When values of
are high enough, essentially the costs of
completing the MHC Enhanced enrollment forms, are offset by the benefits in the Enhanced
Plan, then the member will choose the Enhanced Plan. Further, the values of
are determined
by a set of independent variables and an individual effect.12
12
See Baltagi (2008) for more information on the estimation methods.
84
2.
Results – Selection into the Enhanced Plan
Results from the above specification are presented in the table below. Consistent with
survey and administrative results presented above, adults who had more doctors visits and
prescriptions in the year prior to enrollment were more likely to select the Enhanced Plan. Age
is also an important factor as older members are more likely to select the Enhanced Plan. For
children, higher past prescription use is associated with higher probabilities of selecting the
Enhanced Plan but there is no such effect from past doctor visits. This result is consist with
survey findings that prescriptions are a key motivating factor in choosing the Enhanced Plan.
Interestingly, older children are also more likely to enroll in the Enhanced Plan and the
magnitude of the age effect is more than four times larger than the prescription effect. The
negative coefficient on “Age Squared” indicates that although older children are more likely to
enroll in the Enhanced Plan, this effect diminishes with age.13
The Effects of Past Medical and Prescription Utilization on Enhanced Plan Participation
Variable
Age
Age Squared
Past Doctor Visits
Past Prescriptions
Log Likelihood
Child
Coefficient
0.090 ***
-0.013 ***
0.010
0.018 ***
-10115.300
Adult
Coefficient
0.199 **
-0.002
0.042 ***
0.053 ***
-2050.891
Entries are coefficients from random effects probit estimations.
Specifications also included year/month effects.
Significance levels are indicated as follows:
*** 1 percent level; ** 5 percent level; * 10 percent level.
13
Current interpretation is limited to the sign, significance and relative magnitude of the coefficients. To determine
the size of the effect, one must calculate marginal effects. The marginal effect is calculated assuming that is equal
to zero but the individual effect is so large that efforts to date to calculate marginal effects have been unsuccessful.
85
3.
Specification – Effects of MHC on Service Utilization Given that the administrative data presented above includes the entire population of MHC
eligible members, regression analysis may not seem necessary to conclude that Enhanced Plan
participation leads to more service utilization. This would be an appropriate conclusion if
participation in the Enhanced Plan were random. That is, members were randomly assigned to
the Basic or Enhanced Plans. However, enrollment in the Enhanced Plan is not random and the
above regression results indicate a clear selection bias as those prone to higher service utilization
are more likely to select the Enhanced Plan, particularly among adults. This is often referred to
in the economics literature as “adverse selection” (Gruber, 2004). Members with the highest
demand for health services are more likely to choose the plan with the most benefits. In order to
assess whether enrollment in the Enhanced Plan causes members to have higher levels of
utilization, we must first account for non-random selection.
Fortunately the rollout of MHC was implemented in a way as to provide a natural control
for the selection bias. If all members were eligible for Enhanced Plan enrollment at the same
time, there would be no way to compare those eligible against those not eligible. However, not
only was MHC rollout different by county, eligibility dates differ for members within a county
based on their redetermination dates. It is also crucial to note that the timing of eligibility was
exogenous, or outside of the control of the individual member.14
A word of caution is also warranted regarding the implications of these results. The
analysis is being conducted on data collected either shortly after complete rollout of all members
in a county or during redetermination periods for other counties. This is especially true for the
medical data as there is a lag between when the services are incurred and when the claims are
14
A similar approach is used in the literature to determine if participating in 401(k) programs leads to increased
saving (Pence, 2002).
86
posted to the administrative data. Therefore, the data only speak to the immediate effects of the
Enhanced Plan on doctors visits and prescriptions and do not account for any possible effects of
preventative services on future medical and prescription utilization.
With the these issues in mind, the effects of MHC on service utilization were estimated in
the following context:
where s is the dependent variable and represents either doctor’s visits per month or prescriptions
per month. Control variables including MHC_eligibility, age, age_squared, and birth_month.
MHC_eligibility takes a value of one if the member is in a county where rollout has occurred and
they have reached their redetermination date or are beginning a new spell on Medicaid, and zero
otherwise. The age variables are included to account for different health service demands at
different stages of life. The variable birth_month takes on a value of one if it is the member’s
month of birth or one month prior or after. This variable is meant to control for the likelihood,
particularly among children, that a well visit or an annual physical will occur routinely around
one’s birthday.
We use a fixed effect model to estimate the equations, which implies that any factors
unique to an individual that do not change over time (e.g.,health attitudes, education levels,
gender, etc.) are controlled for implicitly.15 This is a particular strength of panel data and
estimation as control variables missing from the administrative data will not bias the results.
4.
Results – Effects of MHC on Service Utilization Preliminary results from our regression estimations are consistent with Enhanced Plan
participation increasing doctor visits and prescriptions among adults and decreasing doctor visits
15
Specifically, individual fixed effects are differenced out of the data (Baltagi, 2008).
87
among children with no statistically significant effect on child prescriptions. Intuitively, these
results seem plausible as adults on the Enhanced Plan must schedule a doctor visit to complete
the HIP that they might not have otherwise scheduled. It is also plausible that their HIP would
call for more office visits than they would have scheduled under the Basic Plan and more doctor
visits would likely increase the probability of a prescription. For children, well doctor visits are
more frequent and prescriptions are likely heavily focused on treating illnesses that are largely
unassociated with participation in the Enhanced Plan. These results should be viewed as purely
preliminary and suggestive as the magnitude of the effects is so small as to have little if any
economic significance and the amount of variation explained by the model is quite low. More
research is needed to reach any firm conclusions regarding service use and the Enhanced Plan.
VII.
Mountain Health Choices Health Improvement Plans Analysis Data are available indicating the nature of the HIP agreements signed by Enhanced Plan
members in the initial rollout counties, or pilot counties, which began in March 2007. For the
analysis, we have divided the members into three age groups: 2 and under (young child), 3
through 18 (older child), and 19 and older (adult). The description of the HIP element and
percent of the 89 adults, 431 older children and 48 younger children with each element can be
found in the table below.
Including both office and well visits, all children were required to see the doctor at least
once per year.16 Likewise, each adult agreed to at least one office visit per year. About 40% of
adults agreed to monthly or quarterly office visits and more than 60% agreed to at least three
visits in the coming year.
16
It appears that these terms may not be used consistently across providers. 88
Nearly 60% of adults were asked to have blood pressure and lipid testing and 46% agreed
to glucose testing. In terms of education, 27% of adults were assigned nutritional education,
29% were assigned tobacco cessation and 37% were assigned weight management classes.
About 10% of older children were also assigned nutritional education and weight management.
The agreed upon HIP components are consistent with the results from survey and
administrative data that the adults in the Enhanced Plan have relatively high need for health
services. This initial HIP data also indicates that there is a need to address weight and nutrition
issues in childhood. Future research will need to establish the rates of compliance with elements
of the HIP and whether these measures result in better health outcomes for members in the
Enhanced Plan.
89
Health Improvement Plan Elements by Age Category
Description
1 Well Visit
2 Well Visits
3 Well Visits
4 Well Visits
5 Well Visits
6 Well Visits
Age Appropriate Immunizations
Blood Pressure
Colonoscopy
Dental Check-ups
Diabetes Ed
Glucose Testing
Flu Vaccine
Lead Testing
Lipid Levels
Mammogram
Nutritional Ed
1 Office Visit
2 Office Visits
3 Office Visits
4 Office Visits
12 Office Visits
Pap Test
Pneumococcal Vaccine
Prostate Test
Tetanus Vaccine
Tobacco Cessation
Weight Management
Other
Members
Adult
n.a.
n.a.
n.a.
n.a.
n.a.
n.a.
6.74
58.43
2.25
6.74
6.74
46.07
37.08
0.00
60.67
21.35
26.97
28.09
10.11
22.47
32.58
6.74
62.92
7.87
1.12
16.85
29.21
37.08
14.61
Older Child
19.03
1.86
0.23
1.62
0.00
0.23
86.77
0.00
0.00
82.60
0.93
12.30
0.00
9.28
14.15
0.00
10.21
53.60
9.28
0.00
12.30
1.86
n.a.
n.a.
n.a.
n.a.
1.39
10.21
11.37
Young Child
0.00
8.33
25.00
8.33
8.33
22.92
100.00
0.00
0.00
18.75
0.00
2.08
0.00
54.17
2.08
0.00
2.08
2.08
6.25
0.00
12.50
6.25
n.a.
n.a.
n.a.
n.a.
n.a.
4.17
25.00
89
431
48
Table entries are percentages of members.
90
VIII.CONCLUSION We have examined the Mountain Health Choices program using two principal sources of
information: survey data and administrative data. Survey data allows us to learn more about
MHC members’ knowledge, perceptions, and personality traits, but is limited by the inability to
determine whether the respondents differ from nonrespondents and the fact that self-reported
behavior is an imperfect indicator of actual behavior. Administrative data has the advantages of
reflecting actual behavior of the entire MHC eligible population and yielding precise
information, but is unable to provide the depth of understanding psychological constructs offer.
Thus, the strengths and weaknesses of these methodologies are complementary.
These two approaches both find that the adult members choosing the Enhanced Plan are
significantly different than other MHC subpopulations. They visit the doctor more often and fill
more prescriptions. They self-report being in poorer health and have a more negative view of the
future. Fewer differences exist among child members; indeed, most differences are reflected by
by characteristics of their parents/guardians.
The detailed analysis in this document supplies WV Bureau for Medical Services up-todate information about the Mountain Health Choices members upon which to develop strategies
to achieve its goal of improved health among West Virginians. This data will also serve as a
benchmark for comparisons with future research. While we have provided insights and data,
much remains unknown. We encourage continued research into the underlying motivations that
drive a person’s health care decisions as well as the outcomes of this decision. The research team
at West Virginia University appreciates the opportunity to be a part of this important work.
91
I. APPENDICES. A. Appendix I: Eligibility Criteria The following chart lists the different Medicaid coverage groups eligible for the Mountain
Health Choices program: 92
B. Appendix II: Overview of Services Available for Adults Benefits Comparison – Adult
Benefit Description
Basic (Adult)
Inpatient Hospital Care
Inpatient Hospital Rehabilitation
Inpatient Hospital Psychiatric
Services
Prior Auth Required
Not Covered
Not Covered
Outpatient Surgery/Services
Covered (Prior Auth
Required for Certain
Services)
Covered (Prior Auth
Required for Certain
Services)
Covered
Covered
Diagnostic x-ray, laboratory services
and testing
Primary Care Office Visits
Physician Office Visits - specialty
care*
Occupational/Speech/Physical
Therapy
Prior Auth Required
Not Covered
Not Covered
Covered Prior Auth
Required
Covered 20/year Prior Auth
Required
Covered
Covered (Prior Auth
Required)
Not Covered
Covered (Prior Auth Required)
Covered (Prior Auth
Required for Certain
Services)
Covered (Prior Auth Required for
Certain Services)
Covered
Covered
Covered
Covered
Covered
Covered
Covered (Prior Auth Required for
Certain Services)
Not Covered
Covered
Covered
Covered
Covered
Covered (Prior Auth
Required for Certain
Services)
Covered
Covered
Covered (Prior Auth
Required)
Covered (Prior Auth
Required)
Covered (Prior Auth
Required)
Covered
Covered - maximum
benefit of 20 visits/year
Covered
Not Covered
Covered (Prior Auth
Required)
Covered
Covered (Prior Auth
Required)
Not Covered
Covered (Prior Auth Required)
Tobacco Cessation Programs
Family Planning
Cardiac Rehabilitation
Pulmonary Rehabilitation
Not Covered
Chiropractic Services
Not Covered
Podiatry Services
Chemical Dependency/Mental
Health Services*(limited)
Diabetes Education/Nutritional
Counseling
Nutritional Educational Services
Nursing Home Services
Not Covered
Not Covered
Durable Medical Equipment
Non-emergency Medical
Transportation
Ambulance Services
Prescriptions
Hospice
Emergency Dental Services
Orthotics and Prosthetics
Traditional
Prior Auth Required
Not Covered
Prior Auth Required maximum benefit of 30days/year
Covered (Prior Auth
Required for Certain
Services)
Covered (Prior Auth
Required for Certain
Services)
Covered
Covered
Covered - maximum
benefit of 20/year Prior
Auth Required
(Total allowed for all
therapies combined)
Not Covered
Covered - maximum
benefit of 25/year (Prior
Auth Required)
Covered - limited to $1000
per year with Prior Auth
required if limits exceeded
(Prior Auth Required for
Certain Services)
Covered - maximum
benefit of 10/year (5 round
trips)
Emergent Only
Limited - 4/month
Covered
Covered
Covered (Prior Auth
Required for Certain
Services)
Not Covered
Covered
Not Covered
Weight Management
Home Health Services
Enhanced (Adult)
Covered (Prior Auth Required for
Certain Services)
Covered (Prior Auth Required for
Certain Services)
Covered
Covered
Covered
Covered
Not Covered
Not Covered
Covered (Prior Auth Required)
Covered
Covered
Covered
93
C. Appendix III: Overview of Services Available for Children Benefits Comparison -- Children
Traditional
Benefit Description
Basic
Well Child Visits (EPSDT Services)
Inpatient Hospital Care
Inpatient Hospital Rehabilitation
Inpatient Hospital Psychiatric Services
Covered
Prior Auth Required
Prior Auth Required
Prior Auth Required maximum benefit of 30
days/year
Covered (Prior Auth Required
for Certain Services)
Covered (Prior Auth Required
for Certain Services)
Covered
Covered
Covered
Prior Auth Required
Prior Auth Required
Prior Auth Required
Covered
Prior Auth Required
Prior Auth Required
Prior Auth Required
Covered (Prior Auth Required
for Certain Services)
Covered (Prior Auth Required
for Certain Services)
Covered
Covered
Covered (Prior Auth Required
for Certain Services)
Covered (Prior Auth Required
for Certain Services)
Covered
Covered
Covered
Covered - maximum benefit of
20/year
(total allowed for all therapies
combined) (Prior Auth
Required)
Not Covered
Covered - maximum benefit of
25/year
Covered - limited to $1000 per
year with Prior Auth required if
limit exceeded (Prior Auth
Required for Certain Services)
Covered - 10/year (5 round
trips)
Covered
Limited - 4 per month
Covered
Comprehensive eye exam,
glasses - maximum benefit of
$750/year
Covered
Covered - 2/year
Annual exam and hearing aids
when medically necessary
Covered (Prior Auth Required
for Certain Services)
Covered
Covered
Covered (Prior Auth
Required)
Covered (Prior Auth
Required)
Not Covered
Not Covered
Covered - maximum benefit of
26/year (Prior Auth Required)
Covered
Covered
Covered (Prior Auth
Required)
Covered
Covered 20/year Prior Auth
Required
Covered
Covered
Not Covered
Covered
Covered (Prior Auth Required
for Certain Services)
Covered (Prior Auth Required
for Certain Services)
Covered
Covered
Covered
Covered
Covered
Comprehensive eye exam,
glasses, contact lenses, vision
training
Covered
Covered
Covered
Covered
Covered
Covered
Comprehensive eye exam,
glasses, contact lenses
Outpatient Surgery/Services
Diagnostic x-ray, laboratory services
and testing
Primary Care Office Visits
Physician Office Visits - Specialty
Care
Birth to Three Services
Occupational/Speech/Physical
Therapy
Weight Management
Home Health Services
Durable Medical Equipment
Non-emergency Medical
Transportation
Ambulance Services
Prescriptions
Hospice
Vision Services
Emergency Dental Services
Dental Exams (dental check-ups)
Hearing Services/Aids/Supplies
Orthotics and Prosthetics
Tobacco Cessation Programs
Family Planning
Cardiac Rehabilitation
Pulmonary Rehabilitation
Chiropractic Services
Podiatry Services
Chemical Dependency/Mental Health
Services (limited)
Diabetes Education/Nutritional
Counseling
Nutritional Education Services
Skilled Nursing Care (Private Duty
Nursing)
Not Covered
Not Covered
Enhanced
Covered
Covered
Covered
Covered (Prior Auth Required
for Certain Services)
Covered
Covered
Covered (Prior Auth
Required)
Covered (Prior Auth
Required)
Not Covered
Covered
Covered (Prior Auth
Required)
Covered
Covered (Prior Auth Required
for Certain Services
Covered
Covered
Not Covered
Covered
Covered (Limited to 180
days/yr --Prior Auth Required)
Not Covered
Covered
Not Covered
Covered
Covered
Covered (Prior Auth
Required)
Covered
94
D. Appendix IV: Member Responsibility Agreement 95
96
E. Appendix V: Health Improvement Plan 97
98
F. Appendix VI: Adult Questionnaire 99
100
101
102
103
104
105
106
107
108
109
110
111
112
G. Appendix VII: Child Questionnaire 113
114
115
116
117
118
119
120
121
122
123
124
125
126
H. Appendix VIII: Survey Sampling and Weighting Survey participants were selected using a stratified random sample based on a crosssection of Mountain Health Choices eligible members pulled at the end of September 2008. The
file contained 141,113 individuals. Of these members, 17,654 fell into a special category, such
as categorically needy, or children’s specialty categorically needy, and were automatically
enrolled in the traditional Medicaid plan leaving 123,459 MHC eligible members.
Children accounted for 87% of MHC eligible members, which was reflected in our
sampling design. Members were first divided into child or adult categories with 85% of the
sample pulled from the child file and 15% from the adult file roughly corresponding with the
actual percentages of 86.9% and 13.1% for children and adults, respectively. Thus, based on our
total survey sample of 4,000, six hundred surveys were sent to adult members and 3,400 were
sent to the parents/guardians of child members.
Because Enhanced Plan participants represented about 10% of members, a stratified
random sample was used to select the survey sample in order to ensure adequate responses from
Enhanced Plan participants. Enhanced plan participation was slightly higher for children at just
over 10% whereas about 9% of adults were enrolled in the Enhanced Plan. For the adult
sample, we sampled 50% (300 members) from the Enhanced Plan pool and 50% from the Basic
Plan pool. Because the child sample was several times larger than the adult sample, we used a
smaller oversample for child Enhanced Plan members. Specifically, we applied a factor of 3 to
the percent of child Enhanced Plan members (10%) to arrive at 1,050 enhanced surveys for
children in the Enhanced Plan and 2,350 for those in the Basic Plan.
Survey participants were then randomly selected from each of the four groups, Enhanced
child, Basic child, Enhanced adult and Basic adult. Selected statistics for the population and
127
sample are presented in Table 1. Children in the Enhanced Plan and Basic Plan are nearly
identical in terms of age and gender suggesting that there might not be a large selection bias
based on these two factors. Adults in the Enhanced Plan are about 4 years older on average and
slightly more likely to be female than those in the Basic Plan.
Table 1: Population and Sample Statistics
Enhanced
Child
Adult
Basic
Age
Female
Number
Age
Female
Number
Population
7.9
49.6
10,893
8.0
49.6
96,406
Sample
8.2
48.0
1,050
7.9
50.2
2,350
Population
36.2
81.7
1,479
32.1
78.8
14,681
Sample
36.1
86.0
300
32.1
78.3
300
The weighting strategy takes into account our sampling methodology, differences in
response rates across groups and differences in age across groups. First, the probability of being
chosen for the survey sample differed by child status and Enhanced or Basic Plan status. We
sample about 2.0% of Basic adult, 2.4% of Basic child, 20.0% of Enhanced adult, and 9.6% of
Enhanced child members. Failure to account for these differences in sampling would place too
much emphasis on respondents participating in the Enhanced plan. Likewise, response rates
were markedly different across the categories. We received responses from about 21% of Basic
adult and child members and much higher rates of 38.0% of Enhanced adult and 39.1% of
Enhanced child members.
Our final weighting adjustment ensures that our survey sample represents the appropriate
number of members by age category. Children were divided into three categories based on age
(0 through 5, 6 through 12, and 13 and older). Adults were similarly divided into three
categories (25 and under, 26 through 45, and 46 or older). Based on these age categories, the
128
probability of being sampled and response rates, our 1,070 survey responses were weighted to
represent the 123,459 MHC members.
129
I. Appendix IX: Overall Survey Results 130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
J. Appendix X: Adult v. Child Survey Results 145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
K. Appendix XI: Enhanced Plan v. Basic Plan Survey Results 161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
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Notes
179