adapting statesurveyswebinar jan2014

44
Joanne Pascale, US Census Bureau Thursday, January 23, 2014 You will be connected to broadcast audio through your computer. You can also connect via telephone: 800-916-9263

Upload: soder145

Post on 21-May-2015

132 views

Category:

News & Politics


2 download

TRANSCRIPT

Joanne Pascale, US Census Bureau

Thursday, January 23, 2014

You will be connected to broadcast audio through your computer.

You can also connect via telephone: 800-916-9263

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

• For those dialing in: All phone lines are muted

• Submit questions via the chat feature at any time during the

webinar

• Troubleshooting:

• ReadyTalk help line: 800-843-9166

• ReadyTalk chat feature

• Download slides at

http://www.shadac.org/AdaptingStateSurveysWebinar

• Webinar recording will be posted on this page as well

• E-mail notice will be sent to registrants when recording is

available

2

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

3

Kathleen Thiede Call Investigator, SHADAC

Professor, University of Minnesota, School of Public Health

Joanne Pascale, Research Social Science Analyst, Research & Methodology

Directorate, US Census Bureau

Adapting State Surveys to Measure

Health Coverage Post-Reform

Joanne Pascale

US Census Bureau

State Health Access Data Assistance Center

January 23, 2014

1

Outline

• Massachusetts project: 2011-2012

– Research on measuring exchange coverage

– Test questions embedded in CPS Redesign, ACS

General approach for survey adaptation

• Current implementation plans

• Outstanding measurement issues

– Medicaid/CHIP/subsidized exchange overlap

– Question on subsidized premiums

2

Research Goals

Adapt federal surveys to:

1. Identify coverage thru the exchange

2. Determine whether it was subsidized

3. Enable analysis of shifts in conventional

(non-exchange-related) sources of

coverage post-reform

3

Massachusetts Project

• Expert consultation 1. Research on state surveys measuring exchange in

Massachusetts post-2006

2. Monitoring other states’ plans for implementation

• Focus groups with exchange enrollees

• Cognitive interviews with exchange and

Medicaid enrollees

4

Massachusetts Exchange

• Exchange portal = “Health Connector”

• Two programs:

– CommonwealthCare (CommCare): subsidized

– CommonwealthChoice (CommChoice): unsubsidized

5

Expert Consultation Methods

• Series of conference calls with 12 experts

• Expertise in: – Health care administration and finance

– Health policy, research, advocacy

– Survey measurement

• Agencies included: – Health Connector Board -- BC/BS Foundation

– Urban Institute -- Health Care for All

– SHADAC -- Community Catalyst

– Harvard University -- Social Science Research Solutions

6

Mechanics of Exchange

Two-step process:

1. Eligibility screening:

– Apply to Medicaid first

– If ineligible, apply to subsidized exchange

2. Enrollment: multiple pathways including:

– Connector website

– Community-based organizations

– Hospitals and clinics

– Phone, mail

State-level Surveys post-2006

• Two surveys at state-level: – Massachusetts Health Interview Survey

– BRFSS/Massachusetts

• Method: embedded exchange program

names in “laundry list” of plan types

• Results of interview monitoring, data review: – Concurrent Medicaid, subsidized & unsubsidized exchange

– Little correlation between income and subsidization level

– Under-reporting of exchange estimated at 50%

Data on plan type not used; only insured/uninsured

8

Focus Group Methods

• 4 groups; all subsidized (CommCare)

• 2 groups in English; 2 in Spanish

• 8-12 participants per group; 39 total

• Recruited via ads, flyers

• Held December 2012-January 2013

• Conducted in Boston, central Mass,

Lowell/Lawrence

9

Programs, Plans, Levels

Good news: most participants had fairly clear

understanding of distinctions:

•“I have NHP thru CommCare…plan II.”

•“Eligibility is getting accepted into CommCare, then enrollment

is which plan. Do I want Celticare, do I want Network Health

Plan.”

•“They sent me various plans…one with no copay, one that

covered less…I picked the so-so one – the one I thought I

could pay for.”

10

Medicaid vs CommCare

Bad news: many conflated Medicaid with

CommCare (subsidied exchange):

•“I used to have MassHealth. Now I have CommCare

but it is the same thing, the only thing is that I work and

that’s why the coverage changed.”

•“I still call it MassHealth…because of so many years,

prior to being CommCare it was MassHealth.”

11

Premium and Subsidies

Could-be-worse news: premiums and cost

• Participants had solid understanding of

whether the plan carried a premium

• Little knowledge of absolute cost of

premium, only the portion they pay

• Good understanding of link between

income/employment and premium cost

12

“Government” vs “State”

Introduced standardized question from CPS

Redesign on general source of coverage:

“Do you get that coverage through a job, the government or some

other way?”

General reactions: •“…you should differentiate between state and federal. In my mind that’s a big

difference, and it didn’t surprise me that choosing the word government led me to

Medicaid, military, VA, things like that I associate with a level of federal government.”

•“…confused…it doesn’t say state or US…so people assume…US government. I

think of it as a state thing. I would say the state provided me with insurance.”

•“I don’t think of it as government. I think of it as a state thing.”

13

Cognitive Interview Methods

• N=134 subjects total

– 101 in exchange (68% subsidized)

– 28 in Medicaid

– 5 in ESI

• 6 rounds of iterative testing (4 in CPS; 2 in ACS)

• 14-30 subjects/round

• Recruited via Connector; known coverage status

• 54% English; 46% Spanish

• Semi-scripted protocol; retrospective probing

14

“Downstream” Adaptation

of Surveys for Exchange • Exchange is not (arguably) a new source

of coverage

• It is a new mechanism for accessing

existing sources of coverage

• Use existing methods to determine source

• Use follow-up questions to find out:

– If obtained thru the exchange

– If subsidized

15

CPS Redesign Baseline

Questions on Plan Type

16

General source: job, government, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it?

job govt other

Any coverage?

yes

CPS Downstream Adaptations

17

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it?

job govt other

Any coverage?

yes

On the exchange? Thru SHOP?

mil

Mcaid,

Other,

DK, Ref

(non-mil)

Results Overview

• Cross-cutting findings

• CPS redesign plan type reporting among

– Subsidized exchange enrollees

– Unsubsidized exchange enrollees

– Medicaid recipients

• ACS plan type reporting

• Premium and subsidy questions

18

Cross-Cutting Results

Covered, yes/no:

•all exchange enrollees said ‘yes’

General source of coverage:

•Some gave insurance plan name

•Probe was effective: “OK, so that would be the plan

name. What do you call the program? Some examples of programs in

[STATE] are [fill state names for govt programs and exchange].”

19

CPS Subsidized Exchange (1)

20

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it?

job govt other

Any coverage?

yes

On the exchange=YES Thru SHOP?

mil

Mcaid,

Other,

DK, Ref

(non-mil)

CPS Subsidized Exchange (2)

21

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it?

job govt

other

Any coverage?

yes

On the exchange=YES Thru SHOP?

mil

Mcaid,

Other,

DK, Ref

(non-mil)

CPS Subsidized Exchange (3)

22

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it = YES

job govt

other

Any coverage?

yes

On the exchange=YES Thru SHOP?

mil

Mcaid,

Other,

DK, Ref

(non-mil)

CPS Unsubsidized Exchange (1)

23

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it?

job govt other

Any coverage?

yes

On the exchange=YES Thru SHOP?

mil

Mcaid,

Other,

DK, Ref

(non-mil)

CPS Unsubsidized Exchange (2)

24

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it = YES

job govt other

Any coverage?

yes

On the exchange=YES Thru SHOP?

mil

Mcaid,

Other,

DK, Ref

(non-mil)

CPS Medicaid Enrolles

25

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it?

job govt

other

Any coverage?

yes

On the exchange =

No, DK Thru SHOP?

mil

Mcaid,

Other,

DK, Ref

(non-mil)

CPS: Exchange Source of

Coverage Summary

• Questionnaire accommodates multiple

characterizations of the coverage:

– Federal or state government

– Medicaid

– Direct-purchase

– Insurance plan name

– Other/DK/Refused

• Few false-positive reports of exchange from

Medicaid enrollees

26

CPS Exchange Participation

Final Question Wording

27

• Is that coverage through the Health

Connector, such as Commonwealth Care

or Commonwealth Choice?

• [if yes] Which plan is it -- Commonwealth

Care or Commonwealth Choice?

ACS Baseline Questionnaire

1. ESI?

2. Direct purchase?

3. Medicare?

4. Medicaid?

5. Military?

6. VA?

7. IHS?

8. Other (specify)?

28

Issues:

1.ACS mail form can’t accommodate state-specific exchange names

2.Adding exchange program name to laundry list was problematic in

Massachusetts state surveys

3.Exchange not mutually-exclusive with other categories of coverage

Generic Terms for Exchange

Tested generic terms for yes/no question on

exchange:

• Exchange, Marketplace

• State-sponsored program

• Low- and moderate-income cost is reduced

• Insurance thru website to compare plans, apply,

purchase coverage

all failed in Massachusetts, in 2011/12

29

ACS Work-Around Strategy

• Abandon exchange yes/no question

• Ask two follow-up questions:

1. Is there a monthly premium?

[premise: all exchange plans would have at least a modest premium]

• Yes = Exchange

• No = Medicaid

2. [If yes]: Is the premium subsidized?

• Yes = subsidized exchange

• No = unsubsidized exchange OR non-exchange direct-purchase

coverage

30

ACS: Exchange Source of

Coverage Summary • No natural “home” for exchange plans in

laundry list of plan types

• Subsidized exchange tended toward:

– Medicaid or Other

• Unsubsidized exchange tended toward:

– Direct or Other

• Some chose multiple plan types

• Some didn’t choose any plan type

31

Premium & Subsidy Testing

• Premium question unproblematic in CPS and ACS:

– “Is there a monthly premium for this plan?”

• Premium subsidy question:

– “Is the cost of the premium [reduced/subsidized] based

on [your/family] income?”

• Testing results: “Reduced” problematic:

– Sometimes premium went up based on income

– Premium goes up every year, even if subsidized

– “Reduced” b/c they chose lesser plan, not due to subsidy

– Benefits are reduced due to income, not premiums

32

Premium & Subsidy

Final Question Wording “Is there a monthly premium for this plan?” Read if Necessary: A monthly premium is a fixed amount of money people pay each

month to have health coverage. It does not include copays or other expenses such

as prescription costs.

“Is the cost of the premium subsidized based on

[your/family] income?” Read if Necessary: A monthly premium is a fixed amount of money people pay each

month to have health coverage. It does not include copays or other expenses such

as prescription costs.

Read if Necessary: Subsidized health coverage is insurance with a reduced

premium. Low and middle income families are eligible to receive tax credits that

allow them to pay lower premiums for insurance bought through healthcare

exchanges or marketplaces.

33

Recap: CPS ASEC 2014

Downstream Adaptations

34

General source: job, government or state, other?

Who is policyholder?

Type of govt plan? • Medicaid

• Medicare

• VA/miitary

• Other

Buy it?

job govt other

Any coverage?

yes

On the exchange?

Thru SHOP?

Is there a premium?

Is premium subsidized?

mil Mcaid,

Other,

DK,

Ref (non-mil)

Known Reporting Problems

Respondents’ inevitable mis-reporting of plan type:

•Exchange gets mis-reported as Medicaid: application

process went thru Medicaid but enrollee income too high

to qualify for Medicaid

•Medicaid/CHIP gets mis-reported as exchange b/c

enrollee started with state exchange portal but qualified

for Medicaid (‘woodwork effect’)

35

Evolving Complications:

Medicaid vs Subs Exchange

• Some states charge Medicaid/CHIP premium

• Some bronze exchange plans may be fully-

subsidized

• Can’t rely on premium yes/no question to

distinguish Medicaid from exchange: Is there a monthly premium?

–Yes = Exchange [or Medicaid/CHIP, if state charges premium]

–No = Medicaid [or bronze exchange, if state fully subsidizes

premium]

36

Modified Strategy

• “Preponderance of Evidence”

• Rely on multiple data points to classify plan type:

– Respondent reports

• source of coverage

• premium yes/no

• premium subsidization

– State eligibility rules on Medicaid/CHIP premiums

– State eligibility rules for premium-free bronze

exchange plans

37

Ongoing Testing of Q Wording

• Premium Subsidy Question:

– Tax credits did not exist as a form of

subsidy in Massachusetts pre-2014

–Testing on tax credit wording may not

be effective until next year when

enrollees receive/pay back subsidies

• Some premiums are annual, quarterly

38

Harmonization Across Surveys

• Downstream logic:

– Maintain existing methods to identify conventional

source of coverage

– Use follow-up questions about:

• Exchange (yes/no)

• Premium (yes/no)

• Subsidized premium (yes/no)

• Use preponderance of evidence scheme

• Coordinate editing schemes across surveys

39

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level Submit questions via the chat feature on the left-hand side of the screen.

4

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

www.shadac.org

@shadac

Kathleen Thiede Call

SHADAC

[email protected]

Joanne Pascale

US Census Bureau

[email protected]

Webinar recording will be posted at:

http://www.shadac.org/AdaptingStateSurveysWebinar

What are state surveys measuring to evaluate health reform? Visit the State

Reform Survey Item Matrix (SRSIM). We welcome your updates.

http://www.shadac.org/content/SRSIM