Research Report Final Report: Evaluation of Tools and Metrics to Support Employer Selection of Health Plans Soeren Mattke, Kristin R. Van Busum, Grant Martsolf Sponsored by the U.S. Department of Labor The research described in this report was sponsored by the U.S. Department of Labor, and was produced within RAND Health, a division of the RAND Corporation. The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Support RAND—make a tax-deductible charitable contribution at www.rand.org/giving/ contribute.html R® is a registered trademark. © Copyright 2013 RAND Corporation This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of RAND documents to a non-RAND website is prohibited. RAND documents are protected under copyright law. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. For information on reprint and linking permissions, please see the RAND permissions page (http://www.rand.org/pubs/permissions.html). RAND OFFICES SANTA MONICA, CA • WASHINGTON, DC PITTSBURGH, PA • NEW ORLEANS, LA • JACKSON, MS • BOSTON, MA DOHA, QA • CAMBRIDGE, UK • BRUSSELS, BE Preface This Research Report was sponsored by the U.S. Department of Labor. It is based on a review of the trade and scientific literature and health insurers’ websites; an analysis of product and service offerings from a random sample of 70 health insurance companies; an expert panel meeting with 15 individuals representing a variety of perspectives, including academia, consumer advocacy groups, measures developers, and employer coalitions; and case study interviews with nine employers and business coalitions. The report describes a conceptual framework of health plan features, evaluates the current availability of quality measures and decision tools to employers, and describes how employers make decisions when choosing a health plan. This report will be of interest to national and state policymakers, employers and employer coalitions, consumer advocacy organizations, measures developers and health researchers, and others with responsibilities related to achieving better transparency on the quality that different health plans provide and facilitate employer decisionmaking. This research was conducted under contract #DOLJ089327414 with the Employee Benefits Security Administration of the U.S. Department of Labor, as part of a study to help employers understand the structural differences between health plans and the performance dimensions along which plans can differ, as well as to educate them about tools and resources that can be used to compare plan options. The Task Order Officer for the project is Elaine Zimmerman of the Employee Benefits Security Administration, Department of Labor. We thank the Task Order Officer for her guidance and reviews of the document; however, we note that the material contained in this report is the responsibility of the research team and does not necessarily reflect the beliefs or opinions of the Task Order Officer, the Employee Benefits Security Administration, the Department of Labor, or the federal government. This research was conducted in RAND Health, a division of the RAND Corporation. A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health. Comments or inquiries concerning this report should be sent to the lead author, Soeren Mattke, at [email protected] or to his address at RAND: RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA 02116. iii Contents Preface ............................................................................................................................................ iii Figures............................................................................................................................................ vi Tables ............................................................................................................................................ vii Summary ...................................................................................................................................... viii Acknowledgments ...................................................................................................................... xviii Abbreviations ............................................................................................................................... xix 1. Introduction ............................................................................................................................... 1 1.1 Background: The Role of Employers Under the National Quality Strategy ...................................... 1 1.2 Purpose of the Report ......................................................................................................................... 2 2. Technical Approach .................................................................................................................. 4 2.1 Development of Conceptual Framework ........................................................................................... 4 2.2 Environmental Scan ........................................................................................................................... 4 2.3 Expert Panel Meeting ......................................................................................................................... 5 2.4 Interviews with Employers and Business Coalition Representatives ................................................ 5 3. Conceptual Framework ............................................................................................................. 7 3.1 Understanding the Anatomy of a Health Plan ................................................................................... 7 3.2 Defining Care Processes for Measurement Purposes ........................................................................ 8 3.3 Defining Outcomes for Measurement Purposes ................................................................................ 9 3.4 Measuring Quality of Health Care ..................................................................................................... 9 4. Provider-Facing Structural Characteristics of Health Plans ................................................... 11 4.1 Network Management ...................................................................................................................... 11 4.2 Payment Arrangements .................................................................................................................... 12 5. Member-Facing Structural Characteristics of Health Plans .................................................... 18 5.1 Customer Service ............................................................................................................................. 18 5.2 Cost-Sharing Provisions ................................................................................................................... 18 5.3 Care Management ............................................................................................................................ 19 Products and Services for Chronic Condition Management .............................................................. 20 Products and Services for Curative Care ............................................................................................ 21 Products and Services for Health Promotion ...................................................................................... 23 5.4 Evaluation of Member-Facing Characteristics of Health Plans ....................................................... 24 6. Process Measures .................................................................................................................... 27 6.1 Safe Practices ................................................................................................................................... 28 Definition ............................................................................................................................................ 28 State of Measurement Science ............................................................................................................ 29 6.2 Adherence to Evidence-Based Care Guidelines .............................................................................. 29 Definition ............................................................................................................................................ 29 State of Measurement Science ............................................................................................................ 30 iv 6.3 Overuse of Medical Services ........................................................................................................... 31 Definition ............................................................................................................................................ 31 State of Measurement Science ............................................................................................................ 32 6.4 Evaluation of Current State of Process Quality Measurement