Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 3. Satisfaction with Providers Was High Among Our Sample of High-Risk Seniors

01/01/2002

Satisfaction Among the Full High-Risk Sample. Virtually all (95 percent) our sample of high-risk seniors reported having a primary care physician. While the case study MCOs assigned all their members to a primary care physician, some seniors may not remember their physician. Also, at any one time, a few seniors are probably in the process of changing physicians. The rates observed for our sample of seniors are slightly higher than for all Medicare beneficiaries. For example, while 95 percent of our sample reports having a primary care physician, only 91 percent of community-resident Medicare beneficiaries in 1998 reported that they had a usual source other than an emergency room or hospital outpatient department, and 92 percent of those in poor health had such a source of usual care (Health Care Financing Administration 2001; Tables 5.1 and 5.10). Results for our high-risk sample are just below those found for all Medicare beneficiaries in risk plans during 1998, when almost 97 percent of all beneficiaries in risk plans reported having a usual source of care other than an emergency room or hospital outpatient department (Health Care Financing Administration 2001; Table 5.13).

We asked those sample members who reported having a primary care physician a series of questions about their ability to obtain care from that physician and about aspects of the quality of the care provided. In general, only a few high-risk seniors in our sample reported difficulty accessing their primary care physician (Table V.7). Ninety-six percent of them were satisfied with the location of their physician’s office. Similarly, 96 percent reported being very or somewhat satisfied that they can see their primary care physician when they want. Only one percent report being very dissatisfied in that area.

The satisfaction rate among our sample of high-risk seniors compares very favorably with estimates for the broader Medicare population, even though slight differences in question wording make comparisons imprecise. For example, 95 percent of community-resident Medicare beneficiaries surveyed in the 1998 Medicare Current Beneficiary Survey reported being satisfied with the ease of access to their physician’s office (Health Care Financing Administration 2001). This figure is approximately equal to the 96.4 percent of our high-risk sample who reported satisfaction with the location of their primary care physician’s office.

Satisfaction with access to specialists and therapists was also high, although there was more dissatisfaction in this area than there was with primary care physicians. We assessed access to specialists by comparing the number of sample members who said they had difficulty seeing a specialist with the number who had either actually seen a specialist or indicated that they wanted to see one but could not. Access to therapists was measured similarly. Overall, we found that about 61 percent of the full sample either saw or wanted to see a specialist in the six months prior to the interview (for seniors in the hip fracture and stroke sample, we asked about the time since they left the hospital). Of those, six percent reported having difficulty seeing a specialist. There was less use of therapists in our sample, but about the same level of reported access difficulties (23 percent of the sample saw a therapist, and of those, 11 percent reported difficulty).

TABLE V.7. Member Satisfaction with Providers among All Seniors and by Risk Group
  Satisfaction Measures   All High-
  Risk Seniors  
Seniors of
  Advanced Age  
  Seniors in Care  
Management
  Seniors with Hip  
Fracture/Stroke
Satisfied with Location of Primary Care Physician's Office 96.4 96.8 95.7 Not Asked
Level of Satisfaction That Can See Primary Care Physician When Wants to
   Very satisfied 82.7 80.6 87.9 77.6
   Somewhat satisfied 13.1 14.9 9.0 14.7
   Somewhat dissatisfied 3.2 3.6 2.2 4.6
   Very dissatisfied 1.0 0.9 0.8 3.1
Fraction Reporting Problems Among Those Who Wanted a Specialista 5.9 5.5 6.0 9.1
Fraction Reporting Problems Among Those Who Wanted a Therapista 11.0 11.9 9.7 10.0
SOURCE: MPR Telephone Survey, of 1,657 high-risk seniors from three managed care plans.
NOTE: Figures in the table are percentages weighted to reflect the underlying populations. Some subgroup percentages do not sum to 100 percent because of rounding. A total of 31.0 percent of all high-risk seniors have a physician who is a geriatrician or specializes in treating seniors. All physician satisfaction measures are defined only for enrollees who have a physician.
  1. The percentage wanting to see a specialist is defined as those who actually saw a specialist plus those who did not report seeing a specialist but did report a problem seeing one. The percent wanting to see a therapist was computed similarly.

In addition to general access questions, we asked about the sample members’ satisfaction with their primary care physicians and other health care professionals (Table V.8). We asked about the frequency with which:

  • Health professionals spent enough time with the sample member during appointments
  • The sample member received tests or treatments he or she thought necessary
  • The sample member was adequately involved in care-planning decisions
  • Health professionals fully explained test results, medications, and treatments

Approximately 80 percent of the high-risk seniors in our sample reported that their physicians and other health professionals met these criteria always or usually. At the same time, there is some dissatisfaction: for each of the measures, 5 to 15 percent of our sample reported that their physician never met that criterion. This dissatisfaction is mirrored in the findings from our focus groups with primary care providers. Most providers spoke of the need to have extra time for dealing with some high-risk seniors, particularly those with multiple chronic conditions or communication difficulties, and having trouble always finding that extra time.

TABLE V.8. Satisfaction with Provider Interactions, by Risk Groupa
(Percentages)
  Satisfaction Measures   All High-
  Risk Seniors  
Seniors of
  Advanced Age  
  Seniors in Care  
Management
  Seniors with Hip  
Fracture/Stroke
Frequency Physicians Spent Enough Time with Plan Member***
   Always 60.6 58.3 64.7 61.3
   Usually 19.3 20.3 16.8 20.2
   Sometimes   12.0 12.4 11.8 12.8
   Never 8.2 9.0 6.8 5.7
Frequency Member Thought Got Needed Tests or Treatments***
   Always 66.5 64.1 72.7 58.8
   Usually 15.5 16.2 13.0 19.0
   Sometimes 8.0 8.5 6.3 12.7
   Never 10.0 11.2 7.9 9.6
Frequency Member Involved as Much as Wanted in Care Decision***
   Always 54.7 51.4 60.8 57.2
   Usually 15.1 15.5 14.0 16.3
   Sometimes 15.9 17.7 11.9 17.8
   Never 14.4 15.3 13.3 8.7
Frequency Satisfied with Explanations of Test Results, Medications, and Other Treatments***
   Always 66.3 64.0 71.0 62.6
   Usually 19.3 20.3 17.7 18.5
   Sometimes 9.5 10.5 6.7 15.3
   Never 4.9 5.2 4.5 3.6
SOURCE: MPR Telephone Survey of 1,657 high-risk seniors from three managed care plans.
NOTE: Subtotals do not sum to totals because of rounding. Data are weighted to reflect the relevant populations in each MCO, including corrections for survey nonresponse.
  1. These satisfaction measures pertain only to the 95 percent of sample members who reported having a primary care provider.

** A X2 test indicates that the differences among risk groups are statistically significant at the .05 level.
*** A X2 test indicates that differences among risk groups are statistically significant at the .01 level.

The problem a few seniors have in getting information from their providers is also illustrated in data from the 1998 Medicare Current Beneficiary Survey (Health Care Financing Administration 2001; Table 5.2). The survey found that approximately 5 percent of beneficiaries were dissatisfied with the information their physicians gave them about their illnesses and conditions. This is generally consistent with our data that show 5 percent of the high-risk seniors in our sample report never being satisfied with their physician’s explanations of test results, medications, and other treatments. While the proportion of seniors reporting problems is relatively small, the lack of accurate and complete information could have serious consequences, particularly for the high-risk seniors.

Satisfaction Patterns Among the Risk Groups. Our sample of seniors with a recent hip fracture or stroke reported lower overall satisfaction with their MCO than did the advanced age or care management sample (Table V.4). Correspondingly, they tended to have lower reported satisfaction on other measures. For example, they tended to be less satisfied that their MCO would pay for needed medical care and with their out-of-pocket medical expenses (Table V.5). They also seemed less confident that they could see a physician when they wanted to and reported a higher level of problems seeing a specialist (Table V.7). However, the differences are generally not large, and all the measures record at least 75 percent either somewhat or very satisfied. Our focus group discussions suggest that part of the explanation for this pattern is that these seniors receive a lot of care from many providers. This organizational complexity presents more situations where problems may arise. Several of our focus group participants with hip fractures or strokes reported that their care was so complex that they needed to have an advocate or adviser to help them obtain the care they needed. Another part of the explanation is that all the seniors in the hip fracture and stroke sample had experienced a recent and severe illness, while many of the advanced-age sample members and some of the care management sample members had required relatively little care recently. Finally, that seniors who had hip fracture or stroke are less satisfied than seniors of advanced age is one indication that high-risk seniors can experience more difficulty than other seniors accessing care, owing a to greater need and urgency for appointments among multiple providers (primary care physicians, specialists, and therapists).

Satisfaction Differences Among the MCOs. MCO differences in satisfaction with care providers suggest that the experience of high-risk seniors in managed care depends on the structure of benefits, care delivery, and other MCO idiosyncrasies. Members in the three MCOs differed on some measures of satisfaction with provider access (Table V.9). There were no MCO differences in satisfaction with physician location or with difficulty seeing a specialist. The largest difference between MCOs in provider access was in the proportion of members who reported being very satisfied that they could see the physician when they wanted to. The proportion of Aspen members and Keystone East members reporting being very satisfied with their ability to see their physician when they wanted substantially exceeded the proportion of Kaiser Colorado members who reported such satisfaction (80 percent for the Aspen sample, 85 percent for Keystone East, and only 65 percent for Kaiser Colorado).

  TABLE V.9. Satisfaction with Providers among Seniors Who Reported Having a Primary Care Physician  
Satisfaction Measures   Kaiser Colorado  
(Percent)
  Keystone East  
(Percent)
  Medica/Aspen  
(Percent)
Satisfied with Location of Primary Care Physician’s Office 96.8 95.8 95.4
Very Satisfied that Can See Primary Care Physician When Wanted 64.9 85.1 80.4
Had Difficulty Seeing Specialist When Wanted to See One 7.8 7.1 6.1
Had Difficulty Seeing Therapist When Wanted to See One 8.5 11.1 5.5
SOURCE: MPR Telephone Survey of 1,657 high-risk seniors from three managed care plans.
NOTE: All measures have been adjusted for case mix.
  1. These satisfaction measures pertain only to the 95 percent of sample members who reported having a primary care provider.

It is possible that the difference in members’ confidence that they could see their physician reflects Kaiser Colorado members’ difficulty using an automated telephone appointment system. Virtually all the seniors who participated in our focus group at Kaiser Colorado expressed strong dissatisfaction with this system.22

Despite the difference in satisfaction with getting appointments, there were essentially no differences among the MCOs with respect to sample members’ satisfaction with the quality of care they received (Table V.10). More than half of the high-risk seniors we interviewed at all three MCOs reported the highest level of satisfaction with respect to appointment length; getting needed tests; involvement in care decisions; and explanation of tests, medications, and treatments. Interestingly, sample members from Kaiser Colorado were often the least likely to report the lowest level of satisfaction (these estimates are not shown in the tables). For example, only 16 percent of Kaiser Colorado members thought their physician spent too little time with them, a figure that was as much as six percentage points higher for the other two MCOs. Similarly, the proportion of Kaiser Colorado members who reported never getting needed tests or treatments was only 3 percent, in comparison to 10 percent for Keystone East and 8 percent for Aspen.

TABLE V.10. Satisfaction with Provider Interactions, by MCOa
(Percentages)
  Satisfaction Measures     Kaiser Colorado  
(Percent)
  Keystone East  
(Percent)
  Medica/Aspen  
(Percent)
Physicians Always Spent Enough Time with Plan Member 60.9 59.8 59.5
Always Thought Got Needed Tests or Treatments 64.7 64.7 64.8
Always Involved as Much as Wanted in Care Decision 54.5 55.7 57.5
Always Satisfied with Explanations of Test Results, Medications, and Other Treatments   60.7 66.0 62.3
SOURCE: MPR Telephone Survey of 1,657 high-risk seniors from three managed care plans.
NOTE: Data are weighted to reflect the relevant populations in each MCO, including corrections for survey nonresponse.
  1. These satisfaction measures pertain only to the 95 percent of sample members who reported having a primary care provider.

In general, the lack of large systematic differences among the MCOs with respect to seniors’ satisfaction with physicians reflects the absence of any difference in their satisfaction with their plans in general. Our overall sense was that the case study MCOs managed to arrange for care in a way that produced satisfaction levels at least equal to those observed in the entire Medicare population. There were a few differences among the case study MCOs, but nothing that would indicate that one model provided care that was systematically different from that provided by the others.

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