Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 4. A Substantial Fraction of Our Sample of High-Risk Seniors Seemed Unsure of How to Resolve Problems with Care

01/01/2002

If they had been dissatisfied with their care, many high-risk seniors in our sample did not know what recourse they would take (Table V.11). When asked an open-ended question about what they would do if dissatisfied with medical care or service coverage decisions, more than one in five sample members said they did not know. In addition, a sizable number gave fatalistic or vague courses of action, including one fellow who said that if his medical care was bad, he would “just get sick and die.” Combining these two types of responses, 33 percent could not state a concrete course of action if they were dissatisfied with medical care, and 46 percent did not site a concrete action to take if they were unhappy with service coverage decisions. Among the seniors who had a plan, most would complain to their physician or directly to the MCO. Only a few (six percent) would change MCOs over dissatisfaction with medical care, and nearly no one would change MCOs over dissatisfaction with service decisions.

TABLE V.11. Seniors’ Reported Actions to Address Dissatisfaction: Overall and by Risk Group
  Action Measures   All High-
  Risk Seniors  
Seniors of
  Advanced Age  
  Seniors in Care  
Management
  Seniors with Hip  
Fracture/Stroke
If Dissatisfied with Medical Care, Most Common Action Would Take
   Contact physician 11.8 11.3 13.2 11.0
   Complain to plan 18.7 19.0 16.5 26.6
   Change plan 6.1 6.0 6.8 2.9
   Other vague actions   9.4 9.7 9.0 8.7
   Does not know 23.1 25.7 19.4 14.6
If Dissatisfied with Service Coverage Decision, Most Common Action Would Take
   Contact physician 4.1 4.2 4.0 2.7
   Complain to plan 24.2 23.5 24.1 32.0
   Change plan 0.2 0.0 0.7 0.3
   Other vague actions 15.9 16.1 14.9 14.5
   Does not know 29.9 32.9 25.9 18.0
SOURCE: MPR telephone survey of 1,657 selected high-risk seniors in three managed care organizations.
NOTE: Because of rounding, subtotals do not sum to totals. Data are weighted to reflect the relevant populations in each MCO, including corrections for survey nonresponse.

There are, however, noteworthy differences by risk group in actions in response to dissatisfaction with medical care and service coverage decisions. Beneficiaries with hip fracture or stroke were more likely to contact their plan if dissatisfied and less likely to say they did not know what to do than were seniors in our other sample groups. For example, whereas 26 percent of the seniors in our advanced-age group did not know what to do if dissatisfied with medical coverage, only 15 percent of seniors with hip fracture reported that they did not know. There was a similar pattern of differences with respect to not knowing how to respond to dissatisfaction with coverage decisions.

Based on our site visits, we identified two possible reasons for this difference in knowing concrete steps for addressing dissatisfaction. First, seniors who had a hip fracture or stroke may have more interactions with physicians and other care providers, which might give them more experience with complaint processes. Second, many seniors in the other groups had relatively few contacts with providers, and most expressed great satisfaction with their care. As a result, they may have had no experience with complaints and had never bothered to identify effective complaint methods.

There are some differences across MCOs in the actions that members would take over dissatisfaction with medical care and coverage decisions (Table V.12). Kaiser Colorado members were the least likely to contact the physician and the most likely to contact their plan if dissatisfied with medical care. This may reflect the Kaiser members’ perception of health providers as an extension of the MCO. Only six percent of Kaiser Colorado’s members would contact their physician--six to eight percentage points lower than the proportion of members in Keystone East and Aspen. The same general pattern holds for responding to dissatisfaction with service coverage decisions.

TABLE V.12. Seniors’ Reported Actions to Address Dissatisfaction, by MCO
Action Kaiser
  (Percentage)  
Keystone
  (Percentage)  
  Medica/Aspen  
(Percentage)
If Dissatisfied with Medical Care, Most Common Action Would Take
   Contact physician   5.94 13.79 12.12
   Complain to plan 23.57 19.28 17.59
   Change plan 4.54 6.57 2.10
   Does not know 22.11 20.30 24.48
If Dissatisfied with Service Coverage Decision, Most Common Action Would Take
   Contact physician 1.66 4.11 5.79
   Complain to plan 22.78 27.11 20.51
   Change plan 0.01 0.69 0.01
   Does not know 30.51 25.49 29.34
SOURCE: MPR telephone survey of 1,657 selected high-risk seniors in three managed care organizations.
NOTE: Because of rounding, subtotals do not sum to totals. Data are weighted to reflect the relevant populations in each MCO, including corrections for survey nonresponse.

Very few members of any MCO would change MCOs over dissatisfaction with medical care, and virtually no one would change MCOs over dissatisfaction with service coverage decisions. At seven percent, Keystone East members are the most likely to report they would change MCOs. Fewer members from Kaiser Colorado (five percent) and Aspen (two percent) report that they would change MCOs over dissatisfaction with service coverage decisions. This pattern may reflect the fact that changing MCOs would mean changing physicians for all Kaiser members and many Aspen members. Such an action would be unexpected for high-risk seniors, who generally value continuity of care. The pattern also seems likely to reflect the availability of alternative MCOs that offer similar benefit packages and premiums in the Philadelphia market served by Keystone East. Thus, Keystone members could, in many cases, change plans while keeping their physician and maintaining their benefits.

There are no MCO differences in the proportion of members who report not knowing how to handle dissatisfaction with medical care or service coverage decisions. Despite differences in the structure of care delivery and benefit packages, more than one in five high-risk seniors report not knowing what they would do. This suggests a problem that is common among high-risk seniors and not related to specific types of plan features, at least for our small set of well-regarded MCOs.

We found that seniors who were more than 85 years old were substantially less likely to give a concrete plan for addressing dissatisfaction with medical care (Appendix A, Table A.2). In contrast, those with some college education and those for whom a representative proxy answered our survey were more likely to have such plans. (These findings are based on a regression analysis that looks at the effect of each characteristic while controlling for any effects of the variables listed in Table II.6.) This suggests that special efforts may be required to help enable seniors with advanced age. The representative proxies appear to help address information needs, since they were also less likely to report having insufficient information for selecting the best managed care plan.

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