A Randomized Trial Examining Three Strategies for Supporting Health Insurance Decisions among the Uninsured

"Pick a Plan and Roll the Dice": A qualitative study of consumer experiences selecting a health plan in the non-group market

Background

For consumers without access to employer-sponsored or public insurance, health plan choices in the non-group (individual) insurance market that do not meet consumer needs have the potential for negative downstream implications for health and financial well-being.

Objective

This qualitative interview study sought to understand consumers' experiences and challenges with choosing a non-group health plan, among those who later had negative experiences with the plan they chose.

Methods

We conducted semi-structured telephone interviews with a purposive sample of 36 participants from a large regional health insurance carrier in three states who enrolled in non-group plans in 2017 (21 in Affordable Care Act (ACA) Marketplace plans and 15 enrolled off-Marketplace). Participants were included if they reported negative experiences using their plan after enrollment, such as higher-than-expected medical costs. Interviews explored challenges choosing a plan; information needed for choosing; usefulness of available tools; and preferred format for interventions to improve plan choice experiences. We analyzed interview transcripts using thematic content analysis.

Results

Study participants reported experiencing substantial challenges to choosing an insurance plan. Key barriers included understanding insurance terms, finding relevant information, and making comparisons across plans. Participants valued the ability to make comparisons across carriers when using the Marketplace websites but were less satisfied with customer service. Suggestions for improvement included greater standardization of plans and language and availability of customized one-on-one assistance.

Conclusion

Findings from this study suggest that health plan selection in the non-group market presents challenges to consumers that may be addressed through enrollment assistance and improved presentation of information. Personalized assistance to find and choose coverage may lead to plan choices that better meet consumer needs and increase confidence choosing a plan in subsequent enrollment periods.

Association of Health Insurance Literacy with Health Care Utilization: a Systematic Review

BACKGROUND

Given increasing numbers of people experiencing transitions in health insurance due to declines in employer-sponsored insurance and changes in health policy, the understanding and application of health insurance terms and concepts (health insurance literacy) may be important for navigating use of health care. The study objective was to systematically review evidence on the relationship between health insurance literacy and health care utilization.

METHODS

Medline, SCOPUS, Web of Science, CINAHL, PsychInfo, Cochrane Library, and reference lists of published literature were searched in August 2019. Quantitative, qualitative, and intervention studies that assessed the association of health insurance literacy as the exposure and health care utilization as the outcome were identified, without language or date restrictions. Outcomes were independently assessed by 2-3 reviewers.

RESULTS

Twenty-one studies including a total of 62,416 subjects met inclusion criteria: three interventional trials, two mixed-methods studies, and sixteen cross-sectional studies. Ten of thirteen preventive care studies suggested that higher health insurance literacy was associated with greater utilization of primary care and other preventive services. Eight of nine studies of care avoidance demonstrated that individuals with lower health insurance literacy were more likely to delay or avoid care. A few studies had mixed results regarding the utilization of emergency department, inpatient, and surgical care.

DISCUSSION

The emerging literature in this area suggests that health insurance literacy is an important factor that can enable effective utilization of health care, including primary care and preventive services. However, the literature is limited by a paucity of studies using validated tools that broadly measure health insurance literacy (rather than testing knowledge of specific covered services). Improving health insurance literacy of the general public and increasing plain language communication of health insurance plan features at the point of health care navigation may encourage more effective and cost-conscious utilization.

The association of health insurance literacy and numeracy with financial toxicity and hardships among colorectal cancer survivors

PURPOSE

In this study, we examined the association of financial hardship measured by material financial burden and financial toxicity with health insurance literacy and numeracy among colorectal cancer survivors. The lack of evidence on the impact of cost-related health literacy, specifically health insurance literacy and numeracy, on financial toxicity among cancer survivors warrants further research.

METHODS

Between January and November 2019, we used a cross-sectional research design to collect surveys from 104 colorectal cancer survivors (diagnosed within last 5 years) from the Kentucky Cancer Registry. Survey items assessed health insurance literacy (measured by confidence and behaviors in choosing and using health insurance), numeracy, material financial burden, and financial toxicity, in addition to socio-demographic variables. Survey data were subsequently linked to the participant's cancer registry record. Data were analyzed using descriptive, bivariate, and multiple linear regression analyses.

RESULTS

The mean financial toxicity score was 24.5, with scores ranging from 3 to 43 (higher scores indicating greater financial toxicity). Eighty percent of participants indicated they had experienced one or more material burdens related to their cancer. The majority had adequate health insurance (79%); however, the majority also had low numeracy (84%). After controlling for socio-demographic covariates, significant predictors of greater financial toxicity were high material burden scores, low health insurance literacy, and low numeracy.

CONCLUSIONS

Findings indicate the need to develop programs and interventions aimed at improving health insurance literacy and numeracy as a strategy for reducing financial toxicity and hardships among colorectal cancer survivors.

Acceptability, feasibility and implementation of a web-based U.S. Health Insurance Navigation Tool (HINT)

OBJECTIVE

In the U.S., health insurance is a crucial determinant of the affordability of healthcare services and access to care. Population-based studies indicate Americans do not have an adequate understanding of their insurance plans and face difficulties navigating their health insurance coverage. The purpose of this pilot study is to collect qualitative data using a key informant interview format to learn about the acceptability, feasibility and implementation of a newly devised online health insurance navigation tool (HINT).

RESULTS

A total of 57 Florida residents completed the 18-item HINT web-based survey tool and provided feedback on their experience, of which 63.2% were women, 40.7% Black race, and had average sample age of 46.9 years. Participants reported the web tool to be of good length, easy readability, relevant, and overall helpful for insurance selection. All respondents reported that they would use the tool themselves should they find themselves in the process of selecting an insurance plan and 98.2% of respondents reported that they would suggest the web tool to a family or friend. The average time it took to complete the questionnaire was 4 min and 20 s.The HINT tool met study criteria on feasibility, implementation, and acceptability among study participants.

Healthcare Decision-Making Among Dual-Eligible Immigrants: Implications from a Study of an Integrated Medicare-Medicaid Demonstration Program in California

To improve the coordination of long-term services and supports for dual-eligibles (those with both Medicare and Medicaid), California created Cal MediConnect (CMC), an Affordable Care Act-authorized managed care demonstration program. Beneficiaries were "passively enrolled" into CMC, meaning they were automatically enrolled unless they actively opted out. The aim of this study was to examine differences in factors influencing the enrollment decisions of U.S. born and immigrant dual-eligible beneficiaries. To explore differences in decision-making processes, we conducted in-depth interviews with dual-eligible consumers (39 native and 14 immigrant) in Los Angeles County. Interviews were analyzed using a constructivist grounded theory approach. Our findings illustrate a heightened sense of vulnerability and disempowerment experienced by immigrant participants. Immigrant participants also faced greater challenges in accessing healthcare and eliciting healthcare information compared to U.S.-born participants. Understanding the diverse perspectives of dual-eligible immigrant healthcare decision-making has implications for health care reform strategies aimed at ameliorating disparities for vulnerable immigrant populations.

Interpersonal factors contributing to tension in the Chinese doctor-patient-family relationship: a qualitative study in Hunan Province

OBJECTIVE

To identify actionable barriers to communication that contribute to tension in the Chinese doctor-patient-family relationship (DPFR) among surgeons, surgical patients and their family members.

DESIGN

We employed qualitative research methods using in-depth, semistructured interviews in Mandarin and English and conducted preoperatively and postoperatively. Interviews were audio recorded, transcribed and translated into English. Data were analysed using thematic analysis.

SETTING

An urban, tertiary-level teaching hospital in Hunan Province, China.

PARTICIPANTS

We recruited a purposive sample of 11 inpatients undergoing the same minor surgery, 9 of their family members and 9 surgeons between June and August 2015.

RESULTS

We identified three emergent themes. First, trust degradation occurred before and during the healthcare experience. Second, the healthcare-seeking experience for patients and family members was marked by unmet expectations for achieving a basic understanding of the illness as well as powerlessness over their situation. Third, societal pressures on doctors contributed to a state of learned helplessness.

CONCLUSIONS

Our findings suggest that tension in the DPFR is associated with interpersonal and structural challenges, with communication playing an important role. Reforms at all levels are needed to promote a more patient-centred experience while ensuring the well-being and security of providers.

Self-reported Physical Health of Women Who Did and Did Not Terminate Pregnancy After Seeking Abortion Services: A Cohort Study

BACKGROUND

Research demonstrates worse short-term morbidity and mortality associated with childbirth than with abortion, but little research has examined long-term physical health in women with unwanted pregnancies after abortion versus childbirth.

OBJECTIVE

To examine the physical health of women who seek and receive or are denied abortion.

DESIGN

Prospective cohort study.

SETTING

30 U.S. abortion facilities from 2008 to 2010.

PARTICIPANTS

Of 1132 women seeking abortion who consented to participate, 874 were included in this analysis (328 who had first-trimester abortion, 383 who had second-trimester abortion, and 163 who gave birth).

MEASUREMENTS

Self-reported overall health; chronic abdominal, pelvic, back, and joint pain; chronic headaches or migraines; obesity; asthma; gestational and nongestational hypertension and diabetes; and hyperlipidemia were assessed semiannually for 5 years. Mortality was assessed by using verbal autopsy and public records.

RESULTS

No significant differences were observed in self-rated health or chronic pain after first-trimester versus second-trimester abortion. At 5 years, 27% (95% CI, 21% to 34%) of women who gave birth reported fair or poor health compared with 20% (CI, 16% to 24%) of women who had first-trimester abortion and 21% (CI, 18% to 25%) who had second-trimester abortion. Women who gave birth also reported more chronic headaches or migraines and joint pain, but experienced similar levels of other types of chronic pain and obesity. Gestational hypertension was reported by 9.4% of participants who gave birth. Eight of 1132 participants died during follow-up, 2 in the postpartum period. Maternal mortality did not differ statistically by group.

LIMITATION

Self-reported outcome measures, uncertain generalizability, and 41% loss to follow-up at 5 years.

CONCLUSION

Although some argue that abortion is detrimental to women's health, these study data indicate that physical health is no worse in women who sought and underwent abortion than in women who were denied abortion. Indeed, differences emerged suggesting worse health among those who gave birth.

PRIMARY FUNDING SOURCE

An anonymous foundation.

Prevalence and Correlates of Medical Financial Hardship in the USA

BACKGROUND

High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA.

OBJECTIVE

To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship.

DESIGN AND PARTICIPANTS

We identified adults aged 18-64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015-2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18-64 years and ≥ 65 years.

MAIN MEASURES

Prevalence of material, psychological, and behavioral hardship and hardship intensity.

KEY RESULTS

Approximately 137.1 million (95% CI 132.7-141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18-64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001).

CONCLUSIONS

Medical financial hardship is common in the USA, especially in adults aged 18-64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.

Burden Associated With Selecting and Using Health Insurance to Manage Care Costs: Results of a Qualitative Study of Nonelderly Cancer Survivors

This qualitative study explored cancer survivors' experiences selecting and using health insurance and anticipating out-of-pocket care costs. Thirty individuals participated in semistructured interviews. On average, participants were 54 years (SD ± 8.85, range 34-80) and diagnosed with cancer about 5 years prior (range 0.5-10 years). About 57% were female, 77% were non-Hispanic White, and 53% had less than a college education. Participants struggled to access information about health insurance and costs. Lack of cost transparency made it difficult to anticipate expenses and increased anxiety. Many participants were surprised that after cancer, care that was once preventive with no out-of-pocket costs became diagnostic with associated fees. They discussed the cognitive burden of managing finances on top of treatment and overseeing communication between doctors and insurance. Interventions are needed to clearly communicate information about insurance coverage and care costs to improve cancer survivors' confidence in selecting health insurance and anticipating out-of-pocket expenses.

Explanation and elaboration of the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) guidelines: examples of reporting SUNDAE items from patient decision aid evaluation literature

This Explanation and Elaboration (E&E) article expands on the 26 items in the Standards for UNiversal reporting of Decision Aid Evaluations guidelines. The E&E provides a rationale for each item and includes examples for how each item has been reported in published papers evaluating patient decision aids. The E&E focuses on items key to reporting studies evaluating patient decision aids and is intended to be illustrative rather than restrictive. Authors and reviewers may wish to use the E&E broadly to inform structuring of patient decision aid evaluation reports, or use it as a reference to obtain details about how to report individual checklist items.

Access Is Necessary but Not Sufficient: Factors Influencing Delay and Avoidance of Health Care Services

Background: Despite recently expanded access to health insurance, consumers still face barriers to using their coverage to obtain needed health care. Objective: To examine the characteristics of those who delay or avoid health care due to costs. Methods: Participants were recruited via Amazon MTurk and completed a survey assessing demographic characteristics, financial toxicity, health care minimizer-maximizer tendencies, health insurance knowledge, numeracy, delaying/avoiding any care, and delaying/avoiding six common health care services (three preventive and three nonpreventive services). Validated measures were used when available. Delay/avoidance behaviors were categorized into delaying/avoiding any care, preventive care, and nonpreventive care. Logistic regression models examined 1) financial toxicity, 2) minimizer-maximizer tendencies, 3) numeracy, 4) health insurance knowledge, and 5) knowledge of preventive care coverage separately on three forms of delay/avoidance behaviors, controlling for chronic conditions, insurance status, and/or income where appropriate. Results: Of 518 respondents, 470 did not fail attention-check questions and were used in analyses. Forty-five percent of respondents reported delaying/avoiding care due to cost. Multivariable analyses found that financial toxicity was related to delaying/avoiding any care (odds ratio [OR] = 0.884, P < 0.001), preventive care (OR = 0.906, P < 0.001), and nonpreventive care (OR = 0.901, P < 0.001). A tendency to minimize seeking health care (OR = 0.734, P < 0.001) and lower subjective numeracy (OR = 0.794, P = 0.023) were related to delaying/avoiding any care. General health insurance knowledge (OR = 0.989, P = 0.023) and knowledge of preventive care coverage (OR = 0.422, P < 0.001) were related to delaying/avoiding preventive care. Conclusions: Many people delay or avoid health care due to costs, even when insured. Results suggest that there may be different reasons individuals delay or avoid preventive and nonpreventive care. Findings may inform interventions to educate consumers and support discussions about health care costs to facilitate appropriate health care utilization.

Consumer Health Insurance Shopping Behavior and Challenges: Lessons From Two State-Based Marketplaces

Selecting a health plan in a health insurance exchange is a critical decision, yet consumers are known to face challenges with health plan choice. We surveyed new enrollees in two state-based exchanges in 2015 to investigate how a nonelderly, primarily low-income population chose their health plans and the implications of shopping behavior for early experiences in their plans. Financial considerations were most important to enrollees. Prior Medicaid enrollees and the uninsured were more likely to have multiple shopping challenges (e.g., difficulty identifying the best or most affordable plan, fair/poor experience, unmet need for help) than enrollees with prior employer coverage (42.9% vs. 32.5% vs. 16.4%, respectively, p < .01). Shopping challenges were associated with difficulty finding a doctor, understanding coverage, and getting questions answered. Assistance targeting enrollees who previously had Medicaid or lacked insurance could improve both shopping experiences and downstream outcomes in plans.

Show Me My Health Plans: Using a Decision Aid to Improve Decisions in the Federal Health Insurance Marketplace

Introduction: Since the Affordable Care Act was passed, more than 12 million individuals have enrolled in the health insurance marketplace. Without support, many struggle to make an informed plan choice that meets their health and financial needs. Methods: We designed and evaluated a decision aid, Show Me My Health Plans (SMHP), that provides education, preference assessment, and an annual out-of-pocket cost calculator with plan recommendations produced by a tailored, risk-adjusted algorithm incorporating age, gender, and health status. We evaluated whether SMHP compared to HealthCare.gov improved health insurance decision quality and the match between plan choice, needs, and preferences among 328 Missourians enrolling in the marketplace. Results: Participants who used SMHP had higher health insurance knowledge (LS-Mean = 78 vs. 62; P < 0.001), decision self-efficacy (LS-Mean = 83 vs. 75; P < 0.002), confidence in their choice (LS-Mean = 3.5 vs. 2.9; P < 0.001), and improved health insurance literacy (odds ratio = 2.52, P < 0.001) compared to participants using HealthCare.gov. Those using SMHP were 10.3 times more likely to select a silver- or gold-tier plan (P < 0.0001). Discussion: SMHP can improve health insurance decision quality and the odds that consumers select an insurance plan with coverage likely needed to meet their health needs. This study represents a unique context through which to apply principles of decision support to improve health insurance choices.

Stakeholders' perceptions of ways to support decisions about health insurance marketplace enrollment: a qualitative study

Background

Approximately 29 million individuals are expected to enroll in health insurance using the Patient Protection and Affordable Care Act (ACA) Marketplace by 2022. Those seeking health insurance struggle to understand insurance options and choose a plan that best suits their needs.

Methods

We interviewed stakeholders to identify the challenges associated with the ACA Marketplace health insurance enrollment and elicited feedback about what to include in health insurance decision support tools. Interviews were transcribed and themes were identified using inductive thematic analysis.

Results

Stakeholders stated that consumers felt frustrated by unclear terminology, high plan costs, and complex calculations required to assess costs. Consumers felt anxious about making the wrong choice and being unable to change plans within a calendar year. Stakeholders recommended using plain language tables defining complex terms, grouping information, and using engaging graphics to communicate information about health insurance. Stakeholders thought that narratives of how others made decisions about insurance might be helpful to consumers, but recommended that they be tailored to the needs of specific consumers.

Conclusion

Strategies that clarify health insurance terms using plain language and graphics, acknowledge concern associated with making the wrong choice, calculate and enable cost comparison, and tailor information to consumers’ unique needs could benefit those enrolling in ACA Marketplace plans, Narratives developed should be simple and inclusive enough for diverse populations.

Feasibility of Picture-Based Asthma Medication Plans in Urban Pediatric Outpatient Clinics

Picture-based Asthma Action Plans show promise for overcoming parental literacy barriers and improving child asthma outcomes, but it is uncertain how parents respond to pictures of specific medications, which may be particularly important for improving disease self-management. Thus, we assessed parent attitudes toward an asthma-related picture-based medication plan (PBMP) in an urban academic pediatric clinic and examined attitudes by literacy level. Surveys were administered to a convenience sample of parents of children presenting to an urban pediatric pulmonary clinic for asthma consultation between March and August 2011. The Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) was administered to parents. Parents indicated their level of agreement with 9 statements on the potential usefulness of the PBMP: (1) before being shown a PBMP; and (2) after seeing the doctor. McNemar's tests showed that the proportion of high-literate parents (≥9th grade reading level) who endorsed the potential benefits of the PBMP after the clinical encounter was significantly higher than before the clinical encounter. A high proportion of low-literate parents (<9th grade reading level) consistently endorsed the PBMP before and after the clinical encounter. Among a diverse sample seen in an urban asthma clinic, parents of all literacy levels endorse PBMPs as useful, especially after using them in clinical encounters.

Show Me My Health Plans: a study protocol of a randomized trial testing a decision support tool for the federal health insurance marketplace in Missouri

BACKGROUND

The implementation of the ACA has improved access to quality health insurance, a necessary first step to improving health outcomes. However, access must be supplemented by education to help individuals make informed choices for plans that meet their individual financial and health needs.

METHODS/DESIGN

Drawing on a model of information processing and on prior research, we developed a health insurance decision support tool called Show Me My Health Plans. Developed with extensive stakeholder input, the current tool (1) simplifies information through plain language and graphics in an educational component; (2) assesses and reviews knowledge interactively to ensure comprehension of key material; (3) incorporates individual and/or family health status to personalize out-of-pocket cost estimates; (4) assesses preferences for plan features; and (5) helps individuals weigh information appropriate to their interests and needs through a summary page with "good fit" plans generated from a tailored algorithm. The current study will evaluate whether the online decision support tool improves health insurance decisions compared to a usual care condition (the healthcare.gov marketplace website). The trial will include 362 individuals (181 in each group) from rural, suburban, and urban settings within a 90 mile radius around St. Louis. Eligibility criteria includes English-speaking individuals 18-64 years old who are eligible for the ACA marketplace plans. They will be computer randomized to view the intervention or usual care condition.

DISCUSSION

Presenting individuals with options that they can understand tailored to their needs and preferences could help improve decision quality. By helping individuals narrow down the complexity of health insurance plan options, decision support tools such as this one could prepare individuals to better navigate enrollment in a plan that meets their individual needs. The randomized trial was registered in clinicaltrials.gov (NCT02522624) on August 6, 2015.