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Designing ConsumerGuides on Quality forMedi-Cal ManagedCare Beneficiaries

March 2003

The Quality Initiative

Designing ConsumerGuides on Quality forMedi-Cal Managed Care Beneficiaries

Prepared for CALIFORNIA HEALTHCARE FOUNDATION

by Shaller ConsultingDale Shaller, M.P.A.; Elizabeth Hoy, M.H.A.; Karen Onstad, M.P.H., M.P.P.

The Quality InitiativeMarch 2003

Acknowledgments

Shaller Consulting is a health care policy analysis and manage-ment consulting practice based in Stillwater, Minnesota. Itsprincipal, Dale Shaller, has over 20 years of experience in thedesign, implementation, and evaluation of health care qualitymeasurement and consumer information programs at thenational and community level. Shaller Consulting provideseducation and technical assistance to state and local health carecoalitions, purchasing groups, and provider organizations intheir efforts to measure and improve health care quality.

The coauthors of this background paper are members of theteam assembled by Shaller Consulting for the Medi-Calconsumer guide project. Elizabeth Hoy is President of PolarisConsulting, an independent consulting firm in Vienna,Virginia specializing in health care quality measurement andreporting, including the design of quality reports and materialsto support consumer choice. Recently she has focused ondesigning reports on health plan and health care quality forconsumers with varying literacy skills, cognitive skills andcultural backgrounds. Karen Onstad is an independent healthcare consultant based in St. Paul, Minnesota specializing inassessing the quality of managed care organizations andreporting quality information to purchasers and consumers.

About the Foundation

The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improvingCalifornia’s health care delivery and financing systems. Formedin 1996, our goal is to ensure that all Californians have accessto affordable, quality health care. CHCF’s work focuses oninforming health policy decisions, advancing efficient businesspractices, improving the quality and efficiency of care delivery,and promoting informed health care and coverage decisions.CHCF commissions research and analysis, publishes anddisseminates information, convenes stakeholders, and fundsdevelopment of programs and models aimed at improving thehealth care delivery and financing systems.

CHCF’s Quality Initiative is a catalyst for improving thequality and accountability of health care in California throughpublic reporting of performance measures and advancementof improvement and patient safety efforts.

Additional copies of this report and other publications can beobtained by calling the California HealthCare Foundation’spublications line at 1-888-430-CHCF (2423) or visiting usonline at www.chcf.org.

ISBN 1-932064-29-XCopyright © 2003 California HealthCare Foundation

Contents

6 I. Introduction

7 II. Information and Decision Making Context

Medi-Cal Managed Care Program Structure

Current Beneficiary Enrollment Information

11 III. Medi-Cal Managed Care Beneficiary

Characteristics

Literacy Skills

Language Spoken

Cultural Factors: Ethnicity

14 IV. Addressing Cultural and Linguistic Diversity

Beliefs and Behaviors

Translation Issues

Literacy Challenges

Use of Decision Support

19 V. Sources and Content of Quality Measures

HEDIS and CAHPS Data

Other Plan-Level Performance Data

22 VI. Distribution Issues

Report Design

Relationship to Enrollment Materials

Web Version of the Report

Use of Intermediaries

Timing

General Education and Promotion

24 VII. Conclusion

25 Appendix

32 Endnotes

6 | CALIFORNIA HEALTHCARE FOUNDATION

THE OVERALL AIM OF THIS PROJECT IS TO DEVELOPand distribute a consumer-friendly guide on the quality ofMedi-Cal managed care health plans in California. The purposeof the guide is to provide Medi-Cal beneficiaries with compara-tive quality information they can use in making health planenrollment decisions at the county level. While beneficiariescurrently receive information about managed care during theenrollment process, enrollment materials to date have notincluded any quality-related information. The qualityinformation to be presented in the guide will include selectedHealth Plan Employer Data and Information Set (HEDIS)and Consumer Assessment of Health Plans Study (CAHPS)data currently collected by the California Department ofHealth Services (DHS). The guide will be produced inmultiple languages, including English, Spanish, and at leasttwo other languages, and will be updated regularly to reflectcurrent quality measures.

This background paper lays a foundation for developing areport design and distribution strategy that will maximize theinformation and decision making value of the guide for Medi-Cal managed care beneficiaries. The low literacy levels andculturally and linguistically diverse nature of this audience pose a number of challenges that will need to be addressed indeveloping effective report design and dissemination methods.The complex and geographically diverse structure of the Medi-Cal managed care program creates additional challenges inmeeting the specific information and decision-making needs of beneficiaries at the county level.

This paper outlines key characteristics of the Medi-Cal managedcare program and population that will influence report designand distribution. We also identify key design issues and suggestedstrategies based on a review of the literature and consultationwith national experts on developing and distributing healthquality information to low literacy and culturally/linguisticallydiverse populations. The paper concludes with a summary ofconsumer reporting activities undertaken by Medicaidprograms in other states.

I. Introduction

Designing Consumer Guides on Quality for Medi-Cal Managed Care Beneficiaries | 7

Medi-Cal Managed Care Program Structure

The number of Medi-Cal beneficiaries enrolled in managedcare has expanded significantly during the past decade. In2001, approximately 56 percent of Medi-Cal beneficiaries wereenrolled in some form of managed care, with 22 of the state’s58 counties participating in one of the three main Medi-Calmanaged care models.1 These three models are defined as:Geographic Managed Care (GMC), County Organized HealthSystem (COHS), and the Two-Plan Model, which includesLocal Initiatives (LI) and Commercial Plans (CP). The Medi-Cal Managed Care (MMC) enrollment and model type foreach participating county are shown in Table 1. A list of thespecific health plans offered in each of the 22 counties ispresented in Table 2.

II. Information and DecisionMaking Context

Table 1. Medi-Cal Managed Care Enrollment and MMC Model

Type by County (2001)

Total Medi-Cal MEDI-CAL MANAGED CARE (MMC)

C O U N T Y Recipients Model Enrollment: Total / Percent

Alameda 182,472 Two-Plan 98,096 53.8%

Contra Costa 84,442 Two-Plan 43,456 51.5%

Fresno 216,302 Two-Plan 135,749 62.8%

Kern 141,006 Two-Plan 74,776 53.0%

Los Angeles 1,965,047 Two-Plan 1,068,697 54.4%

Monterey 54,151 COHS 42,354 78.2%

Napa 8,800 COHS 7,934 90.2%

Orange 257,157 COHS 219,445 85.3%

Riverside 196,545 Two-Plan 100,422 51.1%

Sacramento 238,553 GMC 156,105 65.4%

San Bernardino 275,879 Two-Plan 139,037 50.4%

San Diego 287,538 GMC 151,323 52.6%

San Francisco 110,255 Two-Plan 41,226 37.4%

San Joaquin 106,450 Two-Plan 58,212 54.7%

San Mateo 41,746 COHS 37,861 90.7%

Santa Barbara 48,417 COHS 41,019 84.7%

Santa Clara 144,345 Two-Plan 60,990 42.3%

Santa Cruz 24,471 COHS 21,356 87.3%

Solano 41,418 COHS 39,958 96.5%

Stanislaus 86,488 Two-Plan 29,305 33.9%

Tulare 102,094 Two-Plan 39,346 38.5%

Yolo 22,435 COHS NA NATotal 4,650,632 2,617,191 56.3%

Sources: Medi-Cal County Data Book, Medi-Cal Policy Institute, January 2002, and “Medi-CalManaged Care Contact List,” California Department of Health Services, Medi-Cal ManagedCare Division, September 4, 2002.


Table 2. List of Health Plans by County Participating in Medi-Cal Managed Care (2001)

M E D I - C A L M A N A G E D C A R E ( M M C )

C O U N T Y Model No. of Plans Plan Name(s)

Alameda Two-Plan 2 • Alameda Alliance for Health • Blue Cross of California

Contra Costa Two-Plan 2 • Contra Costa Health Plan • Blue Cross of California

Fresno Two-Plan 2 • Blue Cross of California • Health Net

Kern Two-Plan 2 • Kern Family Health Care • Blue Cross of California

Los Angeles Two-Plan 2 • L.A. Care Health Plan • Health Net

Monterey COHS 1 • Central Coast Alliance for Health

Napa COHS 1 • Partnership Health Plan of California

Orange COHS 1 • CalOPTIMA

Placer COHS 1 • Placer County Managed Care Network

Riverside Two-Plan 2 • Inland Empire Health Plan • Molina Healthcare of California

Sacramento GMC 5 • Blue Cross of California • Molina Healthcare of California• Health Net • Western Health Advantage• Kaiser Foundation Health Plan (North)

San Bernardino Two-Plan 2 • Inland Empire Health Plan• Molina Healthcare of California

San Diego GMC 7 • Blue Cross of California • Sharp Health Plan• Community Health Group • UCSD Health Care• Health Net • Universal Care• Kaiser Foundation Health Plan (South)

San Francisco Two-Plan 2 • San Francisco Health Plan • Blue Cross of California

San Joaquin Two-Plan 2 • Health Plan of San Joaquin • Blue Cross of California

San Mateo COHS 1 • Health Plan of San Mateo

Santa Barbara COHS 1 • Santa Barbara Regional Health Initiative

Santa Clara Two-Plan 2 • Santa Clara Family Health Plan • Blue Cross of California

Santa Cruz COHS 1 • Central Coast Alliance for Health

Solano COHS 1 • Partnership Health Plan of California

Stanislaus Two-Plan 1 • Stanislaus County Local Initiative (Blue Cross)

Tulare Two-Plan 2 • Tulare County Local Initiative (Blue Cross)• Health Net

Yolo COHS 1 • Partnership Health Plan of California

Sources: Medi-Cal County Data Book, Medi-Cal Policy Institute, January 2002, and “Medi-Cal Managed Care Contact List,” California Department ofHealth Services, Medi-Cal Managed Care Division, September 4, 2002.

The project team made a preliminary decision todevelop a report design and distribution strategythat is county-specific. This means that theinformation content of the guide will focus onthe comparative health plan quality informationthat is relevant to beneficiaries in the counties inwhich they are enrolled. We strongly support thisdecision since it suggests a report design that isfocused and targeted to the specific informationneeds of the guide’s audience, and does notcontain large amounts of extraneous informationthat can burden the cognitive and decisionmaking process of the audience.

Based on the three Medi-Cal managed caremodels, the 22 counties participating in Medi-Cal managed care can be grouped into two major categories related to beneficiary choice of health plan:

Counties with Plan ChoiceThe GMC and Two-Plan Models offer benefi-ciaries a choice of health plan. For the two countieswith GMC models, beneficiaries have a choice ofmultiple plans (five in Sacramento and seven inSan Diego). As its name implies, the Two-PlanModel gives beneficiaries a choice of two plans.This model is currently implemented in 12 countiesand represents the largest number of Medi-Calmanaged care enrollees in the state.

Counties without Plan ChoiceThe COHS model is essentially a county-administered health plan that providesbeneficiaries a choice of managed care providersbut no choice of plan. This model is operationalin eight counties.

A number of project implications follow from adecision to develop a county-specific report designand distribution strategy. Among these are:

■ In counties with plan choice, plan-specificquality information for the available planoptions should be presented.

■ In counties without plan choice, the perform-ance of the COHS “plan” may need to becompared to some external benchmark, suchas the state average or highest performing plan.

■ Customizing health plan quality informationthat is specific to 22 different counties willrequire a flexible report design, production,and distribution process. While some informationin the guide will be consistent across counties,the comparative performance information andhealth plan descriptive information will needto be tailored to the choices available in eachcounty. The need for such a tailoring approachwill have cost, timing, and administrative impli-cations for the project, since it will not bepossible to mass produce and disseminate asingle document that will work in all counties.

One alternative approach to county-specificinformation would be to present comparativehealth plan data by region. The recentlypublished California HMO Report Card by theOffice of the Patient Advocate (OPA) uses aregional approach, presenting HMO and medicalgroup comparisons for eleven regions. Furtherdiscussion will be needed to determine if such anapproach could work for the Medi-Cal population,given the differences in MMC model type bycounty within region.

Creating a Consumer Guide on Quality for Medi-Cal Managed Care Beneficiaries | 9

Current Beneficiary

Enrollment Information

An important consideration for the design of thequality guide is the content, format, and timingof other information provided to Medi-Calbeneficiaries related to enrollment and ongoingprogram participation. The experience of Medicaidprograms in communicating to beneficiaries aboutthe enrollment process has pointed to enormouschallenges stemming from the complexity of thesystem, as well as the characteristics of the enrollees.Without at least a basic understanding of managedcare, the available health plan options, and howto navigate the system; Medicaid beneficiariescannot be expected to care about, understand,and use comparative quality informationregarding their health plan choices.2

Following is a list of items provided to eachMedi-Cal beneficiary at the time of enrollment:

■ Provider directories (printed either by theMedicaid enrollment broker or by the health plans)

■ Enrollment form

■ General information regarding Medi-Calmanaged care

■ County-specific information on Medi-Calmanaged care

■ Information on how to choose a health plan

■ List of enrollment broker presentations and locations

■ Phone numbers for each of the health plans in the beneficiary’s county of residence

■ Enrollment broker phone numbers (differ by language)

■ MER Form (medical exemption request)

■ Nonmedical exemption for Native Americanand other Medi-Cal waiver programs (AIDS,SNF (skilled nursing facilities), IHSS (in-homesupportive services), etc.)

■ Comparison of health plans (benefits, services,list of hospitals, prescription drug coverage, etc.)

■ Prepaid envelope to submit enrollment form

■ Prepaid postcard to request additional packets

■ Envelope with dental plan information

All of these items are currently loosely collated in enrollment packets that are county-specific,although a plan is being developed by HealthCare Options (HCO), the program name of theenrollment broker, to bind the packets with tear-out pages for forms that must be returned. Theenrollment broker currently under contract withDHS to manage the production and distributionof the enrollment materials is Maximus, a nationalconsulting firm with Medicaid enrollmentcontracts in several states.

A careful review of current Medi-Cal enrollmentmaterials will be critical to determine the informa-tion context in which the consumer quality guidewill be placed and the steps required to precluderedundant material. It will also be important toexplore strategies for assuring that the qualityguide is not only compatible and consistent, but does not get lost in the volume of materialalready disseminated to Medi-Cal beneficiaries.



ONE OF THE FIRST STEPS IN DESIGNING CONSUMERreporting materials is to understand the characteristics of thetarget audience. Three types of beneficiary characteristics need to be considered because they can affect the design of the material:

1. Physical characteristics, such as age, degree of visualimpairment, and degree of hearing impairment;

2. Demographic, behavioral, and cultural characteristics,such as education, ethnicity, language spoken, mediaexposure and preferences, access to technology, and abilityto use computers; and

3. Psychological characteristics, such as beliefs, attitudes,and values.

Of these, the characteristics that must be addressed with anytype of materials are literacy skills, language spoken, andcultural factors.3

Literacy Skills

Low literacy is a widespread problem in the United States. The average reading level is between eighth and ninth gradesfor adult Americans in general, and only fifth grade for thosein Medicaid programs.4 One analysis of the National AdultLiteracy Survey (NALS) results, looking at adults who hadreceived Aid to Families with Dependent Children (AFDC,now called TANF) or food stamps within the previous year,showed between one-third and one-half of welfare recipientsscoring at the lowest literacy levels, depending on the type ofliteracy being measured.5 These results have been validated overtime and in other studies of Medicaid beneficiaries. State-specific analysis of the NALS results indicate that 25 percent of adults in California operate at Level 1, the lowest literacylevel measured by the study. People at Level 1 literacy cannotperform such tasks as completing the information on a SocialSecurity application, finding an intersection on a map, orfiguring out if they are eligible for employee benefits.6

III. Medi-Cal Managed CareBeneficiary Characteristics

Language Spoken

Table 3 is compiled from 2001 data in the Medi-Cal County Data Book produced by the Medi-CalPolicy Institute. This book reports the five mostprevalent languages spoken in each county andthe percent of Medi-Cal enrollees in each countywho speak each language. In the 22 Medi-CalManaged Care counties examined, more than 44 percent of beneficiaries have a primary orpreferred language other than English. Lookingonly at languages that were prevalent enough to count in the top five languages spoken in each county, we identified 14 languages otherthan English.

Choosing languages for translation of theconsumer quality report requires balancing thenumber of enrollees who speak the language, the geographic prevalence of the language, andprogram resources for translation, printing, anddistribution. Spanish is identified as either thefirst or second most prevalent language in all 22 counties and over 35 percent of beneficiariesindicated Spanish is their primary or preferredlanguage. It is no surprise, therefore, that Spanishwas identified as a required language for thisproject — along with English. Vietnamese iscommon in 18 of 22 counties, though Vietna-mese is the primary spoken language of onlyabout 3 percent of beneficiaries. The geographicdispersion of Vietnamese would indicate that this should ultimately be included as a targetlanguage for translation of the materials.

There may be strategies that DHS can undertaketo stretch resources available for translation. Forexample, there is a large Armenian-speakingpopulation in Los Angeles County. Translatingonly the materials for Los Angeles County intoArmenian may be an efficient use of resources.Written materials in Chinese would be under-standable to both speakers of Mandarin andspeakers of Cantonese. The written language isthe same for both dialects; only the spokenlanguage differs. There may be other language

groupings where written materials would beunderstandable to speakers of differing dialects.

It is important to determine if any of the preferredlanguages lack a written tradition. Finding waysto report quality information to people whoselanguage is primarily spoken, and not written,would require tremendous creativity and may notbe achievable.


Table 3. Languages Spoken by Medi-Cal

Enrollees in 22 Medi-Cal Managed Care

Counties (2001)

Counties

LANGUAGE Reporting*

English 23 2,584,980 55.1%

Spanish 23 1,635,069 35.2

Vietnamese 18 125,344 2.7

Cantonese 5 47,412 1.0

Armenian 1 41,266 0.9

Russian 4 24,590 0.5

Hmong 5 22,902 0.5

Cambodian 7 10,053 0.2

Lao 8 4,911 0.1

Farsi 3 4,693 0.1

Arabic 2 3,459 0.1

Mandarin 1 2,165 � 0.1

Mien 2 1,159 � 0.1

Tagalog 5 896 � 0.1

Japanese 1 54 � 0.1

Other Non-English 8 11,573 0.2

Total† 4,508,953 96.95%

*Number of counties where this language was among the top five languagesspoken. †Total figures exclude “Other Non-English” data. Source: Medi-Cal County Data Book, Medi-Cal Policy Institute, January 2002.

Medical Enrollees

Number Percentage

Cultural Factors: Ethnicity

Ethnicity is really only a proxy or marker forseveral cultural factors that affect the attitudesand behaviors that the target audience will bringto the table when using a consumer-focusedhealth quality report. These factors include:

■ heritage and residence;

■ reasons for migration and associated economic factors;

■ educational status and occupation;

■ communication patterns;

■ view of temporal relationships;

■ family roles and social organization;

■ spirituality;

■ health care practices; and

■ health care practitioners.

Designers need to understand how these domainsof culture play out within the target audienceand use that information to create focused,culturally relevant reporting materials.7

Table 4 is compiled from county-specific data onthe five most prevalent ethnic groups in eachcounty and the percent of Medi-Cal enrollees in each ethnic group based on 2001 data in theMedi-Cal County Data Book. Approximately 91 percent of Medi-Cal beneficiaries in the targetarea belong to one of the three most frequentlyreported ethnic groups. Latinos, Caucasians, andAfrican Americans were among the top fivereported ethnic groups in each of the 22 counties.However, it is important to note that each ofthese groups may contain more than one distinctcultural group. For example, Caucasians includeRussians, Eastern Europeans, Persians, WesternEuropeans, and many others with distinctcultural characteristics. Further research is neededto determine the nature of these subgroups andthe degree to which report design needs toaddress their concerns if consumer quality reportsare to be accepted and effective at supportingdecision making.

Since the categories used to report ethnicity andlanguage spoken are not the same, it is notpossible to draw direct comparisons betweenTable 3 and Table 4. For example, people mightidentify themselves as either Chinese or Asian/Pacific Islander and report English, Cantonese, or Mandarin as their primary language. Even so,some preliminary inferences may be made fromthe data. For example, the relatively large numberof people identifying themselves as Filipino(17,072) and the relatively small number of peopleidentifying Tagalog as their primary language(896) would indicate that most Filipinos speakEnglish. Thus, there are likely to be a number ofintermediaries within the Filipino communitywho can assist those who speak only Tagalog inusing English reporting materials.


Table 4. Ethnicity of Medi-Cal Enrollees in 22

Medi-Cal Managed Care Counties, 2001

Counties

ETHNICITY Reporting*

Latino 22 2,249,689 48.4%

Caucasian 22 1,234.763 26.6

African American 22 732,108 15.7

Vietnamese 10 118,650 2.6

Laotian 6 48,575 1.0

Asian/Pacific Islander 8 32,560 0.7

Chinese 2 22,408 0.5

Filipino 11 17,072 0.4

Cambodian 6 14,373 0.3

Alaskan/Native American 3 1,366 � 1.0

Total 4,471,564 96.15%

*Number of counties where this ethnicity was among the top five ethnicgroups. Source: Medi-Cal County Data Book, Medi-Cal Policy Institute, January 2002.

Medical Enrollees

Number Percentage


CULTURE IS THE TOTALITY OF SOCIALLY TRANS-mitted behavioral patterns, arts, beliefs, values, and customs.8

Thus, it makes sense that materials intended to support decisionmaking are going to be most effective when they are designedin a way that is consistent with, and affirming of, the cultureof the target audience.

Producing effective reporting and decision-support materialsfor any audience involves a series of steps, including:

■ clearly defining the objective and the intended audience;

■ conducting research to learn about the audience, theirperspectives, their understanding of the objective, and their preferred means of communication;

■ developing and testing the materials with the targetaudience;

■ disseminating the materials;

■ assessing the effectiveness of the materials; and

■ using the results of evaluation and feedback from the targetaudience to improve the materials and distribution strategy.

In a multi-cultural environment, it is not always possible orfeasible to create a separate set of culturally appropriate materialsfor each cultural subgroup because of the extreme diversity ofthe target audience or because of limited resources or both. Inthese cases, there are a number of strategies that can be used toassure that materials developed are useful and appropriate for awide range of audiences.

Beliefs and Behaviors

Culturally driven beliefs and behaviors can affect the use andunderstanding of health care quality information. For example,immigrants to the United States from the former Soviet Unionoften bring with them a deep distrust of government. Thisaffects not only their willingness to participate in surveys andother data-collection efforts, but also the credibility andtrustworthiness they assign to health quality reports that aresponsored by government agencies. Members of cultural groupsthat value spiritual healing practices and use non-Westernmedicine may not understand or value the quality measurespresented in health care quality report cards.

IV. Addressing Cultural andLinguistic Diversity

Following are a few of the many ways sponsors ofhealth quality reports can address barriers presentedby culturally driven beliefs and behaviors andcreate opportunities for acceptance and use of the reports.

Be aware of our own attitudes, biases, andbeliefs. Our attitudes and beliefs, both about thetarget audience and the material presented, willcome through many times and in subtle ways inthe content, organization, and design of materials.Decisions about content organization and designshould reflect a sense of cultural awareness and afundamental respect for the target audience —whose experiences and attitudes may be differentfrom our own.

Look for commonality across cultures andacross audience segments. People from all cul-tures want to be affirmed and treated respectfully.Though they may define family differently, allcultures place a strong emphasis on protecting,nurturing, and caring for family. Commonelements like these can be used to craft keymessages that have broad appeal across cultures.

Involve community members in the design and development of materials. Methods forinvolving community members in the design ofmaterials can range from testing materials usinginterviews and focus groups to participatorydesign by an audience panel. In a participatorydesign process, the audience panel both givesadvice to the designers and is involved in makingdesign decisions and creating the material. Weintend to include community members in thisproject through in-depth interviews to test theinitial design of the materials. Additionally, wewill be engaging representative consumerorganizations that work on issues related todiverse populations.

Explicitly link the information in the materialsto the beliefs and behaviors of the targetaudience. For example, while Anglo-Americanvalues tend to emphasize individual decisionmaking and the nuclear family, in many othercultures extended family and community eldersplay a key role in decision making. To thisaudience, a key message within a decisionsupport document that says, “you may want toshare this booklet with the people you trust tohelp you make decisions,” may be viewed asreassuring and supportive, thus increasing theeffectiveness of the information.

Translation Issues

There are a number of issues related to translationof materials that can affect the use and under-standing of health care quality information.Literal translations may be awkward, misleading,or completely incomprehensible in the targetlanguage. If the translator lacks sufficient culturalknowledge of local language patterns and worduse by the target audience, the translation maystill miss the mark, or the translation might bedone in a style that is too formal or too casual forthe intended purpose. Translations may be doneat a reading level that is too difficult for theintended audience. These are probably the mostfrequently encountered barriers to effectivetranslation of materials.

To assure that translations are of high quality andresult in a document that is understandable anduseful to the target audience, designers shouldconsider the following suggestions.

Ensure an accurate translation. Use a transla-tion procedure that includes a quality controlcomponent such as committee translation orback translation. With committee translation,two or more bilingual individuals create separatetranslations, then meet to produce a final versionby reconciling their differences or by asking anoutside observer to choose the most appropriateoption. In back translation (or two-way


translation), one person translates the documentinto the target language and a separate individualtakes that version and “back translates” from thetarget language into the original language. Anydiscrepancies among the versions are thenreconciled to create a more accurate translation.The reconciliation process in both methods canhelp assure accurate translation of concepts fromone language to another.

Test the cultural appropriateness of thetranslation. The translation techniques describedabove are more likely to result in a translationthat is culturally appropriate. However, it is stillimportant to conduct cognitive testing of thematerials with the target population, using testerswho speak the target language fluently and arefamiliar with the target population. This canhighlight areas where language or concepts in the material are culturally inappropriate or notwell understood.

Present dual language formats. While it isappropriate in many circumstances to produceseparate documents, each in their own language,there are a number of advantages to creating adual-language format for documents such as aconsumer report on health plan quality for Medi-Cal beneficiaries. A dual language format allows asingle document to serve the needs of more thanone target population. Referring back to Table 3,a single Spanish-English report will meet theneeds of more than 90 percent of Medi-Calenrollees in the MMC counties included in thisproject. Also, readers in the target language whohave some proficiency in English can choose whichlanguage to read or check their understanding ofconcepts in both languages. Anecdotal evidenceindicates that a dual language format can deliverinformation more effectively in some situations,such as when an intermediary is assisting thebeneficiary or in families where older membersknow only the language of the home country,while the children may be more comfortablewith materials in English.9

Literacy Challenges

Understanding and using a health quality reportrequires three kinds of literacy skills: proseliteracy, document literacy, and quantitativeliteracy. Prose literacy is the ability to understandand use the information found in passages oftext. Document literacy is the ability to find anduse information in forms, tables, and schedules.Quantitative literacy is the ability to applyarithmetic skills, such as to balance a checkbook,calculate a tip on a restaurant bill, or interpretwhich plan performed better on a reportedmeasure of health quality. One study of Medicaidbeneficiaries in Arizona found that, on average,they were reading at the fourth grade level. Abouttwo-thirds of them were reading at less than aneighth grade level. In contrast, most health planliterature is written at a twelfth grade level.10

These literacy challenges are compounded inmulti-cultural populations. The opportunities for formal education, and the value placed oneducation, differs among cultural and ethnicgroups. While some emigrate to the UnitedStates with significant literacy and education intheir homeland, many emigrate from countrieswhere they may have had fewer than five years of formal education or from communities whereall education is informal and passed down bycommunity elders. Thus, even if materials aretranslated into the spoken language of the targetaudience, members of that audience may not beable to read them.

Some strategies that have been used to addresslow literacy for multi-cultural audiences include:

■ extensive use of pictures and illustrations tosupport the material in the text;

■ photo novels, which tell a story using photosof characters and dialogue in settings familiarto the target audience;

■ use of community liaison intermediaries todeliver information in person and verbally;


■ use of ethnic media by placing public serviceannouncements and participating in talkshows and panel discussions on ethnic radioand television programs; and

■ videotape.

Use of Decision Support

Clearly, integrating decision-support tools inquality information is easier to accomplish withan interactive Web site. However, it is possible tobuild some decision-support tools into printmaterials through worksheets, question-and-answer formats, data displays, and other toolsthat help people discriminate among decisionoptions. The ideal objective is to design materialsthat function as an intermediary would,sequencing information and the decision process,asking questions, organizing the respondent’sanswers, contextualizing those answers, thenlinking the information needed for decisionmaking to the contextualized answers.

This can be especially helpful when the targetaudience is unaccustomed to making the kinds of decisions that are required, for example, in aMedicaid enrollment process. One example ofthis approach is a report of CAHPS survey resultsfor Medicaid enrollees in Oklahoma. The materialscontain a series of questions and check boxesnext to the survey results throughout the reportencouraging the reader to evaluate which plandid better on that measure and if that measure isimportant to the reader. At the end of the reportis a worksheet that pulls together the reader’sanswers and contextualizes them in terms ofmaking a health plan decision. Another exampleis a packet of materials designed for Medicarebeneficiaries in New York City who are consideringjoining a Medicare HMO. These materials werecreated by the Baruch College School of PublicAffairs. They combine benefit and cost informa-tion with quality information in worksheets thatenrollees can use as they go through the processof evaluating and choosing a plan.

Information IntermediariesMany of the language, cultural, and literacychallenges that have been identified as obstaclesto reaching the population of Medi-Cal benefi-ciaries can be potentially addressed through theuse of information intermediaries. Empiricalresearch and experience clearly demonstrate thatconsumers with limited reading skills and fromnon-English speaking cultural backgrounds oftenneed assistance, from a known and trusted source,in obtaining, understanding, and using informa-tion regarding their health care options.11 Providingsuch assistance through in-person interactionswith individuals associated with trusted interme-diary organizations can help assure that theinformation is tailored to the specific needs andcircumstances of the individual being helped.

One of the most promising ways to provide thispersonal assistance is through the engagement ofcommunity organizations with strong ties to thetarget population.12 Community organizations areusually staffed by the residents of the communityand are familiar with the language and culture of the intended audience. Examples of suchorganizations include health clinics, social serviceorganizations, faith institutions, and educationalorganizations. Adult learning centers, whichteach basic reading and writing skills and Englishas a Second Language classes, can provide anespecially powerful vehicle for communicatingcomplex information on health care quality.Adult education courses usually span severalweeks and enroll individuals who are the type of early adopters that most health interventionstrategies aim to reach: motivated individualsseeking new information who are capable ofcommunicating what they learn back to theircommunity.13

While many community groups are ideallypositioned to function as informationintermediaries, few are prepared to assume thisrole without significant training and assistancethemselves. In New York City, the Managed Care


Consumer Assistance Program (MCCAP) of theCommunity Service Society of New York hasbeen working to build capacity and disseminatehealth information to minority communitiesthrough a network of 22 community-basedorganizations (CBOs). These CBOs range inmission from soup kitchens to legal aid groups,but all have in common a strong local presenceand connection with the community membersthey serve. MCCAP trains each agency to provideinformation on health insurance and providers,and to help individuals understand their choicesand make health care decisions. The CBOs offerworkshops to their clients with the use of slideshows and flip charts, disseminate print materials,and provide one-on-one counseling services. Oneof the key lessons to emerge from the MCCAP is that “tailoring the messages, the messengers,and the outreach to meet the needs of each of the communities it targets has been the key to its success.”14

In California, the California HealthCare Foundation(CHCF) has initiated a grant program with eightcommunity organizations to build capacityamong groups that are strategically placed toeducate and empower consumers on health carequality issues. Some of these groups are logicalcandidates to help disseminate the Medi-Calconsumer quality guide.

The following are several issues to consider inexploring the use of intermediaries for thisproject:

■ Which community organizations in Californiaare well positioned to serve as potentialinformation intermediaries for disseminationof the Medi-Cal consumer quality guide?

■ What training and assistance will be requiredto support these groups?

■ How do they relate to DHS and to the Medi-Cal county-level program offices thatadminister Medi-Cal enrollment and benefits?



HEDIS and CAHPS Data

The two major sources of performance measurement data thathave been proposed for use in the consumer guide are theHEDIS and CAHPS data sets collected and published annuallyby the DHS Medi-Cal Managed Care Division. Both data setshave been compiled by an external quality review organization(EQRO), and are published in print and electronic formats.Data are now available for 1999, 2000, and 2001. Data for2002 are expected to be available for inclusion in the consumerguide in September of 2003.

The DHS Accountability Set is a set of audited HEDISmeasures selected to emphasize the areas of maternity care,pediatric care, and chronic illness. The measures include:

■ childhood immunization;

■ asthma medication management;

■ prenatal and postpartum care (timeliness of prenatal care and postpartum care);

■ well-child visits in the first 15 months of life;

■ well-child visits in the third, fourth, fifth, and sixth year of life;

■ adolescent well-care visits;

■ eye exams for people with diabetes.

The CAHPS 2.0H survey is collected for both the adult andchild populations enrolled in Medi-Cal managed care plans.Measures available for reporting from these surveys includefour global ratings and five composite measures:

CAHPS Global Ratings CAHPS Composites

• Personal doctor • Getting needed care

• Specialist • Getting care quickly

• Health plan • Doctors who communicate well

• Health care • Courteous and helpful office staff

• Customer service

V. Sources and Content ofQuality Measures

HEDIS and CAHPS data are the most commonlycollected and reported data in consumer qualityreports. Advantages of using these data sourcesinclude their standardization and consistency ofcollection and reporting. Both data sets havebeen rigorously developed and tested for reliabilityand validity. National comparisons are availablefor benchmarking through several sources,including the National CAHPS BenchmarkingDatabase (NCBD) for CAHPS data and theNational Committee for Quality Assurance(NCQA) Quality Compass for HEDIS data.

Potential drawbacks to using HEDIS data includetheir questionable relevance for the intendedaudience. HEDIS measures were originallyintended for reporting to employers and otherpurchasers for managed care plan monitoringand contracting purposes. They are complex anddifficult to understand because they pertain topopulations of enrollees and usually describe ratesof preventive services that may not be directlyrelevant to some consumers.

CAHPS, on the other hand, was developedexpressly for the purpose of informing consumersabout the quality of managed care plans from theperspective of the enrollee. The content of theCAHPS survey data is designed to relate directlyto issues of concern to many consumers, such asgetting access to care, waiting times for appoint-ments, communication skills of providers, andcustomer service of the plan. These issues arelikely to be more salient to Medi-Cal beneficiariesbecause they may help answer the questions ofgreatest importance to them.

Other Plan-Level Performance Data

Given the relatively extensive public reporting ofhealth plan performance data in California, it maybe useful to consider the possibility of includingadditional measures of potential relevance to theMedi-Cal population in the consumer guide.Such additional measures might include:

HMO services in other languages. The healthplan performance report recently published bythe Office of Patient Advocate (OPA) includes a section on interpreter services and writtenmaterials provided by Medi-Cal managed careplans in other languages.

EQRO focused studies. Any focused QI studiesconducted by Medi-Cal plans in compliancewith state and/or federal requirements, such aslead screening, asthma management, etc.

Retention rates. Data pertaining to rates ofbeneficiary retention and/or disenrollment mightbe of interest as an indicator of consumer satis-faction. However, given the generally high ratesof turnover in Medicaid enrollment, it may bedifficult to disentangle factors influencing rates ofretention that are attributable to the health planas opposed to circumstances of the beneficiarypopulation outside the control of the plan.

Complaints and grievances. Another potentialindicator of health plan performance is the rateof consumer complaints and/or grievancesbrought against the plan, if systematic and accuraterecords are maintained either at the state orhealth plan level.


Provider-Level DataNumerous studies have documented that thequality information most important to consumerspertains to choice of individual doctors andhospitals, not health plans. Given the number of counties “without plan choice” for Medi-Calbeneficiaries, it may be helpful to include someprovider-level quality measures in future iterationsof the consumer guide, even in counties withmultiple choice of plans.

A number of provider-level reporting initiativesare underway in California that may offerpotential data for inclusion in the consumerguide:

Medical group survey measures. TheHealthScope Web site (www.healthscope.org)maintained by the Pacific Business Group onHealth (PBGH) includes selected quality measuresfor over 50 medical groups in the state. Thesequality measures include results from the 2001California Consumer Assessment Survey (CAS).These measures are based on patient-reportedexperiences of care and service for adults (18 yearsand older) who were commercially insured managedcare members or Medicare-risk contract seniors.Medical groups that predominantly serve Medi-Cal members were not included.

Hospital survey measures. The CHCF-sponsored PEP-C project has been collecting andreporting inpatient survey data on a statewide,voluntary basis for more than two years. Whilethese measures are based on all admissions(including Medi-Cal), just over half of allhospitals are participating in the program. In addition, HealthScope includes qualityinformation on hospitals from those organiza-tions that have volunteered to share other data,such as Leapfrog data. Therefore, as with thePEP-C program, data are not available for allhospitals throughout the state.

Other hospital-specific indicators. The Office of Statewide Health Planning and Development(OSHPD) has several condition-specific measure-ment and reporting initiatives underway at thehospital level. These include risk-adjustedmortality rates for acute myocardial infarction(AMI) and coronary artery bypass graft (CABG)procedures. In the near future, OSHPD will bereporting mortality rates for pneumonia, selectedbirth outcomes, and hip fracture outcomes. Forall measures, data are collected for all hospitalsand for all admissions and could be analyzed forMedi-Cal patients only compared to otherpatient groups.

With the exception of the OSHPD data (whichare mandated by the state for all patients), theseprovider-level measures are submitted on avoluntary basis and do not specifically includeMedi-Cal enrollees. These sources therefore maynot be suitable for reporting to Medi-Cal benefi-ciaries. In the future, if these measures includeMedi-Cal members and they become requiredrather than voluntary, they could be an importantaddition to a Medi-Cal performance report.



A NUMBER OF ISSUES NEED TO BE ADDRESSEDwith respect to the distribution strategy for the consumerguide. As noted earlier, a key consideration is the geographiclevel to be used in developing the report content. A county-specific approach to presenting health plan quality comparisonsimplies a county-specific distribution strategy. A regional- orstate-level reporting strategy may have other implications fordissemination. Other distribution issues are described below.

Report Design

It is a given that the report will be produced at least as a printdocument. However, the specific design of the report will alsoinfluence its dissemination. For example, in New York State abi-folded 8.5" � 11" consumer guide for Medicaid beneficiarieswas replaced with a tri-fold version after it was determined thatthe bi-fold version could not be inserted into a standard numberten size envelope for mail distribution. Size is one of manydesign factors that will influence distribution.

Relationship to Enrollment Materials

As mentioned in the earlier section on current beneficiaryenrollment information, one possible distribution method is to include the consumer quality guide with existing enrollmentmaterials. As noted previously, there are both advantages anddisadvantages to such an integration strategy. Opportunities forleveraging the current enrollment materials and process (suchas presentations or orientation meetings facilitated by HealthCare Options) will need to be explored with project sponsorsand the enrollment broker, Maximus.

Web Version of the Report

In addition to a print report, the consumer guide might alsobe made available on one or more Web sites (e.g., CHCFand/or DHS), with links supplied through the sites of otherorganizations (state agencies, community organizations, etc.).Technically, creating a Web version of the report would likelybe straightforward, although not all document designs areeasily transferable to a Web-based format. A far more practicalissue, however, is the extent to which Medi-Cal beneficiaries

VI. Distribution Issues

have access to the Web at all, or how such accessmight be facilitated through use of public institu-tions such as libraries or other county agencies,including Medi-Cal offices. In addition, literacylevels represent a significant issue for Web-basedmaterials, since navigation and comprehensioncan be complex and require substantial short-term memory capacity. Thus, even if accessbarriers could be overcome, it is not clear at allthat a Web-based report is the most effectivemedium for reaching this audience.

Use of Intermediaries

Issues related to intermediaries have been addressedin the section on cultural and linguistic diversity.We remain convinced that effective use of inter-mediary organizations will be a critical determinantof the success of the consumer guide.

Timing

In many instances, timing of report distributionis a critical factor, since the need to use the infor-mation for decision making is tied to a specifictimeframe. For example, open enrollmentmaterials for employed groups need to be producedand disseminated to coincide with the openenrollment season. Given the enrollment processfor Medi-Cal managed care, it is not clear thatthere is a specific enrollment-based timeframethat would drive the timing of the consumerguide distribution. There may be other factors,however, that need to be considered with respectto timing of distribution.

General Education and Promotion

In addition to the report itself, generating aclimate of awareness and understanding of whatthe guide is for and how it can be used can be animportant element of the overall distributionstrategy. Many consumer information projectshave incorporated a series of “marketing” steps in advance of releasing a report, in order to buildanticipation and a receptive audience. Someprojects have also conducted advance trainingworkshops, using mock-up versions of the guide,in order to train users directly or to “train thetrainers” (e.g., intermediary organizations) thatwill be working with the end users.

In summary, an effective distribution strategyneeds to be considered simultaneously with thedevelopment of the guide, since one will influencethe other.



THIS PAPER HAS OUTLINED A RANGE OF ISSUESthat must be considered carefully in the design and distributionof the Medi-Cal consumer guide on managed care quality.These issues include the current information and decisionmaking context for Medi-Cal managed care beneficiaries, keycharacteristics of the beneficiary population (such as literacyskills, languages spoken, and cultural factors), the source andcontent of available quality measures, and the distributionmechanisms available for disseminating the guide.

We will continue to explore these issues with the projectsponsors and stakeholder members of the Advisory Groupcreated for this project, including representatives of Californiaconsumer organizations, health plans, purchasers, and stateagencies. Invariably, new issues and challenges will emerge,along with new opportunities, that will affect the final consumerguide design and distribution strategy. We hope that theinformation and insights presented in this background paperwill provide the foundation needed for developing a consumerguide that will be meaningful and useful for Medi-Calmanaged care beneficiaries.

VII. Conclusion

Although many states collect performanceinformation on Medicaid managed care plansand produce reports comparing contracted plans,relatively few states create report cards specificallytargeted to Medicaid enrollees. To determine the“state of Medicaid managed care report cards” theproject team surveyed state Medicaid programs as to their reporting of performance informationto consumers.15 Our activity followed on theheels of the Community Health Council’s (CHC)Medi-Cal managed care quality initiative projectconducted in 2002, in which CHC surveyed ten states with the highest number of Medicaidmanaged care enrollees about their production of consumer report cards. Our survey targeted allstate Medicaid programs and focused exclusivelyon report cards created for the Medicaid benefi-ciary population. Of all of the states, we wereable to interview representatives of 30 Medicaidprograms. A summary of our findings to date ispresented below. We have also collected copies ofthe print reports produced by each state.

Which States Produce Consumer

Report Cards for Medicaid Enrollees?

Our survey has found that while many statescollect and report Medicaid performance informa-tion from health plans, only a few states producereport cards specifically targeting Medicaidenrollees. Other states produce comprehensivereport cards for a broader audience of managedcare enrollees. For example, Florida produces a60-page consumer report that includes informa-tion for commercial, Medicaid, and MedicareHMOs, and Utah produces two separate perform-ance reports that contain performance data forcommercial and Medicaid HMOs.

The 12 states we interviewed that produceconsumer report cards specifically for Medicaidenrollees are:

■ Colorado ■ Ohio

■ Iowa ■ Oklahoma

■ Massachusetts ■ Oregon

■ Michigan ■ Pennsylvania

■ New Mexico ■ Washington

■ New York ■ Wisconsin

What Information Is Included in Report

Cards for the Medicaid Population?

States that have produced report cards targeted toMedicaid beneficiaries have generally includedboth general information and plan performanceinformation.

General InformationGeneral information presented in consumerreport cards includes Medicaid program contactinformation, health plan contact information,information about managed care and choosing a health plan or a primary care physician (PCP),information about the plan’s network of contractedhospitals, pharmacies, and areas served, as well asinformation about additional benefits plans mayoffer. The following table shows the prevalence ofthese categories of information among the statereport cards collected.


Appendix: Summary of Medicaid Consumer ReportingActivities in Other States


Table A-1. Type of Information Included in Medicaid Consumer Report Cards

T Y P E O F I N F O R M AT I O N CO IA MA MI NM NY OH OK OR PA WA WA

Medicaid Contact ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Plan Contact ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Managed Care Information ✔ ✔ ✔ ✔

Contracted Hospitals ✔ ✔

Locations Served ✔ ✔ ✔ ✔ ✔ ✔ ✔

Covered Benefits ✔ ✔ ✔

Choosing a PCP ✔

Additional Benefits ✔ ✔

Contracted Pharmacies ✔

Transportation ✔

Frequently Asked Questions ✔

Mental Health Services ✔ ✔

IA MI NY OK PA WI

Table A-2. Types of Performance Indicators Included in Medicaid Consumer Report Cards

PERFORMANCE INDICATORS CO IA MA MI NM NY OH OK OR PA WA WA

HEDIS ✔ ✔ ✔ ✔ ✔ ✔ ✔

CAHPS ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Accreditation ✔

State-Defined Measures/Focused Studies ✔ * ✔ ✔ † ✔ ‡ ✔ §

* Includes prenatal care, cultural competency survey, and disability awareness survey.

† Includes lead screening.

‡ Includes language problems, satisfaction with dental care, Hepatitis B testing for pregnant women, finding cervical cancer in women with HIV, emergencyroom visits for asthma, and annual dental visit for members with developmental disabilities.

§ Includes blood lead screening and mental health and drug abuse evaluations.

IA MI NY OK PA WI

Performance InformationStates have included a variety of types of healthplan performance information in their consumerreport cards for the Medicaid population. Exam-ples of the types of performance informationinclude HEDIS results, CAHPS results, accredi-tation outcomes, and state-defined measures

collected as part of the state’s Medicaid qualityassurance system. The Table A-2 presents thetypes of performance information included in the Medicaid consumer report cards collected to date.

How Are Report Cards Formatted

for Medicaid Enrollees?

General AppearanceStates have presented the information in consumerreport cards in a variety of ways. In general, thereport cards are relatively short when comparedto other performance reports. In addition, moststates chose to use symbols to highlight differ-ences in performance and use three or fourcategories to distinguish levels of performance.The general appearance of the consumer reportcards collected is presented in Table A-3.

A brief description of the appearance of eachreport card follows:

Colorado. Four pages formatted for half pagesthat fold out; general information on the firsttwo pages, with performance table and explana-tory information in the fold-out pages, focusedstudy information on another fold, and a blankback cover.

Iowa. Two 10" � 13" pages folded twice; frontcover, two pages of plan service area information,full page fold-out with performance information,and back page with general Medicaid information.

Massachusetts. Twelve-page booklet on 7" � 8.5"pages; front cover follwed by two pages of pictures,two pages of information on using the booklet,six pages of performance information, and a back cover.

Michigan. Four pages; front and back coverswith a two-page table in the middle displayingthe performance information.

New Mexico. Twelve-page booklet on 7" � 8.5"pages; front cover, one page of general information,seven pages of performance information, andthree pages of general information.

New York. Four pages; tri-fold brochure formatfor the front and back covers with a two-pagetable in the middle displaying the performanceinformation.

Ohio. Four pages folded in half; front and backcovers with general information, middle pageswith additional general information, and the lasthalf page displaying performance information.

Oklahoma. Fifteen pages; front cover withgeneral information, two pages of how to use thereport, eight pages of performance informationand a worksheet, one page of how to make adecision, and three pages of general information.


Table A-3. General Appearance Features of Medicaid Consumer Report Cards

F E A T U R E S CO IA MA MI NM NY OH OK OR PA WA WA

LengthNo. of Pages 4 2 12 4 12 4 4 15 1 6 1 1Page Size* 10"�13" 7"�8.5" 7"�8.5"

Symbols Circles Colored None Stars None Stars Stars None Stars Circles Stars StarsSquares

RangeLowest Worse Below Actual Below Actual Below Low Actual � 55th Below Below Below

Average Result Average Result Average Result Percentile Average Average Average

Mid-range Same Average Average Average NA 55–69th Average Average AveragePercentile

70–84th Percentile

Highest Better Better Above Above High 85–100th Above Better AboveAverage Average Percentile Average† Average

*Page size is 8.5"�11" unless otherwise noted. †Benchmark was used in Pennsylvania.

IA MI NY OK PA WI

Oregon. One-page comparison chart thatincludes general information at the top andCAHPS performance information at the bottom.

Pennsylvania. Six pages that fold into one page;front and back covers, with a fold-out page forexplanation and three-page table in the middledisplaying the performance information.

Washington. One page per plan with no folds;the page includes general plan information at the top and CAHPS performance information at the bottom.

Wisconsin. One page, with general informationat the top followed by a table of performanceinformation.

Data Displays States face many decisions regarding how todisplay the performance data contained in thereport cards. Among them are:

Measure-specific results vs. “roll-ups.” One ofthe first decisions is whether to display measure-specific results, or “roll-ups,” which group multiplemeasure results into one composite indicator. Of the report cards collected, all but Michiganpresented measure-level results. New York alsoincluded one “overall rating” that summarized all of the results. Michigan pursued a differentapproach: Results were presented at thecategorical level only.

Comparative data. Another data display issue iscomparison data: Should the data include bench-mark or comparative data, and what sourcesshould be used for comparison? Of the reportcards collected, most used a comparison to thegroup average; only one used a regional averageinstead. In addition, one state also included anational benchmark which they defined asmeeting or exceeding the 75th percentile ofMedicaid plans nationally.

Categories/groupings. Several organizations havedeveloped frameworks for presenting performanceinformation to consumers. The Foundation forAccountability (FACCT) has developed aConsumer Information Framework that includesthe following five categories of measures: TheBasics, Staying Healthy, Getting Better, Livingwith Illness, and Changing Needs. The frameworkused by the National Committee for QualityAssurance (NCQA) for consumer reportingincludes the categories of Access and Service,Qualified Providers, Staying Healthy, GettingBetter, and Living with Illness. Despite thesimilarity of some of the categories, the twoorganizations define them differently. Interestingly,the Medicaid consumer report cards display avariety of groupings for the presented data, andnone of them include all of the categories advo-cated by either FACCT or NCQA. The categoriesused for the Medicaid report cards collected todate are displayed in Table A-5.


Table A-4. Data Display Features of Medicaid Consumer Report Cards

F E A T U R E S CO IA MA MI NM NY OH OK OR PA WA WA

Roll-up ✔ ✔ *

Measure-specific ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Total Number of Measures 15 5 10 5 6 14 5 8 5 28 5 9

Comparison Group Group None Group None Regional Group None Group Group Group GroupAverage Average Average Average Average Average Average† Average Average

*One overall rating. †National Benchmark was also used in Pennsylvania.

IA MI NY OK PA WI

Table A-5. Information Frameworks Used in

Medicaid Consumer Report Cards

S T A T E Categories

CO • Access and service• Staying healthy• Care for kids• Focused study results

IA • CAHPS composites

OH • Overall satisfaction with MCP• Overall rating of health care• Easy to find personal doctor• Easy to get referral to specialist• Plan’s customer service

OK • CAHPS composites and global ratings

OR • CAHPS composites

MA • What members say• Care to keep you healthy

MI • Getting care• Keeping kids healthy• Taking care of women• Living with illness• Accreditation

NM None

NY • Quality of care to children• Quality of care to adults• Patient satisfaction• Overall rating

PA • Quality of care• Access to care and service• Care for those with special needs

WA • CAHPS Composites

WI • HMO reported health care• Consumer satisfaction with the HMO

How Are the Report Cards Distributed

to Medicaid Enrollees?

States face many options regarding the distribu-tion of consumer report cards to Medicaidenrollees. All of the states that produced reportcards released printed versions, and most alsomade them available via a Web site. States alsomade the report cards available in a variety oflanguages, depending on demand within theirstate or region. Regarding multiple versions ofthe report cards, some states produced one reportcard for the state; other states produced regionalversions, depending on available plan choices;and two states produced one report per plan.


How Are the Report Cards Evaluated?

Because consumer report cards are relativelyrecent additions to states’ Medicaid programs,evaluation strategies for the report cards are rare.However, we were able to discuss the state ofNew York’s activities to evaluate their reportcard’s effectiveness. Initially, they distributed anevaluation postcard survey of five questionsrelating to the comprehensiveness and usefulnessof the guide. The postcard was included in theenvelope with the 1998-2000 versions of theguide. Because the response rate was quite low(3.4 percent), the state opted to hold focusgroups to obtain additional information from the intended audience. After holding four focusgroups of six to nine participants and 20 in-depth interviews, the New York Department of Health (DOH) learned the following abouttheir guide:

■ Overall, participants responded favorably to the guide.

■ Participants found the listing of counties inwhich each plan is available very helpful.

■ Participants preferred star symbols over filled circles.

■ Participants liked the overall rating, whichprovided a visual and numeric summary of the information.

■ The symbol for “too few members” and theplacement of the definition beneath the starratings in the key was often misinterpreted.

■ Participants wanted to know the source of the information.

This important feedback from Medicaidrecipients led the DOH to make several changesto the guide and to develop a training manual to educate county-level social services about thepurpose of the guide and how to use it withMedicaid enrollees.


Table A-6. Distribution Methods Used in Medicaid Consumer Report Cards

DISTRIBUTION CO IA MA MI NM NY OH OK OR PA WA WA

Print Report ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Web Site ✔ ✔ ✔ ✔ ✔ ✔

Languages* Spanish None Unknown None Spanish Spanish Spanish Spanish Spanish Spanish Spanish None

NYC- Russian

Chinese Korean

Russian Chinese

Vietnamese

Laotian

Cambodian

Versions State-wide State-wide State-wide State-wide State-wide Regional County Service One/Plan Regional One/Plan State-wide

Region

Included in Enrollment Packets ✔ Unknown ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Available in Medicaid Offices, Community-based Organizations, etc. ✔ ✔ Unknown ✔ ✔ ✔ Unknown ✔ ✔ ✔ ✔

*In addition to English.

IA MI NY OK PA WI

Citations of State Medicaid Managed

Care Performance Reports Reviewed:

■ A Comparison of Iowa’s Medicaid Health Plans.Iowa Department of Human Services, 2001.

■ A Consumer’s Guide to Choosing a ManagedCare Plan in Lorain County: 2002 MedicaidConsumer Guide. Ohio Department of Jobsand Family Services, 2002.

■ A Consumer’s Guide to Medicaid Managed Carein New York City. New York State HealthDepartment, 2001.

■ Compare Your Choices: A Consumer’s Guide tothe HealthChoices Southeast and SouthwestHealth Plans. Office of Medical AssistancePrograms, Commonwealth of Pennsylvania,Department of Public Welfare, 2001.

■ HealthColorado: Your Medicaid Choice.HealthColorado, 2001.

■ MassHealth: The Health Plan PerformanceReport. MassHealth, 1998.

■ Oregon Health Plan Comparison Chart:Multnomah County. Oregon Office of MedicalAssistance Programs, 2002.

■ Quality Checkup: A Guide to MichiganMedicaid Health Plans. Michigan Departmentof Community Health, February 2002.

■ Regence Blue Shield Information Sheet.Washington State Department of Social andHealth Services, June 2002.

■ Salud! Which Healthcare Plan is Right for Me?Medicaid Managed Care of New Mexico, 2001.

■ SoonerCare Plus Report Card. OklahomaHealth Care Authority, 2001.

■ Wisconsin Medicaid HMO Report Card, 2001.


1. Medi-Cal Policy Institute, Medi-Cal CountyDatabase Book (January 2002).

2. S. Kaplan, J. Greene, C. Molnar, A. Bernstein, andS. Ghanbarpour, “Educating Medicaid BeneficiariesAbout Managed Care: Approaches in 13 Cities,”Publication No. 380, The Commonwealth Fund(May 2000).

3. J. McGee, Writing and Designing Print Materials forBeneficiaries: A Guide for State Medicaid Agencies,available from the Centers for Medicare & MedicaidServices, Baltimore, MD, HCFA Publication No.10145 (October 1999). For information on orderingthe guide, contact McGee & Evers Consulting, Inc.at 360-574-4744.

4. National Work Group on Literacy and Health,“Communicating with Patients Who HaveLimited Literacy Skills,” The Journal of FamilyPractice 46(2) February (1998): 168–175.

5. Paul E. Barton and Lynn Jenkins, Literacy andDependency: The Literacy Skills of Welfare Recipientsin the United States (Princeton, N.J.: EducationalTesting Service, 1995).

6. A. B. Rodgers, Making Quality Count: HelpingConsumers Make Better Health Care Choices,Conference Summary, sponsored by the HealthCare Financing Administration (now CMS)(February 1999).

7. L. D. Purnell and B. J. Paulanka, TransculturalHealth Care: A Culturally Competent Approach(Philadelphia, Penn.: F. A. Davis Co., 1998).

8. Ibid.

9. McGee, Writing and Designing Print Materials for Beneficiaries.

10. Rodgers, Making Quality Count.

11. Shoshanna Sofaer, “A Classification Scheme ofIndividuals and Agencies Who Serve as InformationIntermediaries for the People on Medicare,” unpub-lished paper prepared for the Centers for Medicareand Medicaid Services (May 15, 2000).

12. Christine Molnar, “Reporting Health Care Qualityto Minority Populations: Issues and Challenges,”in Improving Health Care Quality for MinorityPatients (Washington, D.C.: National QualityForum, 2002).

13. Ibid.

14. Ibid.

15. Community Health Councils, Inc., “InformingConsumers: A Link to Quality Improvement.”Issue Brief 1 (Summer 2002).

Endnotes


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