Review of Findings from Original Telephone Survey Evaluation of 'What Are My Medi-Cal Choices?' Guidebook
In the spring of 2008, HRA researchers telephoned Medi-Cal beneficiaries to gauge the effectiveness of a guidebook designed to explain options for receiving Medi-Cal benefits, including Medi-Cal Managed Care. Highlights of the study findings included:
- 77% of participants who received a guidebook reported reading it.
- Of participants who read the guidebook:
- 98% found the information in the guidebook useful.
- 83% found the guidebook easy to understand.
- 67% learned something new about their Medi-Cal choices from the guidebook.
- At the follow-up interview, both the intervention group (who received the guidebook) and the comparison group (who did not receive the guidebook) had gained knowledge, but the group that received the guidebook showed a significantly greater increase in knowledge than did the comparison group.
- Those who received the guidebook had increased positive attitudes toward Medi-Cal Managed Care (MMC) compared with baseline.
- Those who got the guidebook were more likely than those who didn’t to say they were likely to switch to MMC.
- Those who got the guidebook improved their confidence about making Medi-Cal choices significantly after receiving the guidebook.
- The most common change reported by participants who received the guidebook was an increased sense of empowerment regarding making decisions about their Medi-Cal benefits.
Three-County Pilot Dissemination Analyses
The guidebook was disseminated by mail to Medi-Cal beneficiaries who were seniors or people with disabilities (SPD) in the three pilot counties (Alameda, Riverside, and Sacramento) between May 16 and May 27, 2008. Maximus produced a dataset that included variables on the type of Medi-Cal (fee-for-service [FFS] or managed care [MMC]) that SPD beneficiaries in 14 managed care counties had at two points in time: May 15 (before the mailed guidebook dissemination) and December 15 (approximately 6 months after the guidebook dissemination was completed). The purpose of the analysis was to compare whether beneficiaries in the pilot counties who received the guidebook were more or less likely to change their type of Medi-Cal within 6 months of receiving the guidebook as compared to beneficiaries in the other 11 managed care counties who had not received a guidebook. Our main outcome variable was a change in the type of Medi-Cal between May and December (e.g., FFS to MMC or MMC to FFS). (Beneficiaries in the other 11 managed care counties may have received a copy of the Health Care Options Manual that is distributed to each beneficiary yearly. In addition to this, there may have been other influences that could impact change in type of Medi-Cal in specific pilot or comparison counties for which we could not control.)
For the pilot dissemination, guidebooks were mailed to SPD beneficiaries who lived in the three pilot counties, who had a language code of English, Spanish, Cantonese, Mandarin, or “not valid,” and who had Medi-Cal only (excluding those who had Medicare). The data we analyzed for the evaluation of the pilot dissemination differed slightly from the actual dissemination in that the dataset included only beneficiaries with English, Spanish, Cantonese, or Mandarin language codes. Our analysis did not include beneficiaries with the language code “not valid” because it was not possible for Maximus to retrieve data for those beneficiaries. While this difference from the mailing list may affect the findings slightly, we do not think they significantly biased the results.
We also excluded from our analyses beneficiaries who:
- Did not have data on type of Medi-Cal for May OR for December;
- Moved to a different county between May and December; and/or
- Lived out of state or did not have a county listed during May or December.
A total of 525,508 beneficiaries were included in the analyses (n=93,254 in the 3 intervention counties; n=432,254 in the other 11 managed care counties).
Overall Findings
Percent of beneficiaries who changed type of Medi-Cal by county group
| Change in type of Medi-Cal |
Comparison Counties |
Pilot counties |
Relative rate of change** |
|
Any change in (from FFS to MMC or MMC to FFS)
|
3.6% |
4.9% |
1.4* |
| Changed FFS to MMC |
1.8% |
3.2% |
1.8* |
| Changed MMC to FFS |
11.5% |
10.5% |
0.9* |
*Statistically significant difference
**Relative rate of change is the rate of change in pilot counties compared to that in comparison counties (Pilot counties rate of change/comparison counties rate of change)
- There was more change in type of Medi-Cal in pilot counties than in comparison counties.
- Beneficiaries on FFS were significantly more likely to change to MMC in pilot counties than in comparison counties (80% higher in pilot counties).
- The effect of being in a pilot county was that an extra 994 beneficiaries changed from FFS to MMC (1.4% of 71,050).
- Beneficiaries on MMC were significantly less likely to change back to FFS in pilot counties than in comparison counties (10% less than the rate in comparison counties).
- The effect of being in a pilot county was that 222 fewer beneficiaries changed from MMC back to FFS (1.3% of 22,204).
Comparing Between Languages
Percent of beneficiaries who changed from FFS to MMC by language and county
| Language |
Comparison counties |
Pilot counties |
Relative rate of change** |
| English |
1.8% |
3.2% |
1.8* |
| Spanish |
1.9% |
3.4% |
1.8* |
| Chinese*** |
1.0% |
3.4% |
3.4* |
*Statistically significant difference between comparison and pilot counties
**Relative rate of change is the rate of change in pilot counties compared to that in comparison counties (pilot counties rate of change/comparison counties rate of change).
***Beneficiaries with Cantonese and Mandarin language codes were combined into one “Chinese” category.
- In all three languages there were significantly higher rates of change from FFS to MMC in the pilot counties than in comparison counties.
- The effect of being in a pilot county was similar between English and Spanish speakers (80% higher in pilot counties).
- The effect of being in a pilot county was greater among Chinese speakers compared with both English and Spanish speakers (240% higher in pilot counties among Chinese speakers) (statistically significant).
Percent of beneficiaries who changed from MMC to FFS by language and county
| Language |
Comparison counties |
Pilot counties |
Relative rate of change** |
| English |
11.6%
|
10.3% |
0.9* |
| Spanish |
10.6% |
11.8% |
1.1 |
| Chinese*** |
14.3% |
11.7% |
0.8 |
*Statistically significant difference between comparison and pilot counties
**Relative rate of change is the rate of change in pilot counties compared to that in comparison counties (pilot counties rate of change/comparison counties rate of change).
***Beneficiaries with Cantonese and Mandarin language codes were combined into one “Chinese” category.
- Among English speakers, there was a significantly lower rate of change from MMC back to FFS in the pilot counties (10% less than the rate of change in the comparison counties).
- Among Chinese speakers, there was also a lower rate of change from MMC back to FFS in the pilot counties (20% less than the rate of change in the comparison counties), although this was not statistically significant. The number of Chinese speakers enrolled in MMC in all 14 counties was very small (n=1,389) which could make a small but significant difference harder to detect.
- Among Spanish speakers, though there was a slightly higher rate of change from MMC back to FFS among Spanish speakers in the pilot counties (10% more than the rate of change in the comparison counties), this difference was not statistically significant. Since the sample size is adequate to detect a significant difference, this represents a finding of no difference across the counties for Spanish speakers.
MAP 6 Month Analyses: Telephone Survey Participant Analyses
We received data from Maximus on the type of Medi-Cal (fee-for-service [FFS] or managed care [MMC]) that SPD beneficiaries who lived in one of the three pilot dissemination counties had on March 15 and on December 15. We matched survey participants who participated in both baseline (T1) and follow-up (T2) interviews by name and date of birth. We excluded people for whom we did not have data on type of Medi-Cal for March or December.
Our outcome variable for the analyses was a change in the type of Medi-Cal between March and December (e.g., FFS to MMC or MMC to FFS). Our analysis included only those survey participants who were in the intervention group (n=281); we stratified by type of Medi-Cal in March (FFS or MMC). We looked at socio-demographic factors and several of the knowledge and attitude variables measured in the survey as predictors of the outcome variable “actual change in type of Medi-Cal between March and December.” It should be noted that there may have been other influences besides receipt of the guide on changing between types of Medi-Cal in the pilot counties for which we cannot control.
Bivariate Analyses
We looked for bivariate associations between changing type of Medi-Cal between March and December and the following variables: age, sex, education, language, proxy/non-proxy, T1 core knowledge score above/below the median, difference between core knowledge score at T1 and T2 above/below the median, positive attitude toward MMC at T2, confidence understanding MMC plans at T2, report that “guide was useful,” reported likelihood of switching MMC to FFS or FFS to MMC (depending on which type of Medi-Cal the individual had in March), reported reading of the guide, and self-rated health status.
Changing from FFS to MMC (Total n=220):
• 8 of 220 (3.6%) switched from FFS to MMC.
• The only factor that showed a statistically significant association with switching from FFS to MMC was age (participants 65 and older more likely to switch, p=.04). We also noted some trends, including that Chinese speakers were more likely to switch (compared to English and Spanish speakers); participants whose change in core knowledge scale score between T1 and T2 was above the median were more likely to switch; and participants who reported being somewhat or very confident that they understood the Medi-Cal plans that they could choose from were more likely to switch. Of those who switched from FFS to MMC, seven out of eight reported their health as “fair.” Forty-eight participants said they were “likely” to switch from FFS to MMC at T2, but only three of them actually switched. Of the thirteen participants who said they were “very likely” to switch from FFS to MMC at T2, only one of them actually switched.
Changing from MMC to FFS (Total n=61):
• 2 out of 61 (6.5%) switched from MMC to FFS.
Logistic Regression
We ran logistic regression models for each of several variables of interest. The variables that were included in the model were:
- T1 core knowledge score,
- Difference between core knowledge score at T1 and T2,
- Attitude toward MMC at T2,
- Confidence understanding MMC plans at T2,
- Felt guide was useful,
- Likelihood of switching type of Medi-Cal, and,
- Guide use (whether or not they read the guidebook).
We created separate models for each of these variables as predictors of switching from FFS in March and to MMC in December. We also entered age, sex, education, and proxy/non-proxy interviewed into each of these models as control variables. We included only beneficiaries in the intervention group.
Logistic Regression Results
The primary finding from the logistic regression analysis was that participants in FFS who were 65 and over were more likely to change to MMC than those who were under 65 (and therefore, had a disability). Age was the only factor that showed a statistically significant association with changing from FFS to MMC.