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Title: Factors Affecting Results of HEDISCAHPS 2'0H Health Plan Member Satisfaction Surveys and Resulting A


1
Factors Affecting Results of HEDIS/CAHPS 2.0H
Health Plan Member Satisfaction Surveys and
Resulting Accreditation ScoresTechnical
Information to Assist Consumers, Purchasers, and
Researchers in Interpreting Results
  • Prepared by
  • Center for the Study of Services
  • 733 15th Street, NW, Suite 820
  • Washington, DC 20005
  • Phone 202-347-9612
  • Paul Kallaur
  • Project Manager
  • Spring 2002

2
Topics
  • Introduction
  • The importance of CAHPS surveys
  • Whats new for HEDIS 2002
  • Collecting CAHPS Data on the Internet
  • Comparing Mail and Phone Surveys
  • The Mailing Package
  • Questionnaire and package format
  • Outreach to Spanish-speaking members
  • Oversampling to Compensate for Disenrolled
    Members
  • The Impact of Combining vs. Separating HMO and
    POS Members
  • Demographic Adjustments to CAHPS Data
  • Trends in Plan Ratings

3
The Center for the Study of Services (CSS) is a
nonprofit corporation founded in 1974
  • CSSs mission is to collect and disseminate
    performance measurement information on various
    types of services
  • Much of our work is in the health care field
    where we have conducted groundbreaking work
    measuring HMO, hospital, and physician
    performance
  • CSS has performed HEDIS/CAHPS data collection for
    more than 500 samples in the past three years

4
This briefing will provide information on how a
plans decisions regarding sampling and
methodology may impact its response rates,
performance scores, NCQA accreditation scores,
and costs
5
NCQA is allowing more flexibility in the CAHPS
survey protocol than it has in the past
  • NCQAs flexibility can result in plans getting
    different scores based on protocol differences,
    not performance differences
  • CSS has repeatedly expressed concern to NCQA that
    flexibility is not desirable
  • It is CSSs opinion that new ideas should be
    tested in controlled experiments and best
    protocols should be mandated for all plans
  • One of the goals of this brief is to ensure that
    all users of HEDIS/CAHPS 2.0H data are aware of
    the non-performance related factors that can
    affect scores

6
This briefing is based on CSSs analysis of data
from the following sources
  • 2001 NCQA Quality Compass
  • This data set includes summary-level data for 267
    adult commercial plans that submitted 2001 CAHPS
    data to NCQA and allowed it to be publicly
    reported
  • 2001 Federal Employees Health Benefit Program
    (FEHBP) Plans
  • This data set includes full respondent-level data
    for the 139 unique adult commercial HMO/POS plans
    that submitted CAHPS data to the U.S. Office of
    Personnel Management (OPM) in 2001
  • Participating FEHBP plans were required to submit
    data
  • Center for the Study of Services (CSS)
  • This data set includes full respondent level
    data, demographic data, and sampling information
    for child, adult, commercial, and Medicaid plans
    that used CSS as their CAHPS vendor over 150
    samples in each of the years 2001, 2000, and 1999

7
Several key terms will be used throughout the
briefing
  • The 10 key measures in the CAHPS survey consist
    of
  • Domains NCQA defines the following six domains
    Getting Needed Care, Getting Care Quickly, How
    Well Doctors Communicate, Courteous and Helpful
    Office Staff, Customer Service, and Claims
    Processing
  • Ratings Questions The four 0-10 ratings
    questions are Rating of Health Plan (Q47 on the
    adult commercial version), Rating of Health Care
    (Q33), Rating of Specialist (Q12), and Rating of
    Personal Doctor or Nurse (Q8)
  • Ratings questions and questions within each of
    the domains are aggregated to determine the
    following two scores, which are calculated
    according to NCQA guidelines
  • Global Proportions range in value from 0 to 100
    and are reported in NCQAs Quality Compass
  • For example The percentage giving a rating of
    8, 9 or 10 on one of the four ratings questions
    is that ratings Global Proportion
  • Composite Scores range in value from 1 to 3 and
    are used for NCQA accreditation
  • Survey responses are rescaled and averaged across
    the several questions constituting a domain to
    calculate Composite Scores
  • Accreditation NCQA assigns HMO and POS plans
    one of five possible accreditation levels based
    on the plans performance on various standards
    and measures

8
It is important to keep in mind that factors that
appear to have a minor impact on responses or
response rates may have an important effect on
how a plans CAHPS data are viewed
  • Even seemingly minor changes in individual
    responses can have a substantial impact on
    Composite Scores and accreditation points
  • For example
  • On the four 0-10 ratings questions, NCQA groups
    respondents into three categories (0-6, 7-8, or
    9-10) for purposes of calculating Composite
    Scores
  • If only one percent of respondents were to move
    from one category into another, the Composite
    Score for any of the ratings questions would
    change by 0.01

9
Relatively narrow ranges separate the thresholds
used to determine points toward accreditation on
many measures
10
NCQA gave health plans more methodological
options for HEDIS 2002
  • NCQAs 2001 protocol required a prenotification
    postcard, two survey mailings, two reminder
    postcards, and at least six attempts to reach
    non-respondents by telephone
  • Beginning in 2002, health plans were given the
    choice of either
  • a mixed methodology consisting of two survey
    mailings and two reminder postcards, with at
    least three attempts to reach non-respondents by
    telephone, or
  • a mail-only methodology consisting of three
    survey mailings and two reminder postcards, with
    no telephone follow-up
  • All health plans also were given the option of
    using the Internet as an enhancement

11
Collecting CAHPS Data on the Internet
12
It is reasonable to expect many potential
benefits from using the Internet to collect
CAHPS 2.0H survey data
  • An increase in the overall response rate
  • An increase in the likelihood of reaching a
    demographically different set of members
  • A decrease in data collection cost by reducing
    return postage and data entry
  • A reduction in the data collection time frame due
    to the instant feedback that the Internet can
    provide
  • A simplification of the response process by
    making skip patterns invisible to respondents

13
In 2001, NCQA allowed plans to use the Internet
as an enhancement for the CAHPS 2.0H Survey
  • The Internet response option was considered an
    enhancement to the standard survey protocol
  • NCQA required vendors to use a defined Internet
    protocol
  • No one had conducted a controlled experiment to
    assess the impact on response rates or ratings of
    using the Internet to collect data
  • One survey vendor had used the Internet to
    collect data in 2000

14
CSS designed and conducted a test to assess the
impact of the the Internet protocol on survey
results
  • CSS recruited 8 plans from across the country to
    participate in the test, consisting of
  • Seven adult commercial samples
  • One child commercial sample
  • Half of each sample was selected randomly and
    given the option to respond using the Internet
  • The control half (without an Internet option)
    followed the regular NCQA protocol
  • The test half (with the Internet option) followed
    NCQAs Internet protocol
  • The cover letters for the survey mailings
    included a web address (www.confidentialsurvey.org
    ) as well as an 8-digit username and 8-digit
    password
  • The pre-notification and reminder postcards did
    not mention the Internet
  • Overall, 2.3 of the eligible sample members
    responded via the Internet

15
The negative effect of offering members the
option of responding on the Internet appeared in
seven of the eight samples
Response Rates Internet Option vs. No Internet
Option
16
The lower response rate was especially evident
among 55- to 64-year-olds in the sample
17
The overall response rate for women was 2.7
percentage points lower among those offered the
Internet option
Response Rates By Gender Internet Option vs. No
Internet Option
18
In both the CSS test and the data submitted to
OPM in 2001, members responding via the Internet
rated their plans lower than did members who
responded by telephone or mail
19
CSS test respondents who used the Internet to
complete the survey gave lower ratings to their
plans across demographic categories
Percent Rating Plan 8-10 Internet vs. Mail
20
Most Composite Scores were driven down when
respondents used the Internet to complete the
survey
CSS Composite Scores Internet vs. Non Internet
Response Mode
21
Applying the CSS test results to 2001 OPM and
NCQA plan scores, a notable percentage of plans
would have received fewer points toward NCQA
accreditation if they had offered the Internet
response option
22
Based on the CSS test, it appears that offering
sample members the option of using the Internet
to respond does not achieve the desired benefits
  • Overall response rates are decreased
  • The demographic distribution of respondents
    appears to become slightly more representative by
    decreasing response rates for over-represented
    groups as opposed to increasing the response rate
    for under-represented groups
  • The Internet response option may cause scores to
    fall
  • The Internet response option does not reduce the
    cost of data collection through mail and phone
    under the currently prescribed NCQA protocol
    given its negative effect on response rates
  • Choosing to use the Internet while other plans do
    not is a risk to a plans ranking relative to
    other plans

23
The Internet might still be a useful tool for
collection of CAHPS 2.0H Data
  • Modifying the mail protocol might increase the
    number of Internet responses
  • Example Send a pre-notification letter asking
    sample members to complete the survey on the
    Internet and then wait two weeks before the first
    survey mailing
  • Any protocol using the Internet should be tested
    before it is fully implemented

24
Comparing Mail and Phone Surveys
25
As noted earlier, plans were given the option of
collecting CAHPS data in 2002 using a mail-only
methodology or a mixed methodology that includes
both mail and phone
  • The new mail-only protocol calls for three
    mailings of the CAHPS survey instrument
  • NCQA has allowed plans to use three survey
    mailings as an enhancement to help increase
    response rates
  • CSS has examined the impact of this protocol
    using CSS and OPM data files
  • The mixed mail and phone protocol calls for two
    mailings of the CAHPS survey instrument followed
    by three attempts to collect response information
    on the phone
  • The number of phone attempts required has been
    reduced by NCQA from six attempts in 2001 to
    three attempts in 2002
  • The protocol that a plan selects will affect its
  • Response rate
  • Plan score
  • Survey cost

26
Historically, the third mail wave and the first
three phone attempts have yielded similar numbers
of returned surveys
Commercial
Medicaid
27
Regardless of which protocol a plan selects in
2002, an estimated 14.5 percent of its survey
responses will be collected after mail waves 1
and 2
  • Whether a plan selects the mail-only or the mixed
    protocol in 2002, it will be required to begin
    the data collection process with two survey
    mailings
  • The scores that would be obtained after the first
    two mail waves serve as a baseline for assessing
    the impact of either a third survey mailing or
    telephone follow-up
  • The chart on the next page shows the average
    difference between scores received on the first
    two survey mailings and those that would be
    obtained on a third mail wave or on the telephone
  • The chart on the page after that shows the
    estimated impact on each overall plan score of
    either sending a third survey mailing or
    conducting telephone follow-up

28
Responses collected on the phone tend to be more
favorable than responses collected from the third
mail wave
Average difference from scores received from mail
waves 1 2
29
The net effect on overall scores favors the
mixed methodology
Average impact on overall plan scores when 3rd
mail wave or phone responses are added
30

On average, the mixed methodology will result in
higher Composite Scores for each composite
measure
Average impact on Composite Scores when phone
responses are added instead of 3rd mail wave
31

Using a mixed mail and phone protocol rather than
a mail-only protocol will cause a plan to reach a
higher accreditation threshold an estimated 1.46
times across the ten CAHPS measures

Percent of plans reaching a higher threshold as a
result of using a mixed methodology rather than a
mail-only methodology
32
There is some debate as to whether the difference
in ratings between mail and phone respondents is
due to a mode effect or due to selection bias
  • Mode effect would mean that a given respondent is
    more likely to say something favorable about a
    plan over the phone than on a written survey
  • Selection bias would mean that there is something
    different about the mix of respondents who
    respond over the phone rather than by mail
  • The argument that dissatisfied members are more
    likely to respond and thus greater effort is
    required to get favorable responses is somewhat
    dispelled by the response results from the third
    survey mailing
  • It is difficult to assess fully the impact of
    selection bias because
  • Differences may be due to a demographic variable
    that is not captured in the survey
  • CAHPS survey data have been collected using a
    mixed methodology involving staggered mail and
    phone waves

33
Comparing ratings from plan members who provided
responses both in the mail and on the phone
provides an interesting test for mode effect
  • When CAHPS 2.0H data are collected, it is
    possible for the same respondent to complete the
    survey both over the phone and in the mail
  • This is unlikely because sample members are
    excluded from the phone portion of the survey as
    soon as the mail survey is received
  • When this occurs, only one survey, the first
    received, is included in the plans HEDIS data
  • In the 2000 and 2001 survey cycles, CSS captured
    603 double responses, providing a direct way
    to test the impact of the data collection mode on
    survey results

34
A sizable percentage of respondents who completed
both a telephone and a mail survey gave higher
ratings over the telephone than they did in the
mail
2000 and 2001 Mail Versus Phone Survey Scores
Overall Health Plan
Overall Health Care
Overall Specialist
Overall Personal Doctor
Claims Processing (Q35)
Customer Service (Q39)
Courteous and Helpful Office Staff (Q28)
How Well Doctors Communicate (Q30)
Getting Care Quickly (Q17)
Getting Needed Care (Q06)
35
Plans scores might be favorably affected by a
plans efforts to maximize the number of
responses collected on the phone
  • There are two straightforward ways a plan can
    increase the number of phone responses
  • Provide better phone numbers to survey vendors
  • Make more than the prescribed three attempts to
    complete the survey on the phone

36
Plans vary widely in their ability to provide
phone numbers for members
  • Not surprisingly, the number of responses
    collected on the phone is highly correlated with
    the number of plan-provided phone numbers

Commercial Plans Correlation .67
Medicaid Plans Correlation .63
37
The HEDIS 2001 protocol called for six attempts
to collect survey responses over the phone, while
HEDIS 2002 changed this requirement to require
only three attempts
  • In 2001, 29.3 percent of all phone responses
    submitted to OPM were collected on attempts 4, 5,
    and 6 (T4, T5, and T6 on the figure below)
  • Plan scores do not appear to be significantly
    affected by the attempt on which the survey was
    completed

38
Extending the phone portion of the survey by
three attempts can have a favorable impact on on
a plans scores
Average impact on overall plan scores when six
versus three phone attempts are used
39
Using the HEDIS/CAHPS 2002 mail-only protocol
is less expensive than the mixed methodology
Price ratios using CSSs 2002 and 2001 prices
40
The Mailing Package
41
Different vendors format their questionnaire
booklets in different ways
  • NCQA provides an electronic version of all CAHPS
    2.0 H surveys in an 8½ by 11 format, but allows
    vendors to adapt this format within certain
    parameters concerning font size and general
    readability
  • Although CSS has used many different formats, our
    default questionnaire design is a 4¼ by 7¾
    saddle-stitched booklet
  • Our general preference for the small booklet
    questionnaire format is based primarily on
    positive feedback that we have received from
    plans and respondents
  • A number of people have mentioned to us that they
    find our survey booklets easy to handle, compact,
    and easy to complete because this single-column
    format leaves little room for confusion about the
    sequence of questions
  • Although the larger questionnaire format is
    easier for optical scanners to read, we have come
    to believe that the small booklet format is more
    user-friendly for respondents

42
The questionnaire booklet size may have an impact
on a plans response rate
  • In addition to this anecdotal evidence that the
    small booklet is preferable, CSS has some
    empirical evidence suggesting that this format
    improves mail response rates
  • In 2001, both CSS and another NCQA-certified
    survey organization conducted the adult
    commercial CAHPS survey for the same health plan
  • Samples were drawn from the same populations, and
    the surveys were fielded simultaneously
  • The main difference between the two
    organizations fielding of the survey was that
    CSS used its small booklet format while the other
    organization used the common large booklet format
  • The CSS format returned a higher number of
    responses in the first two mail waves (464 or
    33.8 percent) than the format used by the other
    organization (412 or 30.0 percent)
  • This difference is statistically significant at
    the 95 percent confidence level

43
CSS has conducted various tests of the effects of
mail package design variants on response rates
and plan scores
  • Using as a baseline the response rate achieved by
    two mail waves, each using a standard 8½ by 4½
    carrier envelope, we have found that
  • Stamping URGENT on the envelope used for the
    second wave increases overall response rates by
    about four percentage points
  • Sending the second wave as Priority Mail
    increases overall response rates by about six
    percentage points
  • Placing an official-looking mail verification
    sticker on the second-wave envelope increases
    overall response rates by about three percentage
    points
  • Using a 9 by 12 carrier envelope for the second
    wave increases overall response rates by about
    two percentage points

44
CSS has also tested the impact of other mailing
approaches not currently allowed by NCQA for
HEDIS/CAHPS surveys
  • Highlights of elaborate experiments involving
    additional follow-up mailings beyond a standard
    two survey mailing protocol
  • Certified mail Follow-up with an additional
    questionnaire mailing sent as certified mail
    achieved a 14.9 percentage point lift in the
    response rate
  • The words Postal carrier may leave without
    signature were typed on the outer envelope to
    avoid inconveniencing the recipient
  • Cash incentive An extra wave of First Class
    mail with 1.00 cash enclosed resulted in a 13.3
    percentage point lift in response rate
  • Additional CSS controlled experiments with
    non-HEDIS mailings indicate that response rates
    can be improved noticeably by offering either
    cash incentives or a useful, subject-related
    publication free to respondents
  • Extra questions A CSS controlled experiment
    showed that adding 45 extra questions to the
    CAHPS survey reduced the response rate only
    three percentage points, a difference that was
    not significant

45
Some plans with a large Hispanic membership offer
the option of completing the survey in Spanish
which likely increases their response rates
within this population
  • In 2001, CSS mailed out Spanish surveys to 2,858
    sample members and received 157 completed Spanish
    surveys (5.5)
  • Providing survey materials in both English and
    Spanish appeared to boost Spanish response rates
    more than offering respondents the option of
    calling to request a Spanish questionnaire
  • CSS has yet to conduct a controlled experiment to
    assess the impact of bilingual surveying on
    overall response rates

46
Outreach to Spanish-speaking respondents has a
positive effect on a plans ratings
  • Respondents to Spanish-language surveys are more
    likely to give the health plan a positive overall
    rating than are those who complete the survey in
    English
  • On a 2001 adult Medicaid survey which offered all
    respondents the option of responding in either
    language, 90.3 percent of respondents in Spanish
    gave the health plan an overall rating of 8, 9 or
    10, compared to 70.6 percent of those completing
    English-language surveys

47
Oversampling to Compensate for Disenrolled
Members
48
NCQA guidelines allow plans to oversample for
their CAHPS surveys if they so choose
  • Plans may wish to consider oversampling for two
    reasons
  • To purge disenrolled respondents from the HEDIS
    data set
  • To ensure a threshold number of responses for
    each question and avoid non-report status

49
At their own discretion, plans may oversample
from 0 to 30 percent in increments of five percent
  • Plans that oversample may provide their vendors
    with an updated sample frame
  • Vendors mark disenrolled sample members and their
    response data is no longer reported to NCQA
  • The updated sample frame can be provided at any
    time prior to data submission to NCQA
  • Disenrollees who left the plan after the first
    survey mailing are still required to be included
    in the response data

50
Disenrolled respondents tend to rate plans lower
than current enrollees
  • 119 CSS plans in 2001 had disenrollees to purge
  • Of the 65 plans with at least 10 disenrollees, 50
    (76.9) had disenrolled respondents who were less
    satisfied with their health plan than those
    currently enrolled
  • Of the 25 plans with at least 20 disenrollees, 20
    (80.0) had disenrolled respondents who were less
    satisfied with their health plan than those
    currently enrolled

51
Disenrollees were much less likely to respond
(and say they were still in the plan) than
currently enrolled members for both commercial
and Medicaid plans
52
The effect on the overall health plan rating had
the disenrollees been included would have been
minimal
53
The Impact of Combining vs. Separating HMO and
POS Members
54
NCQA gives health plans the option of drawing
separate samples of HMO and POS members, or
combining them proportionately into one survey
sample
  • NCQA stipulates that the plans decision on
    whether to use combined or separate HMO and POS
    samples must be consistent with how they report
    other HEDIS measures
  • Plans must collect and report HEDIS member
    satisfaction results for PPO members separately
  • In 2001, 61 percent of samples reported in
    Quality Compass were combined HMO/POS samples
  • Some plans that have both HMO and POS product
    lines opted to seek accreditation for only one of
    them

55
Members may judge the same health plan
differently depending on whether they are
enrolled as an HMO or a POS member
  • Such a difference might be caused by various
    factors
  • Ratings may differ between the HMO and POS
    products because of plan performance or plan cost
  • POS members may appreciate the greater
    flexibility that they have for seeking care from
    providers outside the plans network, and
    therefore give the plan higher marks than would
    HMO members
  • The POS product line may attract those members
    who have less faith in managed care or who place
    greater demands on the plan, resulting in a more
    critical evaluation of the plan from POS members
    than from HMO members
  • For 89 adult commercial plans surveyed by CSS
    with both HMO and POS members, CSS broke down the
    Global Proportions for the NCQA accreditation
    domains according to whether the respondent was a
    member of the plans HMO or POS product line
  • Plans with fewer than 100 cases on a given
    measure were excluded from the reported results

56
On average, HMO plan members had higher Global
Proportions, particularly on the Customer Service
and Getting Needed Care domains
57
Similarly, HMO members tended to have higher
Global Proportions on the 0-10 ratings questions,
particularly on overall satisfaction with the
health plan
58
HMO members are consistently more positive
about their experiences on each of NCQAs 10
Global Proportions
  • This difference in Global Proportions is fairly
    small on many NCQA domains
  • However, the measure on which there is a notable
    difference in Global Proportions (3.2) is
    arguably one of the most important measures on
    the CAHPS survey the overall rating of the
    health plan (Q47)
  • Beyond its impact on NCQA accreditation, this
    measure is most likely to get reported in the
    media as a summary measure for all of the CAHPS
    results and be used to compare plans to each
    other

59
On average, HMO plan members had higher Composite
Scores, particularly on the Customer Service and
Getting Needed Care domains

60
Similarly, HMO members tended to have higher
Composite Scores on the 0-10 ratings questions,
particularly on overall satisfaction with the
health plan
61
Separating the HMO and POS samples would have an
impact on accreditation scoring
  • NCQA bases its accreditation scoring on Composite
    Scores, not Global Proportions
  • Across the 88 plans with reportable Composite
    Scores in all 10 domains, CSS looked at 880
    percentile assignments.
  • We compared how often a plans actual ranking
    (based on a combination of HMO and POS members)
    differed from the rankings that their HMO and POS
    samples would have attained separately

62
A plans accreditation scores on many of NCQA
domains are likely to increase if it surveys only
its HMO members rather than HMO and POS members
together
63
Many of a plans accreditation scores are likely
to decrease if it surveys only its POS members
rather than combining HMO and POS members together
64
Demographic Adjustments toCAHPS Data
65
The Agency for Healthcare Research and Quality
(AHRQ) recommends adjusting CAHPS data to
account for demographic differences among plans
  • NCQA does not adjust CAHPS data
  • In order for risk adjustment to impact plan
    scores, two conditions must be met
  • The demographic breakdown of respondent
    characteristics must vary from plan to plan
  • The respondent characteristics to be adjusted
    must have a substantial effect on ratings
  • For example, if age is related to satisfaction
    levels on composite and ratings questions, and
    the age distribution varies from plan to plan, an
    adjustment for age may be justified

66
There are some substantial differences in plan
ratings based on member characteristics
67
CSS created an adjustment model including age,
health status and education for adult commercial
HMO and POS plans that submitted data to OPM in
2001
  • Adjusted scores were calculated for each Global
    Proportion and ratings question
  • The rank order (Spearmans) correlation between
    actual and adjusted scores for Global Proportions
    and ratings questions ranged from 0.977 to 0.996
  • Rating of Specialist had the lowest correlation
    and Rating of Health Plan had the highest
    correlation

68
The greatest impact of adjustment was seen in the
Rating of Specialist question
69
Plans with abnormal distributions are the most
affected by the NCQA policy of not making risk
adjustments
70
Trends in Plan Ratings
71
Over three years of conducting HEDIS/CAHPS
surveys plan scores have increased somewhat
  • Increases in plan scores may be due to any or all
    of the following
  • Plans have improved
  • Plans that have low scores no longer conduct
    CAHPS
  • Dissatisfied customers have left plans
  • People are more educated about managed care
  • People are less critical of managed care

72
The NCQA Averages for 0-10 ratings questions and
Global Proportion scores increased from 1999 to
2001 for adult commercial plans
73
Of HMO/POS plans that submitted CAHPS data to
OPM in both 2000 and 2001, the majority of plans
scores increased in 2001
  • All scores except for Getting Care Quickly
    and Courteous and Helpful Office Staff
  • increased in 2001
  • The largest increases were in Overall Plan
    Rating, Customer Service, and Claims
  • Processing

74
Many scores for adult Medicaid plans have also
increased since 1999
75
Thresholds used to determine accreditation
scoring were established by NCQA in 1999
  • NCQA established percentile thresholds in 1999
    based on that years data for all of the
    Composite Scores
  • In order to account for plan-to-plan variations,
    NCQA adjusts Composite Scores by adding either
    0.05 or 0.07 to each score
  • A plans percentile ranking in 1999, 2000, and
    2001 was based on its score plus the NCQA
    adjustment
  • Plans were awarded points toward accreditation
    based on their percentile ranking for each
    Composite Score
  • 90th percentile 1.25 points
  • 75th percentile 1.10 points
  • 50th percentile 0.85 points
  • 25th percentile 0.50 points
  • Less than 25th percentile 0.25 points
  • A maximum number of 12.50 points can be awarded
    for the CAHPS survey

76
Thresholds have not been updated since 1999 to
reflect this increase in scores
  • If we take into account the NCQA adjustment, over
    10 percent of plans should be in the 90th
    percentile, under 25 percent of plans should be
    in the lowest percentile
  • Since the thresholds and adjustments have
    remained the same and scores have increased, a
    disproportionate number of plans are in the
    higher percentile rankings

77
Since scores have increased over the past two
years, the percentage of plans in the 90th
percentile has increased
78
If NCQA establishes new thresholds based on 2002
data, it is likely that many plans points
towards accreditation will decrease
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