Wisconsin: BadgerCare Plus Healthy Living Update

Wisconsin's BadgerCare Plus, an expansion of its State Children's Health Insurance Program (SCHIP) launched on February 1, 2008, extends health coverage and at the same time emphasizes individuals' responsibility for improving their own health. This is expected to achieve better health outcomes and value for each health care dollar spent. The program expands state-sponsored health insurance coverage to all children and greater numbers of pregnant women, adult caretaker relatives, and parents by increasing the income level for eligibility.[1] As reported in the September/October issue of States in Action, BadgerCare Plus members are encouraged to take responsibility for their own health through three strategies: individual incentives, a member pledge, and health literacy campaigns.

In early December, the state released a request for applications from health plans to design and manage individual incentive programs for BadgerCare Plus members. These two-year pilots will test whether various types of incentives can encourage members to change their behaviors to improve their health. Six proposals have been selected for funding, each with different target populations and goals. Each proposal also varies in the amount and types of incentives offered and in outreach strategies (see figure).

The pilots began April 1, 2008, and extend through March 31, 2010. They will be evaluated to answer the following questions:

• What effect do incentives have in engaging members in healthier behaviors?
• What types of incentives are effective and at what levels?
• How does effectiveness vary depending on member characteristics (e.g., urban, suburban, or rural residence; economic status; age; race; and educational level)?
• What are the administrative and management considerations in implementing individual incentive programs?
• What short-term health outcomes result from engagement in individual incentive programs?
• What are the prospects for long-term improved health outcomes for the BadgerCare Plus population from changes in behavior that result from individual incentives?
• Is adoption/implementation of individual incentive programs cost effective?

Improving Quality Through Health Literacy
Findings from focus groups with more than 100 individuals enrolled in BadgerCare (the state's SCHIP program and predecessor to BadgerCare Plus) held last fall were used to inform the design of the pilots. A "member pledge" in which enrollees sign a form promising to keep appointments, adhere to medical protocols, and follow other measures has been incorporated into three of the individual incentive proposals and will be evaluated to determine its role in helping members take responsibility for their own health.

Findings from the focus groups also informed Wisconsin's health literacy campaign. Wisconsin will use "Ask Me 3" materials developed by the Partnership for Clear Health Communication to help BadgerCare Plus members become more engaged in their own care.[2] Ask Me 3 encourages patients to ask three key questions at each health care visit: "What is my main problem?," "What do I need to do about it?," and "Why is it important for me to do this?" Pilot sites will use the following measures to examine the impact of this effort:

• Did patients better understand their doctor's instructions and feel more capable of participating in their care following introduction of Ask Me 3?
• Did patients' satisfaction with their provider interactions increase after introduction of Ask Me 3?
• What do providers perceive to be the impact of the Ask Me 3 program?

The state will identify six to eight health care clinics serving a large number of BadgerCare Plus members to test one of two models for using Ask Me 3. Some of the clinics will test a "social marketing" approach: providing Ask Me 3 materials in clinic waiting rooms and other locations in the community, with clinic staff given a brief orientation to the Ask Me 3 materials. The other clinics will test a more intensive intervention. In addition to receiving a wider variety of Ask Me 3 materials, these clinics will undergo provider training and engagement about simple strategies for improved patient interactions, such as speaking more slowly, using common language and avoiding medical jargon, giving patients time to ask questions, and asking for feedback (e.g., "Can you tell me what you are supposed to do?"). An environmental scan of these facilities may also be conducted to review the various points of contact with patients (written, visual, and verbal), including: how information is provided to patients; the reading level of existing materials; and protocols for patient follow-up and questions.

Wisconsin will use the Patient Activation Measure, developed by Judith Hibbard of the University of Oregon, to measure the degree to which the Ask Me 3 program affects patient engagement in their care. The state will also use data from the Consumer Assessment of Healthcare Providers and Systems survey and patient and provider focus groups. In the longer-term (over two years) the evaluation can begin to assess whether patients who were exposed to Ask Me 3 improved their adherence to treatment plans and/or had better health status for certain conditions such as asthma or diabetes.

For More Information Contact: Linda McCart, chief of policy and research, Office of Policy Initiatives and Budget, Wisconsin Department of Health and Family Services, [email protected]

References
[1] In addition to making all children up to age 19 eligible for care, regardless of income, BadgerCare Plus extends coverage to pregnant women up to 300 percent of the FPL, parents and caretakers up to 200 percent of the FPL, and young adults leaving foster care at age 18. Previously it was available for families up to 185 percent of the FPL.
[2] For further discussion of AskMe3, see S. E. Barrett, J. Sheen Puryear, and K. Westpheling, The Commonwealth Fund, January 2008 and Quality Matters: Health Literacy, November/December 2006, The Commonwealth Fund, Vol. 21.