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Health Serv Res. 1999 June; 34(2): 547–576.
PMCID: PMC1089023

No exit? The effect of health status on dissatisfaction and disenrollment from health plans.


OBJECTIVE: To examine the implications of serious and chronic health problems on the willingness of enrollees to switch health plans if they are dissatisfied with their current arrangements. DATA SOURCE: A large (20,283 respondents) survey of employees of three national corporations committed to the model of managed competition, with substantial enrollment in four types of health plans: fee-for-service, prepaid group practice, independent practice associations, and point-of-service plans. STUDY DESIGN: A set of logistic regression models are estimated to determine the probability of disenrollment, if dissatisfied, controlling for the influence on satisfaction and disenrollment of age, race, education, family income and size, gender, marital status, mental health status, pregnancy, duration of employment and enrollment in the plan, number of alternative plans, and HMO penetration in the local market. Separate coefficients are estimated for enrollees with and without significant physical health problems. Additional models are estimated to test for the influence of selection effects as well as alternative measures of dissatisfaction and health problems. DATA COLLECTION: Data were collected through a mailed survey with a response rate of 63.5 percent; comparisons to a subsample administered by telephone showed few differences. PRINCIPAL FINDINGS: In group/staff model HMOs and point-of-service plans, only 12-17 percent of the chronically ill enrollees who were so dissatisfied when surveyed that they intended to disenroll actually left their plan in the next open enrollment period. This compared to 25-29 percent of the healthy enrollees in these same plans, who reported this level of dissatisfaction and 58-63 percent of the enrollees under fee-for-service insurance. CONCLUSIONS: Switching plans appears to be significantly limited for enrollees with serious health problems, the very enrollees who will be best informed about the ability of their health plan to provide adequate medical care. These effects are most pronounced in plans that have exclusive contracts with providers. We conclude that disenrollment provides only weak safeguards on quality for the sickest enrollees and that reported levels of dissatisfaction and disenrollment represent inaccurate signals of plan performance.

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Selected References

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  • Allen HM., Jr Toward the intelligent use of health care consumer surveys. Manag Care Q. 1995 Autumn;3(4):10–21. [PubMed]
  • Allen HM, Jr, Rogers WH. The consumer health plan value survey: round two. Health Aff (Millwood) 1997 Jul-Aug;16(4):156–166. [PubMed]
  • Allen HM, Jr, Darling H, McNeill DN, Bastien F. The Employee Health Care Value Survey: round one. Health Aff (Millwood) 1994 Fall;13(4):25–41. [PubMed]
  • Berki SE, Ashcraft ML. HMO enrollment: who joins what and why: a review of the literature. Milbank Mem Fund Q Health Soc. 1980 Fall;58(4):588–632. [PubMed]
  • Blendon RJ, Knox RA, Brodie M, Benson JM, Chervinsky G. Americans compare managed care, Medicare, and fee-for-service. J Am Health Policy. 1994 May-Jun;4(3):42–47. [PubMed]
  • Brock DW, Daniels N. Ethical foundations of the Clinton administration's proposed health care system. JAMA. 1994 Apr 20;271(15):1189–1196. [PubMed]
  • Buchanan JL, Cretin S. Risk selection of families electing HMO membership. Med Care. 1986 Jan;24(1):39–51. [PubMed]
  • Davis K, Collins KS, Schoen C, Morris C. Choice matters: enrollees' views of their health plans. Health Aff (Millwood) 1995 Summer;14(2):99–112. [PubMed]
  • Edgman-Levitan S, Cleary PD. What information do consumers want and need? Health Aff (Millwood) 1996 Winter;15(4):42–56. [PubMed]
  • Enthoven AC. The history and principles of managed competition. Health Aff (Millwood) 1993;12 (Suppl):24–48. [PubMed]
  • Enthoven AC, Singer SJ. Market-based reform: what to regulate and by whom. Health Aff (Millwood) 1995 Spring;14(1):105–119. [PubMed]
  • Fishman P, Von Korff M, Lozano P, Hecht J. Chronic care costs in managed care. Health Aff (Millwood) 1997 May-Jun;16(3):239–247. [PubMed]
  • Fox JG, Storms DM. A different approach to sociodemographic predictors of satisfaction with health care. Soc Sci Med A. 1981 Sep;15(5):557–564. [PubMed]
  • Gold M, Nelson L, Brown R, Ciemnecki A, Aizer A, Docteur E. Disabled Medicare beneficiaries in HMOs. Health Aff (Millwood) 1997 Sep-Oct;16(5):149–162. [PubMed]
  • Greenley JR, Young TB, Schoenherr RA. Psychological distress and patient satisfaction. Med Care. 1982 Apr;20(4):373–385. [PubMed]
  • Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30(7):811–818. [PubMed]
  • Hanchak NA, Schlackman N, Harmon-Weiss S. U.S. Healthcare's quality-based compensation model. Health Care Financ Rev. 1996 Spring;17(3):143–159. [PubMed]
  • Harrington C, Newcomer RJ, Preston S. A comparison of S/HMO disenrollees and continuing members. Inquiry. 1993 Winter;30(4):429–440. [PubMed]
  • Hillman AL, Welch WP, Pauly MV. Contractual arrangements between HMOs and primary care physicians: three-tiered HMOs and risk pools. Med Care. 1992 Feb;30(2):136–148. [PubMed]
  • Hoffman C, Rice D, Sung HY. Persons with chronic conditions. Their prevalence and costs. JAMA. 1996 Nov 13;276(18):1473–1479. [PubMed]
  • Juba DA, Lave JR, Shaddy J. An analysis of the choice of health benefits plans. Inquiry. 1980 Spring;17(1):62–71. [PubMed]
  • Klinkman MS. The process of choice of health care plan and provider: development of an integrated analytic framework. Med Care Rev. 1991 Fall;48(3):295–330. [PubMed]
  • Knutson DJ, Fowles JB, Finch M, McGee J, Dahms N, Kind EA, Adlis S. Employer-specific versus community-wide report cards: is there a difference? Health Care Financ Rev. 1996 Fall;18(1):111–125. [PubMed]
  • Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med. 1987;24(4):351–357. [PubMed]
  • Long SH, Settle RF, Wrightson CW., Jr Employee premiums, availability of alternative plans, and HMO disenrollment. Med Care. 1988 Oct;26(10):927–938. [PubMed]
  • McCormack LA, Garfinkel SA, Schnaier JA, Lee AJ, Sangl JA. Consumer information development and use. Health Care Financ Rev. 1996 Fall;18(1):15–30. [PubMed]
  • McGlynn EA. Six challenges in measuring the quality of health care. Health Aff (Millwood) 1997 May-Jun;16(3):7–21. [PubMed]
  • McHorney CA, Ware JE, Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993 Mar;31(3):247–263. [PubMed]
  • McHorney CA, Ware JE, Jr, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994 Jan;32(1):40–66. [PubMed]
  • McMullan M. HCFA's consumer information commitment. Health Care Financ Rev. 1996 Fall;18(1):9–14. [PubMed]
  • Mechanic D. Consumer choice among health insurance options. Health Aff (Millwood) 1989 Spring;8(1):138–148. [PubMed]
  • Mechanic D, Ettel T, Davis D. Choosing among health insurance options: a study of new employees. Inquiry. 1990 Spring;27(1):14–23. [PubMed]
  • Luft HS, Miller RH. Patient selection in a competitive health care system. Health Aff (Millwood) 1988 Summer;7(3):97–119. [PubMed]
  • Newcomer R, Preston S, Harrington C. Health plan satisfaction and risk of disenrollment among social/HMO and fee-for-service recipients. Inquiry. 1996 Summer;33(2):144–154. [PubMed]
  • Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Program Plann. 1983;6(3-4):185–210. [PubMed]
  • Riley GF, Ingber MJ, Tudor CG. Disenrollment of Medicare beneficiaries from HMOs. Health Aff (Millwood) 1997 Sep-Oct;16(5):117–124. [PubMed]
  • Riley T. The role of states in accountability for quality. Health Aff (Millwood) 1997 May-Jun;16(3):41–43. [PubMed]
  • Robinson JC, Gardner LB. Involuntary health plan switching: case study of a corporate health benefits program. Med Care Res Rev. 1996 Jun;53(2):225–239. [PubMed]
  • Robinson JC, Gardner LB, Luft HS. Health plan switching in anticipation of increased medical care utilization. Med Care. 1993 Jan;31(1):43–51. [PubMed]
  • Rosenbaum S, Serrano R, Magar M, Stern G. Civil rights in a changing health care system. Health Aff (Millwood) 1997 Jan-Feb;16(1):90–105. [PubMed]
  • Ross CE, Wheaton B, Duff RS. Client satisfaction and the organization of medical practice: why time counts. J Health Soc Behav. 1981 Sep;22(3):243–255. [PubMed]
  • Rossiter LF, Langwell K, Wan TT, Rivnyak M. Patient satisfaction among elderly enrollees and disenrollees in Medicare health maintenance organizations. Results from the National Medicare Competition Evaluation. JAMA. 1989 Jul 7;262(1):57–63. [PubMed]
  • Sainfort F, Booske BC. Role of information in consumer selection of health plans. Health Care Financ Rev. 1996 Fall;18(1):31–54. [PubMed]
  • Schlesinger M. Countervailing agency: a strategy of principaled regulation under managed competition. Milbank Q. 1997;75(1):35–87. [PubMed]
  • Schlesinger M, Mechanic D. Challenges for managed competition from chronic illness. Health Aff (Millwood) 1993;12 (Suppl):123–137. [PubMed]
  • Shaughnessy PW, Schlenker RE, Hittle DF. Home health care outcomes under capitated and fee-for-service payment. Health Care Financ Rev. 1994 Fall;16(1):187–222. [PubMed]
  • Simon GE. Psychiatric disorder and functional somatic symptoms as predictors of health care use. Psychiatr Med. 1992;10(3):49–59. [PubMed]
  • Sofaer S, Hurwicz ML. When medical group and HMO part company: disenrollment decisions in Medicare HMOs. Med Care. 1993 Sep;31(9):808–821. [PubMed]
  • Ullman R, Hill JW, Scheye EC, Spoeri RK. Satisfaction and choice: a view from the plans. Health Aff (Millwood) 1997 May-Jun;16(3):209–217. [PubMed]
  • Ware JE, Jr, Bayliss MS, Rogers WH, Kosinski M, Tarlov AR. Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. Results from the Medical Outcomes Study. JAMA. 1996 Oct 2;276(13):1039–1047. [PubMed]
  • Weiss GL. Patient satisfaction with primary medical care. Evaluation of sociodemographic and predispositional factors. Med Care. 1988 Apr;26(4):383–392. [PubMed]
  • Wersinger RP, Sorensen AA. Demographic characteristics and prior utilization experience of HMO disenrollees compared with total membership. Med Care. 1982 Dec;20(12):1188–1196. [PubMed]

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