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Health Risk Factor Surveys of Commercial Plan- and Medicaid-Enrolled Members of Health-Maintenance Organizations -- Michigan, 1995

Behavioral risk factors involving tobacco use, improper diet, physical inactivity, alcohol abuse, and motor-vehicle-related injury contributed to approximately 850,000 deaths in the United States in 1990 (1). CDC's Behavioral Risk Factor Surveillance System (BRFSS) has been the primary means for tracking progress toward reduction of these and other health risks at the state level (2). This report summarizes the use of telephone surveys conducted by the Michigan Consortium for Quality Improvement in Health Care during April-August 1995 to evaluate the health-risk profiles of commercial plan- and Medicaid-enrolled health-maintenance organization (HMO) members in Michigan. The findings indicate that HMOs can use the BRFSS model to monitor health risks, health status, and use of preventive services among member groups.

Of the 18 licensed HMOs in Michigan, eight agreed to participate in the commercial members survey; five of these eight HMOs also participated in the Medicaid members survey. The National Committee for Quality Assurance coordinated the survey sampling and data collection through an independent statistical survey firm. The survey targeted a random sample of non-Medicare beneficiary members aged greater than or equal to 18 years from within each category (i.e., commercial members or Medicaid members). For each category and each HMO, 450 respondents were targeted from a random sample of 2000 members. The overall response rate across all samples was 90.8% (86.5% within the commercial sample and 94.6% within the Medicaid sample). The mean number of commercial respondents per plan was 453, and the mean number of Medicaid respondents per plan was 430. For all analyses, data were pooled across HMOs, and separate analyses were conducted of commercial and Medicaid HMO members. Final samples consisted of 3626 commercial respondents and 2151 Medicaid respondents.

Survey questions were taken directly from the 1993 and 1994 Michigan BRFSS and asked about demographics; diabetes; and health factors including alcohol use, cigarette smoking, physical inactivity, general health status, cholesterol and blood pressure screening, and breast and cervical cancer screening. For comparisons between the commercial and Medicaid HMO members and between HMO members and statewide Michigan BRFSS participants from 1994 and 1995 (3,4), all estimates were directly standardized by age and sex to the 1992 Michigan intercensal population.

Of the alcohol-related factors, the prevalence of driving after drinking during the preceding month was higher in the commercial sample (1.5%) than in the Medicaid sample (0.2%) (Table_1) (less than or equal to 0.05), and the prevalence of binge drinking (consuming five or more alcoholic drinks on one or more occasion during the preceding month) was similar in both the commercial (13.1%) and Medicaid samples (12.5%). The prevalences of both of these behaviors were lower among the HMO populations than in the statewide sample (pless than or equal to 0.05).

The prevalences of current cigarette smoking and physical inactivity during the preceding month were higher in the Medicaid sample (44.1% and 27.9%, respectively) than in either the commercial sample (19.4% and 12.9%) or the state BRFSS sample (25.9% and 23.4%). Nonuse of safety belts was most prevalent in the Medicaid HMO sample (23.3%), followed by the state BRFSS sample (13.3%), then by the commercial HMO sample (10.1%). Among persons in the Medicaid sample, the prevalences of self-reported fair or poor health status, ever having had a high cholesterol level, and ever having had diabetes were higher than among those in either the commercial HMO sample or the statewide BRFSS sample (pless than or equal to 0.05).

Prevalences of reported blood pressure screening during the preceding 2 years and cervical cancer screening during the preceding 3 years were similar for the two HMO sample groups, and for both groups were higher than those prevalences statewide. In comparison, the prevalences of reported cholesterol and mammographic screening were lower among the Medicaid HMO population than either the commercial HMO population or statewide sample.

Reported by: VF Gurley, RM Davis, Center for Health Promotion and Disease Prevention, Henry Ford Health System, Detroit; M Dascola, DataStat Inc., Ann Arbor; Blue Care Network of East Michigan, Saginaw; Blue Care Network of Mid Michigan, Lansing; Care Choices, Farmington Hills; Health Alliance Plan of Michigan, Detroit; HealthPlus of Michigan, Farmington Hills; OmniCare Health Plan, Detroit; SelectCare HMO, Troy; The Wellness Plan, Detroit; Michigan Dept of Community Health, Community Public Health Agency. RG Finkbiner, CM Mercil, MJ Braid, National Committee for Quality Assurance, Washington, DC. Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In previous health risk factor surveys conducted by managed-care organizations (5), the prevalences of clinical preventive service use have been higher, and behavioral risk factors have been lower among privately insured members when compared with statewide BRFSS samples. The health risk factor survey in Michigan illustrates how a collaborative effort involving multiple independent HMOs enabled comparisons of the prevalences of risk factors and clinical preventive service use among privately and publicly insured populations.

HMOs in Michigan have used the findings of this survey to guide risk-reduction program planning or refinement. For example, the unstandardized rates were used by quality managers in each HMO to compare their rates with the aggregate rates of the other participating HMOs. In addition, some HMOs used the findings to encourage physicians to address risk-reduction issues with their patients, to compare survey data on medical screening with administrative data sources, and to identify geographic areas for targeting interventions toward high-risk populations.

In 1995, CDC created a Managed Care Working Group to encourage public-private collaboration on preventive health activities (6). This group recommended that managed-care organizations provide leadership in community health promotion, develop partnerships with public health agencies to improve health outcomes, develop prevention-related surveillance, use information systems in health-risk and disease assessment, and evaluate disease prevention intervention effectiveness. The Michigan HMO surveys addressed many of these recommendations through the characterization of population-based health risks, planning of targeted interventions, and establishment of a baseline for evaluating long-term trends in population risk profiles. Routine health risk factor surveys can assist health plans in collecting information on health behaviors for future versions of HMO "report cards," such as the Health Plan Employer Data and Information Set.

The findings in this report are subject to at least three limitations. First, health-risk behaviors may have been underreported because respondents were informed that the survey was being conducted by their HMO; even though confidentiality was assured at the beginning of the interview, some respondents may have feared that unhealthy behaviors might lead to health plan premium increases or membership cancellation. Second, because data were pooled across HMOs, health plan-specific differences in prevalence estimates may be obscured. Third, certain subgroups (e.g., men in the Medicaid sample and persons aged greater than or equal to 65 years in both HMO samples) were under-represented in the sample populations.

The findings in this survey are consistent with previously reported associations among demographics, health-risk factors, and the development of disease (1,7). In addition, the findings highlight the persistence of the low prevalence of use of preventive services among persons receiving care through Medicaid and suggest the need for targeted interventions to reduce risk and promote health. Health risk factor surveys are effective approaches for monitoring progress toward disease prevention and health promotion regionally, nationally, in special populations, and in health-care-delivery systems. Further collaborations between public health agencies and HMOs, and among HMOs, will enable improved use of traditional public health approaches in the managed-care setting.


  1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.

  2. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-1987. Public Health Rep 1988;103:366-75.

  3. Center for Health Promotion and Chronic Disease Prevention. Health risk behaviors, 1994: results from Michigan's Behavioral Risk Factor Survey. Lansing, Michigan: Michigan Department of Community Health, 1996.

  4. Center for Health Promotion and Chronic Disease Prevention. 1995 Michigan Behavioral Risk Factor Survey: prevalence of selected risk factors and behaviors among adults. Lansing, Michigan: Michigan Department of Community Health, 1996.

  5. Campbell KM, Holm K. Preventive services utilization among older women: a comparison of HMO members, private insurance policy holders, and Medicare recipients. Olympia, Washington: Washington State Department of Health, 1995.

  6. CDC. Prevention and managed care: opportunities for managed-care organizations, purchasers of health care, and public health agencies. MMWR 1995;44(no. RR-14).

  7. Kaplan GA, Pamuk ER, Lynch JW, Cohen RD, Balfour JL. Inequality in income and mortality in the United States: analysis of mortality and potential pathways. Br Med J 1996;312:999-1003.

Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Estimated prevalence of selected health-risk factors among members of  Michigan health-maintenance organizations
(HMOs), by payor category, * 1995, and estimated prevalence from the Michigan Behavioral Risk Factor Surveillance System
(BRFSS), 1994-1995 +
                                                                                   Payor category
Characteristic                                                            Commercial HMO   Medicaid HMO   1995 BRFSS
Drank >=5 alcoholic beverages on >=1 occasion during the preceding                13.1% &        12.5% &       17.1%

Engaged in drinking and driving @                                                  1.5% & **      0.2% &        3.3%

Reported being a current smoker ++                                                19.4%          44.1% &       25.9% &&

Had no leisure-time physical activity during the preceding month @@               12.9% & **     27.9% &       23.4% &&

Did not use safety belt                                                           10.1% & **     23.3% &       13.3%

Self-reported fair or poor health status                                           8.1% & **     34.5% &       13.5% &&

Ever been told had high cholesterol                                               27.2% & **     34.6% &       31.4%

Ever been told had diabetes ***                                                    3.9% & **      9.0% &        5.4%

Had blood pressure checked during the preceding 2 years                           97.8% &        98.5% &       94.8%

Had cervical cancer screening during the preceding 3 years +++                    93.2% &        91.8% &       81.2% &&

Ever had cholesterol checked                                                      78.5% & **     62.3% &       75.3%

Ever had a mammogram &&&                                                          93.3%& **      86.7%         88.0%
*   Eight HMOs agreed to participate in the commercial members survey, and five of these eight HMOs also participated in
    the Medicaid members survey.
+   Data standardized by aged and sex to the 1992 Michican intercesnal population.
&   HMO weighted prevalence (commercial or Medicaid) significantly different from Michigan BRFSS at p<=0.05.
@   Drove at least once during the preceding month after having had "perhaps too much to drink."
**  Commercial HMO and Medicaid HMO weighted prevalences significantly different at p<=0.05.
++  Ever smoked 100 cigarettes and was a current smoker.
&&  1994 Michigan Behavioral Risk Factor Survey rate used for comparison.
@@  Had no physical activities such as running, calisthenics, golf, gardening, or walking for exercise.
*** Excludes pregnancy-related diabetes.
+++ Includes women aged >=18 years.
&&& Includes women >=40 years.

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