Made in the USA: the import of American Consumer Assessment of Health Plan Surveys (CAHPS) into the Dutch social insurance system

Background: In the Dutch social insurance system, based on regulated competition, sickness funds should attract clients by contracting efficient and qualitatively good services. For that sake, sickness funds need information about their own performance and about the quality of care they contract, as perceived by their insured. In the Unites States, the Consumer Assessment of Health Plan Surveys (CAHPS) have been developed specifically for that purpose. CAHPS instruments focus on the patient-centeredness of health care (e.g. respect, dignity, prompt attention) and the service of the health plan. These surveys have recently been adopted by the largest Dutch sickness fund (AGIS). Aim: This paper presents the results of a validation study, commissioned by AGIS Zorgverzekeringen, looking at: a) Can the CAHPS be adapted for use in the context of the Dutch social insurance system? b) Do these questionnaires generate valid information about the quality of health care and the performance of Dutch sickness funds? Methods: The American core CAHPS was translated forward and backward. It was subsequently piloted in a sample of 977 AGIS clients (response rate 56%, with a slight over-representation of elderly). Internal validation consisted of evaluations of item response rates, distributions of scores, reliability analyses, and tests of internal consistency. For external validation data are compared with the American CAHPS benchmark data, and with results of other Dutch studies. Results: In general, the questionnaires are filled out completely and consistently. As expected, the distribution of scores on the perceived quality of care is somewhat skewed towards positive answers. The questionnaire contains a reliable scale about the patient-centerednesscenteredness of care (Cronbach’s alpha .83). That scale correlates significantly with respondents’ general rating of the quality of health care on scale of 0 to 10. The comparison with the American CAHPS benchmark data showed that respondents in the US’ system experience more problems with the accessibility of care than do their Dutch counterparts. However, once patients manage to get into the system, the patient-centeredness of the two health care systems is remarkably similar. Conclusions: It is possible to import American patient questionnaires into the Dutch social insurance system and use them to improve the accountability of sickness funds. Particularly, questions that refer to the primary process in health care (the doctor-patient interaction) generate scores that are quite comparable between the American and the Dutch health system.