The health insurance puzzle: a new approach to assessing patient coverage preferences

Previous studies of preferences for health insurance benefits have required individuals to make a series of complex and repetitive decisions, and have assumed that all insured benefits are desirable. This study reports the development and testing of a simple, innovative instrument to measure preferences for health insurance benefits. The newly developed instrument (Puzzle) is designed to allow subjects to select health benefits in a way that underscores the trade-offs dictated by budgets and costs. A "puzzle-like" frame representing budget constraints and "puzzle piece" benefit cards proportionately sized to represent the premium price of a single year's coverage comprise the instrument. In a comparison procedure (Money Game), participants "purchase" individual benefits by exchanging "play" money for benefit tokens. The Puzzle's utility was assessed by examining the convergence of results from both instruments and the subject's ratings of and preference for the instruments. One hundred five elderly Medicare enrollees seen in the general Internal Medicine outpatient clinic of a major southeastern teaching hospital were interviewed. Subjects answered interviewer-administered questionnaires and completed both the Puzzle and the Money Game. Both McNemar's test and Kendall's tau-b indicated a high degree of concordance between benefit choices made using the two instruments. Descriptive statistics demonstrated that the Puzzle was clear, easy to use, understandable, and preferred to the Money Game. The results suggest that the Puzzle is a promising tool for assessing health insurance coverage preferences under circumstances of limited expenditures, which can be modified for use with various populations who face limited insurance benefits.