In recent years it has been often repeated that we are on the verge of a new era of health care consumerism as “the role of the individual in healthcare is rapidly transforming from passive patient to active consumer” and that “the shift is being driven by patients’ increased financial responsibility for their healthcare costs, the availability of highly convenient and low-cost care delivery options such as retail clinics and virtual care, and the increasing number of tools that consumers can use to compare cost and quality among providers.”
The expectation and vision of those that subscribe to this model is that consumers will ultimately purchase health care like other goods, combining price and quality, and purchasing that mix of services that maximizes their expected utility subject to their budget constraints. While we feel strongly that consumers should have access to both price and quality information, how sophisticated consumers’ decision-making capabilities are with regards to both remains an open question.
An earlier Health Affairs Blog post of ours addressed the price-side of the value-equation reporting that less than half of all health care dollars, at most, were spent on shoppable services. Here we present our perspective on the quality-side of the value equation.
What’s the Current State of Quality Measurement?
For years this country has been trying to deal with the issue of measuring quality in health care, and many problems still persist, including: too many measures, too few measures, and in some settings the wrong measures. And these persist as we try to measure quality at the provider, facility, and system levels, while making these measures actionable by providers, system managers, purchasers, and consumers.
A recent Health Affairs article documented that:
state and regional agencies currently use 1,367 measures of provider quality, of which only 20 percent are used by more than one state or regional program. A study of twenty-three health insurers found that 546 provider quality measures were used, few of which matched across insurers or with the 1,700 measures used by federal agencies.
The study further found that the cost of dealing with quality measures across four specialties was more than $15.4 billion a year and only about 30 percent of all practices reported using the quality scores frequently or very frequently. Similarly, Dr. Donald Berwick, formerly the CMS Administrator, recently suggested a 50 percent reduction in the number of quality metrics. While the above highlights that we have too many measures, CMS recently responded to both the too many and too few complaint through its efforts to align measures and develop core quality measures.
While the wrong measures argument likely resonates with most stakeholders, for our purposes, we contend that few available quality measures actually resonate with consumers or drive them to make better decisions and that an excessive focus on consumer requirements may be at the expense of measures that are actually likely to improve system delivery.
Quality measures are valuable, and we adhere to the notion that if it is not measured it cannot be improved. Moreover, the proliferation of quality measures speaks to the demand for quality information at the provider, specialty, and facility-level, and for consumers. The question is where to focus the effort in order to achieve the greatest impact. A recent Consumer Reports article detailed not just the importance of quality care for consumers, but also the difficulties consumers face when trying to locate actionable quality information. According to an Altarum study, just 27 percent of individuals report using online quality ratings when choosing a provider.
We believe that the efforts at quality measurement should be focused on good, actionable measures of provider and system performance and should be used to improve quality across the health care system, such that all patients benefit from good care regardless of whether they are active consumers or not. This focus also means that we do not have to prod, educate, or cajole patients to be good consumers.
We Need to Remove Quality from the Discussion with Consumers
Clearly, the follow-up question is what is the consumer to do when shopping for health care if there are no consumer-focused measures of quality? Our answer is two-fold. First, for consumers and patients the quality aspect of health care should be removed from their calculus. Patients should not be able to choose substandard quality care, and substandard quality care should not be allowed to be offered in the market.
By analogy, imagine walking down the street in New York City and passing several restaurants with food safety inspection signs in their windows documenting their “A” and “B” ratings from the New York City Department of Health. Continue walking down the street a bit further and you might see a restaurant on the corner closed by the Health Department because it failed its food safety inspection. Since we want consumers to “buy value” in the marketplace, using both price and quality, why don’t we allow the restaurant to offer a discount or lower the price for people who are willing to chance getting sick in exchange for a lower-priced meal? Society has determined that this trade-off is unacceptable, and we believe that the same logic that compels us to close unsafe restaurants equally applies to the value debate in health care.
Second, as a practical matter observing consumerism we are inclined to agree with Richard Frank’s observation made more than 10 years ago that “. . . the quality signal based on extant market information or even an improved public reporting of quality may not yield strong demand response to quality signals as has generally been assumed. The normative implication is that improved information may not result in an efficient quality equilibrium in the market unless some other institute is introduced that overrides the type of patient decision making we have described (e.g. employers guiding provider choice based on systematic data).” In other words, consumer action alone is unlikely to result in large-scale shifts in quality.
Who is Responsible for Promoting Quality Improvement?
Much like our previous argument around prices and shopping, we return to the usual suspects and ask them to do more. Sophisticated purchasers, both employers and insurers, have access to large samples of data and insights into the performance of providers and suppliers. These purchasers could and should use this information not only to identify high and low performing providers in their networks, but also make this information more generally available to other sophisticated buyers so collectively they can use their market leverage to both prod poor performing providers and suppliers to get better and to remove from the system those that cannot improve.
State regulators, health care systems and hospitals, accrediting organizations, and professional medical associations similarly have greater capacity than they have historically been willing to assume. Where most consumers are purchasing care as a one-off exercise where they do not gain the knowledge acquired from repeatedly purchasing services, the “usual suspects” above have detailed and repeated experiences with providers and suppliers that allow them to better ascertain and measure the quality of services on offer. Physicians repeatedly note that they “know” the good providers and hospitals are able to see the comparative performance of their staffs. Recent research on “serial malpractice” suggests that regulators and professional associations can do a better job culling the system of repeat poor performers.
One idea that resonates with us is the notion that these core quality measures could be aggregated to provide consumers with a summary metric of plan quality. Since consumers do not necessarily know whether they will need an oncologist, an orthopedist, or some other health service when they select their plan, they should at least have insight into the overall quality of the plan. All state and federal exchanges will be required to offer consumers plan-level quality data by 2017. Early evidence suggests that providing plan quality information, such as through star ratings, can nudge consumers towards buying high-value health plans.
To repeat, measuring provider and system performance is fundamental to improving quality of care. By encouraging all providers to improve the quality of care offered and by using quality measures to remove low-quality providers we can nudge the health care system towards value. Focusing on metrics that are actionable by physicians, managers, purchasers, professional associations, and regulators mean that when they ratchet up quality, everyone benefits regardless of whether they were an uber-consumer or otherwise. Improving quality and moving to value should not be dependent on activating 300 million consumers to respond with their dollars and feet.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/22YbJhC
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