In August 2006, Health and Human Services (HHS) Secretary Mike Leavitt announced a Value-driven Health Care Initiative based on "four cornerstones," two of which involved transparency: reporting of price information and reporting of quality information. A decade later, in the eighth year of an administration of the opposite political party, HHS remains committed to this strategy, upping the ante with the rollout of five-star rating systems for each of the provider types that participate in the Medicare program. Soon another administration, also on record favoring consumer-directed health care, will take office.
In the view of most health policy analysts, reporting and transparency have an intrinsic value separate from their actual use by consumers to choose providers — publicizing quality information marshals the competitive instinct of professionals to protect their reputation and prestige, thereby incentivizing improvement. But the consumer advocate is concerned with how patients might be empowered by transparency tools — including how patients can be channeled to higher quality providers in the marketplace.
The author, as policy director for a group advocating the interest of end-stage renal disease patients, became involved in this issue in 2014 when HHS announced its intention to post five-star ratings on its Dialysis Facility Compare website. To satisfy his further interest in this subject as a health services researcher, the author filed a Freedom of Information Act request for the contractor reports commissioned by HHS to guide development of its transparency tools. These documents are of interest to the health policy community because they report results of survey and focus group research not publicly available in the scholarly literature, and we've posted them here.
What becomes evident when one asks actual consumers about quality information is that there is some disconnect between the quality communication process being implemented by HHS and the predisposition of health care consumers. This article identifies what might be called four health care transparency paradoxes — aspects of HHS transparency communications in which assumptions are contradicted by what consumers have told researchers.
Assumptions of HHS Health Care Transparency Tools
The goal of health care transparency is to drive consumers to providers with high quality and efficiency, thereby improving outcomes and reducing resource use. For instance, when a patient is diagnosed with end-stage renal disease, the assumption is that the patient will visit the Dialysis Facility Compare website, look at quality indicators, and choose a clinic based on those indicators. Similarly, a patient for whom joint replacement surgery is recommended would visit the Hospital Compare website to look at quality indicators and then choose a hospital at which to undergo the procedure.
As such, transparency as envisioned by HHS embraces what is sometimes called the consumerist approach to health care, in which competition in the market occurs at the level of the individual provider. Porter and Teisberg argue that competition "should occur in the prevention, diagnosis, and treatment of individual health conditions or co-occurring conditions. It is at this level that true value is created… [a]nd it is here where competition would drive improvements in efficiency and effectiveness, reduce errors, and spark innovation." An alternative approach, managed competition, invites consumers to choose an insurer/provider network dyad, with the selection of individual providers made by professionals within that dyad.
Health Care Transparency Paradoxes
Since 2014 a key priority for HHS policymakers has been "making it easier to use the information on our Compare sites." HHS went to work developing five-star rating systems for the Compare websites, and apparently is giving consideration to a new tool to be called "Carefinder.gov."
Various components of CMS commissioned research to inform the creation of these tools. At least two CMS contractors gauged consumer attitudes. The resulting documents discussed here are: "Quality Measures Survey 2014," an online poll of 800 consumers conducted by Aeffect; and "Topline Findings from Focus Groups around Media Use and Comparison Information," conducted by L&M and Mathematica Policy Research.
Four themes emerge from the reports:
Physicians, not websites, are the most trusted source of information about health care
Aeffect's survey found that a doctor's recommendation or referral has the highest influence on consumers' selection, (77 percent in choosing a hospital, 73 percent in choosing a doctor), with 61 percent citing quality ratings as an influence. Most participants in focus groups conducted by L&M said that their "most trusted" resource for finding a doctor was a "physician or nurse" (58 percent), compared to 47 percent citing "friends/family," 14 percent "insurance or drug plan," and 6 percent "internet."
Aeffect reported that about a third of respondents had visited a website with reviews of hospitals or doctors, although it is difficult to credit this finding in light of other surveys that find use in the 10-13 percent range. (My organization's surveys of end-stage renal disease patients consistently find that only around a tenth have visited CMS' Dialysis Facility Compare website.)
There is ambivalence about the role of government as a source of quality information
Of brands presented to respondents in Aeffect's survey, Consumer Reports (50 percent) and AARP (37 percent) outpolled "US Government Healthcare Quality Reporting Website" (36 percent) and Medicare (32 percent). The L&M focus groups expressed "mixed reactions and raised doubts about government involvement in quality ratings information. At least one participant in each group expressed skepticism about "trusting 'the government' to compile information." Yet participants gravitated to ".gov" websites over ".org" websites as a more authoritative source.
Quality measures don't report what consumers want to know most
Aeffect's survey presented consumers with the familiar "STEEEP" dimensions of quality and asked them to rank their importance. "Nearly half of respondents select treatment effectiveness as either the most important or second most important factor." One imagines these consumers wondering "Will this cataract surgery leave me seeing better?" or "Will this hip replacement reduce my pain and restore a normal level of activity?" but such data is not available on CMS' Compare sites. Probably the closest CMS quality sites come to reporting effectiveness are mortality measures for heart attack and dialysis patients, but treatment for heart attacks may not be "shoppable."
Many consumers don't feel empowered to act upon ratings
L&M reported that their focus group participants "were largely unaware that they had options or choice in picking a surgeon or hospital," with one saying "you don't get to pick your surgeon, your doctor refers you to a surgeon." Others believed that their choices were limited by insurance networks and proximity to their residence. The former belief would be true of most commercial insurance, but unfettered freedom of choice is a foundation of fee-for-service Medicare, making the fact that none of the participants had ever heard of the CMS Compare tools prior to July 2015 somewhat ironic.
Transparency tools are supposed to impact health care markets by driving patient choices, but the degree to which this behavior will materialize remains uncertain. The good news is that HHS appears committed to developing and collecting patient-reported outcome measures that address one of the paradoxes. But here are three questions the contractors' findings provoked in this reader:
If consumers continue to rely on doctor referrals to hospitals and specialists, how can we incentivize doctors to use their influence to channel patients to the best providers?
If quality measures are more likely to be known by providers than by consumers, does it make sense for policymakers to be more deferential to provider preferences about how they are to be measured? If providers accord greater legitimacy to measures, wouldn't they be more likely to use them for goal setting?
Is the federal government an appropriate entity to rate providers? Collection of quality data is surely a public good, but it does not necessarily follow that the government must aggregate this data, determine cut points that separate the "good" from the "fair," and add a federal imprimatur to quality judgments — especially when so many private-sector entities are active in this space.
A final observation worth considering is that CMS' star rating programs exist wholly apart from another of the agency's top priorities: alternative payment models. A beneficiary considering a joint replacement can retrieve aggregated quality measures for a hospital but whether that hospital has volunteered for a payment bundling arrangement is not publicized on the Hospital Compare site. Participation in a program, such as Bundled Payment for Care Improvement Initiative, that puts providers at financial risk for complications can be viewed by consumers as akin to a "warranty" for quality outcomes. This information would seem as relevant to a consumer's choice as, say, process measures relating to antibiotic use.
Given the ubiquity of the internet in so many consumer transactions it is perhaps hard to believe that the Compare sites are not more heavily trafficked. But policymakers should heed the findings of the research they commissioned and explore means of patient engagement that meet beneficiaries where they are.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2iEM40n
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