Communicating Health Care Quality To Consumers

Communicating Health Care Quality To Consumers

Adapted from a talk given to the Managed Care Executive Group on March 25, 2004 by Brad Fluegel, CEO of Reden & Anders, and Jeff Levin-Scherz, CMO, Partners Community HealthCare, Inc

Partners Quality Measurement CommitteeMay 11, 2004

Goals

• Describe pressures to increase information transparency on health care quality

• Evaluate stakeholder implications• Describe implementation challenges • Examine incentives to promote information

transparency in health care quality• Suggest future impact of availability of health care

quality data

Introduction

Pressure for Transparency

Stakeholder Perspectives

Incentives to Promote

Information Transparency

Implementation Challenges

The Future: How To Use

This Information

When it’s time to purchase a car, we go to www.consumerreports.org

Pressure For Transparency

To evaluate a mutual fund, we go to www.morningstar.com


Current State

• There are already quality data out there

• However, the source and usefulness of the data vary


http://www.bostonmagazine.com/

Increasing total financial cost of medical care will also drive demand for increased information about value

$1,300$1,424

$1,546

$1,902

$2,816

17.0%

15.6%14.7%

14.0%13.2%

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

2000 2001(e) 2002(e) 2005(e) 2010(e)

NH

E in

Bill

ions

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Perc

ent o

f GD

P

National Health Expenditures Percent of GDP


Source: Centers for Medicare and Medicaid Services, Office of the Actuary, 2002.

Increasing consumer financial responsibility will increase pressure for information transparency

Consumer Out of Pocket Payments

$218.0 $231.3

$315.0

$205.5$194.7

$146.9$118.9

$396.3

$0$50

$100$150$200$250$300$350$400$450

1988 1993 2000 2001 2002 2003 2008 2012

Billi

ons


Source: Heffler, Stephen, et al, “Health Spending Projections for 2002-2012,” Health Affairs Web Exclusive, February 7, 2003.

Growing interest in consumer directed health care will also increase pressure for information transparency

• Employers are looking to shift more responsibility in terms of health care selection, cost and utilization

• Cost savings may have been squeezed out of managed care practices

• Consumer directed health care presents several opportunities– Increased employee accountability– Enables consumerism and cost-effective use of services– Requires employee tools

• Web-based health information• Health risk assessments• Provider pricing and quality information

– Encourages provider competition in terms of price and quality








This Information

Consumers demand (but often ignore) information on health care quality

• When is information available?– Time of selecting care?– Time of enrollment in health plan?

• Is information readily understandable?– Reading level– Implications

• Is the information relevant to the consumer?– At the level of consumer decision-making?– Appropriate based on consumer demographics?

• Are statistics appropriately conveyed graphically?


In 2002, impact of quality ratings on consumers was negligible


Source: Harris Poll, 2002, http://www.harrisinteractive.com.

Other consumer findings from Harris Poll

• Quality is…– More $ and more treatment– Having choices– Being in a waiting room with people who earn more money than

you– Evidence based medicine and community health applied

systematically– The right to sue

• A subsequent Forrester internet only poll is a bit more optimistic:– 11% used the internet to determine hospital or MD quality– 10% made choices based on this information– Demographics of this group are unusual (ie >50% broadband at

home)


Employers are pushing hard for information transparency (but not taking primary responsibility)

• Many would like to move away from responsibility for health care, and see consumer information as a means to get there

• Employer collaboratives are pushing health care parties to provide additional data– Leapfrog– Bridges to Excellence– Mercer and Group Insurance Commission (Massachusetts)– Niagara Business Group on Health

(http://www.myhealthfinder.com) – Many others


Health Plans want to stake out their role as providers of consumer information

• Although NCQA rates health plans, it is less and less relevant given that health plans increasingly have the same providers

• Health plans, historically differentiated by provider networks and care delivery, are now about benefit design and administration

• Fearful of loss of position on value chain


Health plans are likely to combine patient education with financial incentives


Source: Milliman USA 2002 HMO Intercompany Rate Survey

Pacificare Quality Index


Tufts Health Plan Physician Group Profile


Health plans and providers are increasingly adding quality measures to “pay for performance” contracts

• Discharge management• Outpatient management• Engagement with case and disease management

programs• Risk assessment• Generic utilization• Access to care


How much is enough?Should the “pay for performance” measures be

self-financing?

Government has led the way in providing health care quality information

• HCFA produced hospital quality data in late 1980s– Criticized for lack of severity adjustment

• Pennsylvania Cost Containment Council– Hospital specific cardiac mortality and complication rates

• New York State– Cardiac surgery mortality and complications by facility and

individual surgeon• Massachusetts

– 1999: Law directed the Department of Public Health to produce data comparing cardiac surgery outcomes

– 2002: Debate about HIPAA implications of data request– 2004: Public report still not available


Dialysis Compare @ www.medicare.gov

http://www.medicare.gov/Dialysis/Search/QualityCompare/QualityCompare.asp


Percent of the facility's patients who received adequate hemodialysis in 2002



Patient Survival: Actual Compared to Expected (January 1999 - December 2002)

Patient Survival for the Facilities you Selected is:



Percent of the facility's patients treated for anemia (low blood count) in 2002* that were adequately managed

Nursing Home Ratings: CMS


Physicians believe that they are all (far) above average in quality

• …and will generally quarrel with any data set that suggests otherwise.

• Questions raised on true intent of profiling• Administrative data is often

• Inconsistent or just plain wrong• Less than timely• Difficult to appropriately risk adjust

• Dilemma about profiling larger groups (more statistically valid but more heterogeneous and less useful to patients) or individual doctors (less valid but more useful to patients)

• Providers will devote considerable effort to those measures that will be disclosed…and might neglect other, more important clinical issues


Hospitals also believe they are above average in quality

• Longer history of regulation and reporting• Leapfrog acceptance rate up

– 59% of queried hospitals in 22 regions responded – 410 additional hospitals responded voluntarily

• JCAHO core measures• Claims data are inaccurate and unreliable, but the

most readily available source of information


The Wisconsin Hospital Association recently initiated the http://www.wicheckpoint.org/ web site where quality indices

(JCAHO Core Measures) of 122 hospitals are listed

Wisconsin Hospital Association Quality Ratings


New York State Hospital Quality Ratings


Interpretation: N, Confidence Range, Risk-Adjusted Mortality

http://www.myhealthfinder.com/newyork/full.php?table=15







This Information

Implementation challenges

• Metrics• Opportunity to educate often not proximate to

decision point• Public transparency can discourage complete

reporting of complications• Difficult to get “winners” to play• Presentation


Report card authors face difficult choices


Choice Approach Issues

Source of data Claims Easy and cheap to obtain, but inaccurate

Chart review More accurate, but very expensive

Level of reporting Large groups of physicians

Heterogeneous, more valid statistically, less useful to patients

Individual physician “n” too small, hard to do risk adjustment, most useful to patients

Display of data Stars or bar graphs Intuitive and familiar to consumers but inaccurate

Statistical ranges Closer to “truth,” but more difficult to explain

Report card subjects can find plenty of (valid) reasons to object strenuously

• Data integrity• Timeliness• Comparability of data• Benchmark determination• Validity of measures as indicators of quality• Appropriateness of display methodology• Distraction of attention from other quality

improvement objectives


What if the data just don’t seem to make sense?

Challenges in Presentation

WHITE COAT NOTES NEWS FROM BOSTON'S MEDICAL AND SCIENTIFIC COMMUNITY;A NEW WAY TO RANK HOSPITAL QUALITY

Boston Globe, March 2, 2004“Tops in Heart Attack Care”• Winchester Hospital• Melrose-Wakefield Hospital• South Shore Hospital• Brockton Hospital• Massachusetts General Hospital (5)• Beth Israel Deaconess (23)• New England Medical Center• Brigham and Women's Hospital (3)• Boston Medical Center• Beverly Hospital

…it's enough to get a patient thinking: Am I going to an outlier hospital?" -ManagerHealth Share

Technology







This Information

Leapfrog Quadrants

Incentives for Transparency

The Leapfrog methodology gives some credit just for reporting

Bridges to Excellence Program


Clinical Information

System

Patient Education & Support

Care Management Total for meeting all measures

Level A Y1 $20 $10 $15 $50

Y2 $15 $5 $10 $35

Y3 $10 $5 $5 $25

Level B Y1 $20 $10 $15 $50

Y2 $20 $5 $10 $40

Y3 $15 $5 $5 $30

Level C Y1 $20 $10 $15 $50

Y2 $20 $10 $15 $50

Y3 $20 $10 $15 $50

Year 1 total based on 200 patients

$4,000 $2,000 $3,000 $10,000

Bridges to Excellence pays physicians based on meeting certain criteria.

Pay for Performance Contracting

• CMS has agreed with Premier Hospital System– Incentive payments of 1-2% on Medicare members for

hospitals in top 10-20%iles for quality measures

• Blue Shield of California– Incentive payments for hospitals with top quality rankings

• Harvard Pilgrim Health Care– Incentive payments for delivery systems with high HEDIS

scores

• Tufts Health Care– Incentive payments for delivery systems with high HEDIS

scores and improvements in Leapfrog measures








This Information

Tiering of consumer copayment or health care premium by quality and efficiency

• Already in place in some health plans– HealthNet– Pacificare– Harvard Pilgrim – Aetna

• Likely to increase as part of consumer directed health care

Future Uses of Information

More robust credentialing, especially for volume-sensitive procedures


HMO Rates Hospitals; Many Don't Like It, But They Get Better --- Heart-Care Assessment Finds Reputation and Reality Don't Necessarily Match

WSJ April 22, 1999…Anthem uses the survey to eliminate all but the top 15 such units from its million-member health-maintenance organization in Ohio, the state's largest. That gives them all an incentive to do what it takes to rate well.

-- UnitedHealth Creates New Premium Network(SM)to Expand Patient Access to Better Health Outcomes through Program PR Newswire, April 22, 2004

UnitedHealth Group (NYSE:UNH <stock_info.asp?ticker=UNH>), citing significant gains in health outcomes and affordability, today announced the expansion of its long -established Centers of Excellence programs for complex health conditions.…

Future Uses of InformationHealth Plan Leadership in Identifying E2 MDs

E2 = efficient and effectiveSource: The Leapfrog Group

Purchasers will be better able to “shop for value”

• But providers will also have a greater sense of their value, and will charge for it


0

50

100

150

200

250

300

350

400

450

Carotid Endarterectomy Volume

These hospitals perform 24% of all CEAs for a commercial health plan

Beth Israel Deaconess* 227Brigham and Women's* 216Lahey Clinic* 110Mass. General* 382Saint Vincent* 118St. Luke's 119U. of Mass. Med. Cr.* 168U. of Mass. Memorial* 109

Elements that are publicly reported will garner the lion’s share of resources for improvement


Quality improvement

programs aimed at issues not

subject to public reporting

Quality improvement

projects aimed at issues that ARE subject to public

reporting

Doctor 'Scorecards' Are ProposedIn a Health-Care Quality DriveMarch 25, 2004; Page A1In one of the most ambitious efforts yet to provide health-care quality ratings for consumers, 28 large employers, including Sprint Corp., Lowe's Cos., BellSouth Corp., J.C. Penney Co. and Morgan Stanley are teaming up to develop "scorecards" to help employees choose doctors based on how well they care for patients -- and how cost-efficient they are.

….claims data remains the only reliable source to verify the treatments doctors use and the drugs they prescribe. "It's imperfect, but it's better than being totally blind…"

Arnold MillsteinMercer Consulting

"This is a very hard issue…The more quality measures, the better, but we don't want the information to be misleading. Without the appropriate statistical models, every time you start ranking doctors or putting a number of stars next to their name people are going to be misclassified…”Bruce Landon MD MBAHarvard Medical SchoolQuoted in Landro, L “Doctor 'Scorecards' Are Proposed In a

Health-Care Quality Drive” Wall Street Journal March 25, 2004

Resources• www.talkingquality.gov• www.ncqa.org• www.medicare.gov/Dialysis/Home.asp• www.medicare.gov/NHCompare/Home.asp• www.myhealthfinder.com• http://www.wicheckpoint.org/• Rosenstein, AH “Hospital Report Cards, Friend or Foe?” JCOM

11:98 (2004)• Krumholz, HM et al “Evaluation of a Consumer-Oriented Internet

Health Care Report Care” JAMA 278:10 (2002)• Landro, L “Doctor 'Scorecards' Are Proposed In a Health-Care

Quality Drive” Wall Street Journal March 25, 2004

Communicating Health Care Quality To Consumers

Documents

Transcript of Communicating Health Care Quality To Consumers