Slide 1
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
Slide 2
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
Slide 3
Pressure for Transparency
Stakeholder Perspectives
Incentives to Promote
Information Transparency
Implementation Challenges
The Future: How To Use
This Information
Slide 4
When it’s time to purchase a car, we go to www.consumerreports.org
Pressure For Transparency
Slide 5
To evaluate a mutual fund, we go to www.morningstar.com
Pressure For Transparency
Slide 6
Current State
• There are already quality data out there
• However, the source and usefulness of the data vary
Pressure For Transparency
Slide 7
Slide 8
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
Pressure For Transparency
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, 2002.
Slide 9
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
Pressure For Transparency
Source: Heffler, Stephen, et al, “Health Spending Projections for 2002-2012,” Health Affairs Web Exclusive, February 7, 2003.
Slide 10
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
Pressure For Transparency
Slide 11
Pressure for Transparency
Stakeholder Perspectives
Incentives to Promote
Information Transparency
Implementation Challenges
The Future: How To Use
This Information
Slide 12
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?
Stakeholder Perspectives
Slide 13
In 2002, impact of quality ratings on consumers was negligible
Stakeholder Perspectives
Source: Harris Poll, 2002, http://www.harrisinteractive.com.
Slide 14
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)
Stakeholder Perspectives
Slide 15
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
Stakeholder Perspectives
Slide 16
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
Stakeholder Perspectives
Slide 17
Health plans are likely to combine patient education with financial incentives
Stakeholder Perspectives
Source: Milliman USA 2002 HMO Intercompany Rate Survey
Slide 18
Pacificare Quality Index
Stakeholder Perspectives
Slide 19
Tufts Health Plan Physician Group Profile
Stakeholder Perspectives
Slide 20
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
Stakeholder Perspectives
How much is enough?Should the “pay for performance” measures be
self-financing?
Slide 21
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
Stakeholder Perspectives
Slide 22
Dialysis Compare @ www.medicare.gov
http://www.medicare.gov/Dialysis/Search/QualityCompare/QualityCompare.asp
Stakeholder Perspectives
Percent of the facility's patients who received adequate hemodialysis in 2002
Slide 23
Dialysis Compare @ www.medicare.gov
Stakeholder Perspectives
Patient Survival: Actual Compared to Expected (January 1999 - December 2002)
Patient Survival for the Facilities you Selected is:
Slide 24
Dialysis Compare @ www.medicare.gov
Stakeholder Perspectives
Percent of the facility's patients treated for anemia (low blood count) in 2002* that were adequately managed
Slide 25
Nursing Home Ratings: CMS
Stakeholder Perspectives
Slide 26
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
Stakeholder Perspectives
Slide 27
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
Stakeholder Perspectives
The Wisconsin Hospital Association recently initiated the http://www.wicheckpoint.org/ web site where quality indices
(JCAHO Core Measures) of 122 hospitals are listed
Slide 28
Wisconsin Hospital Association Quality Ratings
Stakeholder Perspectives
Slide 29
New York State Hospital Quality Ratings
Stakeholder Perspectives
Interpretation: N, Confidence Range, Risk-Adjusted Mortality
http://www.myhealthfinder.com/newyork/full.php?table=15
Slide 31
Pressure for Transparency
Stakeholder Perspectives
Incentives to Promote
Information Transparency
Implementation Challenges
The Future: How To Use
This Information
Slide 32
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
Implementation Challenges
Slide 33
Report card authors face difficult choices
Implementation Challenges
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
Slide 34
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
Implementation Challenges
Slide 37
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
Slide 38
Pressure for Transparency
Stakeholder Perspectives
Incentives to Promote
Information Transparency
Implementation Challenges
The Future: How To Use
This Information
Slide 39
Leapfrog Quadrants
Incentives for Transparency
The Leapfrog methodology gives some credit just for reporting
Slide 40
Bridges to Excellence Program
Incentives for Transparency
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.
Slide 41
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
Incentives for Transparency
Slide 42
Pressure for Transparency
Stakeholder Perspectives
Incentives to Promote
Information Transparency
Implementation Challenges
The Future: How To Use
This Information
Slide 43
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
Slide 44
More robust credentialing, especially for volume-sensitive procedures
Future Uses of Information
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.…
Slide 45
Future Uses of InformationHealth Plan Leadership in Identifying E2 MDs
E2 = efficient and effectiveSource: The Leapfrog Group
Slide 46
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
Future Uses of Information
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
Slide 47
Elements that are publicly reported will garner the lion’s share of resources for improvement
Future Uses of Information
Quality improvement
programs aimed at issues not
subject to public reporting
Quality improvement
projects aimed at issues that ARE subject to public
reporting
Slide 48
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.
Slide 49
….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
Slide 50
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
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