Health Affairs

When making health care choices, is there a relationship between what health care consumers pay and the quality of services they receive?

While this has been long debated, a soon-to-be published survey commissioned this year by the California HealthCare Foundation (CHCF) found uncertainty about the relationship between the cost and quality of care. The survey queried 1,500 California residents whether they thought higher price was associated with better care.  Thirty percent of respondents thought it was, while 65 percent assumed the care was probably about the same, regardless of price.

This survey – and others like it – continues to show that most consumers are uncertain about how to factor price into the way they shop for health care services. As health care costs continue to outpace inflation rates of other goods and services, however, consumers are increasingly faced with new health benefit plan provisions that encourage them to become better shoppers.  By increasing their awareness of the actual costs of the care they seek – through high-deductible health plans and other approaches –  the theory is that making choices of financial consequence will lead consumers to take greater control of their health care decision making. The hope is that consumers will choose the best quality providers for a given cost.

If We Build It, Will They Come?

But in spite of an explosion of available online health care quality information, U.S. consumers, who are more frequently researching simple decisions online, have been reluctant to adopt the same behaviors to research their health care options. They may be going online to search out the best movie screening times, look for a free table at their favorite restaurant, or compare hotel prices, but when it comes to researching aspects of their health and health care, consumers have been slow to jump on the Web.

For those consumers who do conduct significant research before making health care choices, sorting out the good information from the bad has become an increasing challenge.  There are now more than 200 Web sites competing for consumer attention. Each uses different quality measures, calculated in different ways. Added to that, the materials are often displayed in highly complex tables and charts.  Is this making things clearer or ever yet more confusing in an era of information overload?

Another CHCF-commissioned survey shows that few Californians (fewer than 25 percent) are aware of available resources on health care quality and cost.  The question is, with such important decisions at stake, why are these rates so low? If consumers are not aware of the information available to them, is it still worth hospital and health plan investments to create, collect, and display the data?

Throughout its 12-year history, transparency has been a cornerstone of CHCF’s work in the area of cost and quality.  As part of this program, the foundation, a $750-million nonprofit philanthropy and health policy think tank based in Oakland, Calif., oversees two resources for Californians, CalHospitalCompare.org, which provides consumers with comparative hospital quality rating data to help them make well-informed choices, and CalQualityCare.org, which helps consumers compare long-term care facility quality to research–either for themselves or family members.

Yet, even with years of experience, extensive user testing, and resulting state-of-the-art display, we have not seen a dramatic increase in the percentage of consumers who “shop” for health care providers.

Just-in-Time Engagement?

Is there something more about human behavior that accounts for this lack of engagement? Health policy researcher Atul Gawande’s work, referenced in the widely cited book The Paradox of Choice by Barry Schwartz, notes that patients often prefer to have others make their health care decisions for them. Gawande states that as many as 65 percent of those surveyed say that if they were to get cancer they would want to choose their own treatment; however, he notes, among those who do in fact contract cancer, only 12 percent actually want to direct their own care.

In addition, a May 1997 study in the Journal of the American Medical Association on information and decision preferences in women with breast cancer found that only 22 percent of those surveyed wanted to select their own cancer treatment; 44 percent wanted to collaborate on their treatment choices with physicians, and 34 percent want to delegate this responsibility to their physicians.  When life-and-death decisions are at stake, it appears many still want an expert guide to lead the way.

Credible Threat?

Despite these issues with respect to health care consumers, our experience has confirmed there is a real audience for quality and performance data from “within” the health care industry – hospital boards, hospital management and administration, and health plan leadership.  Providing a stable and transparent set of metrics helps to focus improvement in areas that matter to health plans and other purchasers. In an age of tighter and tighter margins and fierce competition, hospitals and health plans perceive that their continued survival depends on proving the value and quality of their services.  No one wants to be referred to a “Center of Mediocre Care”.

The question is, will this perceived “credible threat” of consumer engagement be enough over time to keep hospitals and health plans engaged and moving ahead with sustained quality-reporting efforts?  If hospitals and doctors think there is no one using this information, will they continue to invest the time to collect it?  Is the “threat” of consumers shopping for health care enough?  And, if not, what can be done to unleash the power of health care consumers?

So what do we need to do to close the gap between what health consumers want to know and what data is currently available from providers? Perhaps we are compounding the problem by measuring the “wrong” things.  We already understand a great deal about how certain providers, such as hospitals, perform on a variety of certain health conditions—cardiac care and pneumonia are two good examples. Unfortunately though, we know almost nothing about quality performance for some very high-cost, high-volume conditions such as joint replacements and — even worse — some life-and-death conditions, such as various cancers.

Health care consumers are therefore frustrated because it is just these types of conditions they want to research, as quickly as possible, at a critical time that they need to be making informed decisions about their care.

A Push to Standardize

To help patients and their family members better understand that health care quality does indeed vary from facility to facility and provider to provider, there is need for greater standardization in quality reporting, as well as standardized means of making this information more accessible to health care consumers.  One path is to understand the different needs of different “shopping” groups.  For relatively low-risk conditions, such as maternity care, process measures and measures linked to patient preference may take precedence over mortality measures for which there is little clinical variation.  Here measures like breastfeeding rates at discharge – applicable to every birth – trump infant mortality rates, which remain fortunately rare occurrences.  Conversely, for very serious conditions with highly variable outcomes, clinical quality measures can be used to differentiate performance.  Even if consumers are not likely to use this information, it should be available to their physicians and other advisers to encourage appropriate referrals.

Communication is Key

Ideally, information that helps consumers make substantive choices about quality of care should be available at the time they are faced with serious health care decisions, and be presented at a level of detail they can understand.

Along those lines, CHCF has devoted significant time and resources to help make comparative hospital quality data understandable for health care consumers. CalHospitalCompare.org is the result of a partnership between CHCF, the University of California, San Francisco (UCSF), and the California Hospitals Assessment and Reporting Taskforce (CHART), a not-for-profit public benefit corporation. The comparative hospital quality data on the site for more than 240 California facilities (representing 85 percent of the state’s acute care hospital admissions) is displayed in a user-friendly format, rating hospitals on the spectrum of “poor” to “superior,” based on an algorithm of specific quality measures.

CalQualityCare.org, another CHCF partnership with UCSF, aims to do just that—help arm health consumers with key information at the time of a critical health care decision point. At the time an individual is faced with making a long-term care decision for himself or a family member, the site takes some of the guesswork out of choosing a long-term care provider. By providing  free, unbiased, and easy-to-use comparative information about the quality of care these facilities deliver, the site helps  health care consumers and their families choose among the many options that exist—from nursing homes, to home health care agencies, to assisted living facilities.

In addition to the critical aspect of timely assistance, many current public reporting systems tend to get tied up by focusing on the complexity of the data, rather than working to simplify it for the average health care consumer.  Behavioral economics research shows that when processing complex information, consumers generally go for the “default” option – extrapolating from the first piece of relevant information they find.

In designing information for display on these Web sites, CHCF strived to put the most critical pieces of information first (mortality rates) but also to include other information of interest to users (such  as patient experience data). This is the equivalent to putting impulse items at eye level at the check-out stand.

If we are expecting consumers to play a critical role in choosing the best path, we must help them better navigate the twists in the road, providing them with easily understandable roadmaps.

This entry was posted on Tuesday, October 4th, 2011 at 1:38 pm and is filed under All Categories, Competition, Consumers, Health Care Costs, Hospitals, Long-Term Care, Quality, States. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.