What's New with HCFO - 08/14/2006
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In this issue:
The Informed Patient: Do Consumers Have the Tools To Make Healthcare Decisions?
Grantee Spotlight – Curtis Florence, Ph.D.
This Month in the News
Spotlight on Grantee Publication
New HCFO Findings Brief
New HCFO Grant Announced
AcademyHealth Health Policy Orientation: Behind the Scenes of Decision Making in Washington
New NCHS Data Available for Researchers
Conflicts of Interest Curriculum Module
The Informed Patient: Do Consumers Have the Tools To Make Healthcare Decisions?
The Institute of Medicine highlighted a trend toward increased responsibility for consumers in health care in a 2004 report stating, “[i]ndividuals are asked to assume new roles in seeking information, advocating for their rights and privacy, understanding responsibilities, measuring and monitoring their own health and that of their community, and making decisions about insurance and options for care.”1 In keeping with the trend, President Bush, in May 2006, outlined five key policies to make health care more affordable and accessible for all Americans.2 His top two recommendations were to: 1) expand Health Savings Accounts (HSAs); and 2) increase price transparency.3 Both of these initiatives require consumers to be more involved in their health care decisions, demanding increased knowledge about the health care system, health insurance plans, and the treatment and prevention of disease. Congress and the states have also supported policies leading to a larger role for consumers in health care.4 This increased attention to the consumer’s role in health care raises an important question: are there appropriate and useful tools for consumers as they struggle to make decisions about their health insurance coverage, as well as their treatment?
What tools are available for consumers?
Tools such as pamphlets and advertisements provide consumers with information about various conditions and treatments. One of the major challenges, however, was identifying the person who needed the information and making tools available to them on a timely basis. With the advent of the internet, searching for and disseminating information has become easier and less costly. A recent Harris Interactive poll found that eighty percent of adults with internet access report seeking health care information online.5 Over the past several years, websites such as WebMD have emerged to provide basic health information to consumers. Consumers cannot depend on all web-based health information to be accurate, however. A recent article in The Washington Post profiled a consumer attempting to use the internet to obtain health information.6 Among his “hits” were medical sites that provided in-depth information about conditions and treatments, as well as sites that provided false information. Consumers must therefore be able to differentiate between reputable and legitimate information and other information.
The Agency for Healthcare Research and Quality (AHRQ) develops and maintains guidelines for quality care, including an annual report on quality care, which is available to the public.7 AHRQ offers a variety of tools, for both direct consumer use and for providers to use and distribute to patients, which explain specific conditions and treatments, as well as guides to improving and maintaining a healthy lifestyle. An AHRQ sponsored website, “Quality Tools”, offers consumers, providers, payers, and policymakers tools that help facilitate quality healthcare. Such tools aim to provide an objective view of specific conditions and treatment options, which differ from the mainstream direct-to-consumer ads that have surfaced in recent years promoting specific treatments or diagnostic tools.
In addition to tools that help to explain conditions and treatment options consumers may seek help in identifying high quality providers. Under the Department of Health and Human Services’ (HHS) Quality Initiative, the Centers for Medicare and Medicaid Services (CMS) launched four websites to assist consumers in their choice of providers. These websites are designed to track the quality of nursing homes, hospitals, home health agencies, and dialysis facilities, “to assure quality health care for all Americans through accountability and public disclosure.”8 CMS recently announced that it will expand its “Hospital Compare” website to include mortality rates, additional quality measures, and patient satisfaction.9
There are also tools that help consumers in the individual health insurance market sort through their insurance choices. Such sites attempt not only to help consumers find plans that fit their needs, but also to explain key health insurance terminology and the laws, both nationally and by states, that regulate health insurance.10 For example, CMS provides Medicare beneficiaries with two websites that help them find Medicare Advantage and Medicare Prescription Drug plans that fit their needs.11, 12
Are consumer health tools useful and appropriate?
While there is clearly an abundance of medical information available to consumers, both through the internet and through more traditional outlets such as pamphlets handed out in physician’s offices and television advertising, much can still be done to improve information available to inform patients’ healthcare decision-making.
While informed patients are becoming accepted by the provider community, it is important to note that consumers cannot always assess the validity of the information available.13 Consumers are increasingly being bombarded with information that is provided by a biased party, such as a pharmaceutical company. Studies have shown that consumer response to direct-to-consumer advertisements for specific medications affect the treatment plans of physicians, even if the advertised treatment may not be the most effective.14 This reinforces the need for more research on the consumer behavior and the tools that are available to guide them, in addition to the creation of objective, evidence–based tools that can be used collectively by consumers and providers.
HCFO has funded several projects that examine consumer healthcare decision-making behavior and the tools available to guide these decisions, in their many forms. Judith Hibbard, Ph.D., of the University of Oregon, examined how information on health plan quality can be effectively presented to consumers. Hibbard found that information is more likely to be understood and used by consumers if it is easier to map onto a good/bad scale. Katherine M. Harris, Ph.D., of the RAND Corporation, examined whether health status affects the impact of quality information on health plan and physician choices. Harris found that only 27 percent of consumers use formal sources of information (i.e. surveys, employers, or websites) to help them choose a physician. In another HCFO grant, Judith Hibbard, Ph.D. examined the impact of public hospital reporting in the state of Wisconsin. Hibbard found that public hospital reports influenced consumer views about the quality of individual hospitals in the community 2 to 4 months after the release of the report. Meredith B. Rosenthal, Ph.D., of the Harvard School of Public Health, examined the impact of performance reporting on consumer and physician behavior. Rosenthal found that new health plan enrollees were more likely to choose medical groups that performed well on clinical metrics after the publication of public report cards than they were before these reports were made. These and other projects funded by HCFO, described below, are adding to the growing literature on how consumers use information to make choices in health care.
HCFO Related Projects
Title: Methods to Present Quality Information to Assist Consumers to Make Health Plan Decisions
Institution: University of Oregon
Principal Investigator: Judith Hibbard, Ph.D.
Grant Duration: January, 1999 - March, 2000
Paragraph Summary: How can information on health plan quality be most effectively presented to consumers? Researchers at the University of Oregon used laboratory studies to examine how consumers process and integrate information in making choices about health plan. While there are many health plan "report cards" available to consumers, little is known about how consumers actually use the information they are given to make decisions. Consumers in a cognitive laboratory situation were presented with different types of information on health plan quality, in different formats, and asked about how they use the information in their decision-making process. The researchers also assessed how specific pieces of information are used and weighted in decisions. The objective of the study was to help determine how best to present information on health plan quality so that it is valued and understood by consumers, and so that consumers can make the maximum use of information on quality when choosing a health plan.
Title: The Impact of Quality Information on Consumer Plan Choices: Does Health Status Matter?
Institution: RAND Corporation
Principal Investigator: Katherine M. Harris, Ph.D.
Grant Duration: July, 2001 - June, 2002
Paragraph Summary: What is the impact of health status on consumers' use of quality information in making health plan choices? Using an Internet-based survey, researchers at RAND will build on a dataset collected as part of an AHRQ-funded small grant to include a series of health status and service use measures. They are addressing the following research questions: What is the effect of health status and experience with the health care delivery system on (1) the overall impact of quality information on plan choices, (2) the relative impact of various forms of information on plan choices, and (3) the trade-offs between provider access and quality that consumers make in choosing health plans? The objective of the study is to inform policy makers and employers whether the substantial investment in the collection and dissemination of plan performance measures which is designed to support consumers’ plan choices also meets the needs and concerns of those in poor health status for whom the consequences of plan choice are the greatest.
Grantee Publications:
Title: How do Patients Choose Physicians? Evidence from a National Survey of Enrollees in Employment-Related Health Plans
Author(s): Harris KM
Journal: Health Services Research
Volume: 38(2)
Date: April 2003
Title: Assessing the Impact of a Public Report on Hospital Quality: A Controlled Experiment in the State of Wisconsin
Institution: University of Oregon
Principal Investigator: Judith H. Hibbard, Dr. P.H.
Grant Duration: September, 2001 - May, 2005
Paragraph Summary: How do hospitals react to public reports of their quality and how do such reports influence consumers’ perceptions of hospital quality? This study, conducted by researchers at the University of Oregon, will assess whether public reports of quality lead to improvement efforts within hospitals. The researchers also are studying whether the public reports create a general impression among consumers about the quality and safety of hospitals in the community. Hibbard and her colleagues are working with The Alliance, a large purchasing group based in Madison, Wisconsin, that will disseminate the public report. The researchers are conducting a controlled experiment in which hospitals will be assigned to one of the following three groups. Hospitals in The Alliance, 25 in the region surrounding Madison, will be included in the public report. The remaining 100 hospitals in Wisconsin will be separated by size (large and small) and randomly assigned to either the other treatment group or the control group. The second treatment group will receive a report of their own performance compared with other hospitals that will not be made public. The control group will not receive any reports. The objective of the study is to assess whether public reporting of hospital quality motivated improved behavior and performance and how public reporting affects consumer perceptions of hospital quality.
Grantee Publications:
Title: Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts?
Author(s): Hibbard J, Stockard J, and Tusler M
Journal: Health Affairs
Volume: 22(2)
Date: March/April 2003
Title: It Isn't Just about Choice: The Potential of a Public Performance Report to Affect the Public Images of Hospitals
Author(s): Hibbard J, Stockard J, Tusler, M
Journal: Medical Care Research and Review
Volume: 62 (3)
Date: June 2005
Title: The Impact of Performance Reporting on Consumer and Physician Organization Behavior
Institution: Harvard School of Public Health
Principal Investigator: Meredith B. Rosenthal, Ph.D.
Grant Duration: March, 2003 - October, 2004
Paragraph Summary: How are public “report cards” on consumer and physician behavior being disseminated? The researchers evaluated PacifiCare’s Quality Index report cards which provide a relative performance assessment of provider groups in selected areas of clinical, service and administrative quality. The researchers tested (1) how new and continuing health plan enrollees use comparative quality information to select a physician group; (2) how mobilization of consumer choice based on comparative quality information drives physician group performance improvements; and (3) how physician groups are responding to performance measurement when data are used for confidential benchmarking only while other dimensions of quality are reported to consumers. This project fills an information gap concerning the value of publicly reported quality information and to provides guidance to public and private decision makers on the measurement and dissemination of provider quality information.
Grantee Publications:
Title: Doughnut Hole Economics
Author(s): Rosenthal M
Journal: Health Affairs
Volume: 23(6)
Date: November/December 2004
Title: Testing the Value of Patient-reported Physician Quality Information for Quality Improvement and Consumer Choice
Institution: Pacific Business Group on Health
Principal Investigator: Ted von Glahn
Grant Duration: December, 2004 - June, 2006
Paragraph Summary: What is the value of periodic reporting of patient-reported quality information for quality improvement and consumer choice? The researcher is evaluating the impact of patient-reported physician performance information on patient selection of doctors, quality improvement activity in group practices, and patient-reported performance measures. Specifically, the researcher is testing the premise that a brief survey of patient-reported physician experiences is valued by medical groups for quality improvement and by consumers for physician choice. The project includes a case-control study at two California group practices, where patient-reported performance scores are already linked to financial reimbursement levels in HMO and POS plans. The objective of the project is to help overcome resistance to the public reporting of physician quality performance by evaluating the value to medical groups and consumers of patient-reported survey results.
Title: Involving Consumers in Physician Choice: Making Data into Useable Information for Chronically Ill Patients in Consumer-Directed Health Plans
Institution: Massachusetts General Hospital
Principal Investigator: David Blumenthal, M.D.
Grant Duration: March, 2006 - August, 2007
Paragraph Summary: What tools will consumers need to help select high performing physicians, within CDHPs? Physician performance data is one of the tools that can be used to help consumers make these decisions. However, there are important opportunities and challenges facing consumer-directed health plans (CDHPs) trying to engage consumers in using physician performance data (PPD). The specific aims of the project are: 1) to develop methods for informing consumers about physician clinical performance; 2) to test the effectiveness of these methods in helping consumers with chronic conditions in CDHPs to make an informed choice of primary care physician (PCP); 3) to explore how consumer characteristics affect their ability to understand PPD and their response to that data. The objective of this study is to understand how and whether PPD can be appropriately and effectively used in CDHPs.
Title: The Impact of Consumer Health Plan Decision Support Tools on Health Plan Choice and Quality
Institution: University of Minnesota
Principal Investigator: Jean Marie Abraham, Ph.D.
Grant Duration: January, 2006 - April, 2007
Paragraph Summary: The researchers will examine the use of decision support tools to inform health plan selections. Because of the concern regarding the abilities of consumers to understand the financial implications of an array of complicated plan designs when choosing among health insurance options, decision support tools are being developed to help consumers evaluate their health plan options. In March of 2006, Ingenix will develop will release a Plan Cost Estimator (PCE) that can track use of individual employees and incorporate prior claims experience into the algorithm for producing cost estimates. Using this decision-support tool, the researchers will investigate the following research questions: 1) what factors are associated with the decision by an employer to provide a decision support tool for its workers during open enrollment; 2) which demographic, health status, and job-related factors are associated with a worker's use of the PCE tool; 3) does decision support tool use directly influence a worker's choice of health plan; and 4) is there an association between low-cost plan choices and quality, and by how much does expected quality change as a result of tool use. The objective of this study is to identify important managerial lessons for employers relative to employee health plan enrollment choices.
1 Nielson-Bohlman, L., et al. 2004. Health Literacy: A Prescription to End Confusion. Washington: The National Academies Press.
2 “Making Health Care More Affordable and Accessible for All Americans.” The White House. http://www.whitehouse.gov/infocus/healthcare/. Accessed: August 2, 2006.
3 Ibid.
4 U.S. House of Representatives. 109th Congress. “Expressing that the House of Representatives recognizes the rising cost of health care and encourages greater patient empowerment, choice, and responsibility in health care decisions.” H.Res. 876. June 16, 2006.
5 “Many Adults Seek Health Care Information Online, Poll Finds.” Kaiser Daily Health Policy Report. August 2, 2006. http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=38886.
6 Stoltz, Craig. “A 10-Year Checkup.” The Washington Post. August 1, 2006. http://www.washingtonpost.com/wp-dyn/content/article/2006/07/31/AR2006073100893.html.
7 National Healthcare Quality Report: 2005. http://www.qualitytools.ahrq.gov/qualityreport/2005/browse/browse.aspx. Accessed: August 7, 2006.
8 “Search Tools.” Centers for Medicare and Medicaid Services. http://www.medicare.gov. Accessed: August 2, 2006.
9 Robeznieks, Andis. “Quality Groups Announce Plans to Expand Web Site.” Modernhealthcare.com. Accessed July 31, 2006.
10 http://www.healthinsurance.org. Accessed: August 7, 2006.
11 “Medicare Prescription Drug Plan Finder.” http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?version=default&browser=IE%7C6%7CWinXP&language=English&defaultstatus=0&pagelist=Home&ViewType=Public&PDPYear=2006&MAPDYear=2006&MPDPF%5FMPPF%5FIntegrate=N. Accessed: August 11, 2006.
12 “Medicare Personal Plan Finder.” http://www.medicare.gov/MPPF/Include/DataSection/Questions/Welcome.asp?version=default&browser=IE%7C6%7CWinXP&language=English&year=2006&defaultstatus=1&pagelist=Home&user=&MPDPF_zip=. Accessed: August 11, 2006.
13 Siegel, Marc. “Who’s in Charge?” The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2006/07/10/AR2006071000701.html. July 11, 2006.
14 Weissman, J, et al. “Physicians Report On Patient Encounters Involving Direct- To-Consumer Advertising.” Health Affairs, Web Exclusive, Vol. 4, April 28, 2004, pp. 219-233.
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