Our ailing economy has boosted the number of people who are unemployed, without health insurance or with minimal coverage. The popularity of high deductible health plans is soaring as employers and individuals look for affordable insurance. Twenty-nine percent of bankruptcies are said to be caused by medical bills. Many of us now choose health care services and providers carefully, trying to stay within tight budgets.
The American people, long protected from the price of health care by insurance, are now forced to act as consumers. This situation is a free marketer's dream. According to this model, we will rationally calculate the price/quality trade-offs of each doctor visit, procedure, test and drug. We will stop overusing services. We will demand better care. And the result will be reduced health care costs for the nation while the quality of care and the health of individuals will remain the same, if not improve.
There's nothing like a good theory.
But the theory can only be tested if a) It's easy to find publicly reported, relevant quality information about the services we need, matched with what we would pay out of pocket; and b) We use that information as the basis of our health care decisions. Neither of these conditions can be met today.
A new Cochrane review titled Public release of performance data in changing the behaviour of healthcare consumers, professionals or organizations published earlier this month finds what previous reviews on this topic have found: there is little evidence that public reporting produces meaningful, long term changes in individuals choices about their care. This review examined four studies that included 35,000 potential patients and 1,560 hospitals. It found that the public reporting of performance data had no effect on people's choice of health plans. In one of the studies, reporting mortality and complication data on two specific surgeries had a small impact on people's choices about where to have those surgeries performed for two months following the release of the information.
What kind of information do public reporting advocates believe will shape our decisions about care? Composite measures of hospital safety? Patient satisfaction ratings based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS)? Report cards on specific outcomes of specific surgeries? With the possible exception of CAHPS, currently available quality information seems based on small elements of clinical care that can be measured with minimal burden. This may be useful for clinicians and administrators, but not for us.
Focus groups consistently find that people want to know answers to questions such as "Who can I trust to tell me if I really need back surgery?" "Where should I go to get a hip replacement that will allow me to walk well again?" "Who can really help me get my diabetes under control?" Information that answers our questions and is presented so we can make sense of what is available where and when we need it from a trustworthy source does not exist. Cost information for specific services, tests and procedures is almost impossible to find and is rarely matched with corresponding quality information.
It's early in the performance measurement business. Advances in computer technology have only recently made it possible to collect quality information on a broad scale. Dr. Paul Shekelle of RAND noted that after public reporting (in combination with incentives to change clinician and institutional behavior) produced a few small victories (such as an increase in the use of beta-blockers following a heart attack), unintended consequences of both measurement and reporting sometimes emerge. Be careful what you measure and report, since this action will distort the system, and you want to make sure you are distorting it for the good!
Meanwhile, buckets of money pour into quality measurement and improvement. Eventually this field will mature, probably in lock step with the lumbering implementation of Electronic Health Records. But without meaningful quality indicators and timely reporting along dimensions that can really improve care and that patients care about, maturity will merely produce new wrinkles in lieu of wisdom.
The lack of good, relevant quality and price information to help us make decisions is only one barrier, however. Our orientation toward being knowledgeable, active participants in our care is also immature. We have no tradition of exercising critical judgment about our health care. We don't believe that its technical quality varies. Many of us believe that the higher the cost, the better the care. Most of us have little understanding of how health care is organized or how our insurance works. We don't know whether our physician is part of a practice, a clinic, a hospital or an ACO and why that matters. Our connection is with our doctor that's the level at which we understand and care about quality. Further, most of us don't know how to ferret out the price of an individual service, procedure or test even if we need that information.
So this is where we are at the end of 2011: a juvenile collection of performance measurement and public reporting initiatives aimed at influencing a public that is largely unprepared (uninformed, unwilling, and often unable) to do the currently difficult work of finding information that can help us make good health care choices.
I have few illusions that the growth in the cost of health care will be slowed through our efforts, even if most of us make well-informed decisions based on price/quality trade-offs. Dr. Shoshanna Sofaer of CUNY reminds me that the targets of public reporting choices are not the big budget items driving health care expenditures. Five percent of the population accounts for 49 percent of health care expenses. The cost-saving efforts of garden variety patients will always only nibble around the edges. Few of us will disaggregate the costly treatment of a brain tumor, for example, into price/quality bits: this neurologist, the neurosurgeon who will do the operation for half the price of the other, an oncologist in the neighboring town, a cheaper radiologist down the street. We have other things to worry about at that point.
Now, however, the need to make good decisions about our care in the absence of relevant price and quality information has the potential to erode our individual health. There is already evidence that our decisions to delay needed care and titrate our drugs because we can't afford them are not informed or smart ones: we are just sicker when we eventually do seek care. Those who are most likely to need price/quality information are likely to already be ill and lack the energy, skills and resources to use it even if it were easy and familiar.
This will change over time: quality measurement will mature and eventually will produce information that is relevant, interesting and useful to us. Our personal mastery of health information online and the critical attitude we are acquiring will continue to grow prompted by the economic necessity to be informed and involved.
In the meantime, we are experiencing a rocky adolescence. The assumptions behind the theory that people's informed, rational choices of better quality, lower cost care will shape the market and bend the cost curve have yet to be met. The immature status of public reporting on health care metrics, combined with our general passivity, means most of us still operate as semi-educated guessers, making semi-OK, sometimes semi-disastrous decisions based on the advice of our doctors, convenience, familiarity, a little Google searching and the suggestions of friends.