Welcome to Value-Based Care Outcomes and Reimbursements, this is Lecture b- Consumer Understanding of Quality and Cost. This lecture focuses on the consumers understanding quality and cost, as it relates to healthcare value. The learning objectives for this lecture are to, articulate how the consumer experience can be measured, and the importance of measuring it in value based care models. Understand what HEDIS measures are, and articulate how they are used by different stakeholders. Describe resources that consumers can use to find out about quality, and cost of health care. Describe how effective these measures have been, in affecting consumer behavior, and some of the strengths, and weaknesses of current consumer-facing measures. In this lecture, we'll discuss how consumers can be engaged in order to improve the value of the healthcare they are receiving, we'll review how the consumer experience can be measured, and how that is especially valuable for the concept of value based care. We'll look at healthcare effective data information set, or HEDIS measures, and describe how consumers can use different resources to examine information about the quality and cost of healthcare, and whether this has been effective in influencing consumer behaviors. We'll end by identifying the key strength, and weaknesses of current consumer facing measures. You may have noticed that in this lecture we're using the word consumer, usually, when we talk about consumers, we are referring to people who are deciding what to buy, or are actually buying something. In healthcare, we make some buying decisions about the care we receive. When we make those decisions, we probably want information about cost and quality, among other factors, we may have a choice between health plans. We choose which clinic to go to, if we have a planned surgery, we may choose which hospital, or ambulatory surgical center to go to. At the same time, we are patients, people receiving care from our physicians, and other providers, and using whatever insurance coverage we have. So there isn't always a clear line, between being a consumer, and being a patient, but we're using the word consumer to call out that each of us is making some choices about the health care services we purchase. Let's start by looking at how health care consumer experiences is currently measured. One commonly used tool is the Consumer Assessment of Health Care Providers and Systems, or CAHPS surveys. CAHPS surveys ask a sample of patients a set of questions about their experiences. These surveys are meant to produce more specific, and relevant feedback for consumers, than what might be communicated through more general ratings. CAHPS measures look at areas such as, the quality of communication, between the patient and provider, and include information that is best gathered directly from the patient. CAHPS surveys also try to gather information on subjects that patients have identified, as important to them. The CAHPS program is overseen by the US Agency for Healthcare Research and Quality, or AHRQ, which develops, and maintains surveys, but does not administer any surveys. All CAHPS surveys are in the public domain, and available for use by anyone. Hospital consumer assessment of healthcare providers and systems, or HCAHPS, is the first national standardized publicly reported survey of patients perspectives on hospital care. It is a 32-item survey administered to people who have been hospitalized. The HCAHPS survey questions concern the consumer's view of her hospital experience, including communication with physicians. Communication with nurses, responsiveness of hospital staff, cleanliness, and noise level, pain management, communication about medicines, clarity of discharge information. Overall rating of hospital, and willingness to recommend this hospital to friends and family. To see how the consumer experience can be measured, and why it can be important in value based care models, let's take a closer look at a specific CAHPS Survey for ACOs. CMS requires Medicare ACOs to measure the patient experience of care, through the CAHPS Survey for ACOs. This survey has 12 care summary survey measures, the first eight summary survey measures are listed here. To better understand how the measures work, let's review the questions for the first summary measure, timely care. There are multiple questions asked for this measure, in the last six months, when you phoned this provider's office to get an appointment for care you needed right away, how often did you get an appointment, as soon as you needed? In the last six months, when you made an appointment for a check up, or routine care with this provider, how often did you get an appointment, as soon as you needed? In the last six months when you phoned this provider's office during regular office hours, how often did you get an answer to your medical question that same day? In the last six months, when you phoned this provider's office after regular office hours, how often did you get an answer to your medical question, as soon as you need it? Wait time includes time spent in the waiting room, and exam room, in the last six months, how often did you see this provider with in 15 minutes of your appointment time? The CAHPS survey questions ask for specific feedback on each summary measure. The last four measures shown here are not part of the payment calculation for ACOs, but the information is provided back to the ACO. Remember that ACO beneficiaries can choose to go outside the ACO for care, so each ACO should be very interested in hearing this feedback. CMS required Medicare ACOs to have the CAHPS survey for ACOs done each year. The surveys must be done by a CMS approved vendor, CMS also identifies the patients who will be surveyed. Choosing a random sample of 860 medicare patients, who receive primary care services from the ACO. The CAHPS survey for ACOs generates scores at the ACO level, in other words, this survey would show you consumer experience ratings for an ACO, as a whole, not for a particular physician, or clinic who provides care within the ACO. For anyone who is interested in reviewing an ACOs performance on the CAHPS measures, the survey results are publicly reported. As the consumers of healthcare services improving quality and value, relies on understanding the perspective of the patients, CAHPS surveys are one way to gather that information. HEDIS is a set of standardized quality measurements designed to show, how well health plans perform on common standards. This steward of HEDIS is a private nonprofit organization, the National Committee on quality assurance, or NCQA. NCQA was founded in 1990, in addition to HEDIS, NCQA engages in other quality and accreditation programs, such as certifying patient centered medical homes. Currently, HEDIS measures is used by over 90% of US health care plans. For 2016 HEDIS contains 81 quality measures which fallen to six domains including effectiveness of care, access and/or availability of care, experience of care utilization, and risk adjusted utilization, relative resource use, and health plan descriptive information. In 2016 there is also a first year measure to track the utilization of the PHQ9. A screening tool to monitor depression symptoms as reported by patients. This measure is collected using electronic clinical data systems. The HEDIS reports are standardized and broad. All health plans report on the same measures. The measures are qualified by NCQA, so the numerators and denominators of those measures are the same for everyone, which allows for apples to apples comparisons between health plans. However, there are criticisms that HEDIS is overly focused on process measures as opposed to outcome measures. As we discussed in the previous lecture, quality measurement is in a state of development where outcome measures are harder to produce. For now, HEDIS measures continue to play an important role in providing a comparison of health plans. Some HEDIS data is available through subscription to the NCQA's quality compass tool available at http://www.ncqa.org/hedis-quality-measure- ment/quality-measurement-products/quality- -compass. This can be used for comparisons with competitors and benchmarking plan performance. HEDIS provides reports that can be used by health plan buyers. Employers can look at HEDIS reports and see the overall quality of an individual plan, and then they can compare it to other health plans. However, there is a lack of employer awareness of HEDIS. Besides employers, consumers also use HEDIS reports. Consumers can access some HEDIS data through a public report, the annual State of Healthcare Quality Report. HEDIS also includes a CAHPS survey on health plan member experience, including claims processing and getting needed care quickly. Consumer Reports Magazine takes HEDIS information and provides it to consumers who are looking at buying health plans. The HEDIS reports are also used by the Centers for Medicare and Medicaid, or CMS, to create star ratings for different insurance plans. Large state entities that contract with health plans to provide Medicaid services often use HEDIS reports, too. Here is an example of a HEDIS report. In this example, United HealthCare is the insurance provider. This screenshot is just a very small portion of the multiple screens for United HealthCare plans in the 2015,16 summary report. The report indicates that the United HealthCare plans are not the highest performers in the states in the plan that are shown. This data could be used by employers in those states comparing the results with United HealthCare in other states, or to compare with other health plans operating in their state when they are in contract discussions for the next benefit year. If the scores are low on prevention services, an employer could ask the health plan to increase employee communications around the importance of preventive services. The overall effect, if any, that HEDIS has had on the cost and quality plenty of care is not well documented. None the less, HEDIS continues to be an important standardized measurement, and one of the efforts that have been made to measure quality and value of healthcare. The Choosing Wisely campaign is a non profit sector effort to reduce overuse of health care by developing patient friendly educational materials, and promoting conversations between patients and providers about tests and procedures that are often overused. The campaign sites survey finding from 2014, where 72% of physicians said that the average physician prescribes an unnecessary test or procedure at least once a week. And 47% said that their patients ask for an unnecessary test or procedure at least once a week. On the bright side, 70% of physicians reported that if they have a conversation about the reason a test or procedure is unnecessary, the patient often avoids it. CMS launched the Physician Compare site in 2010, as required by the Affordable Care Act. It builds on the other compare sites that are maintained by CMS, including hospital compare, nursing home compare, home health compare, and dialysis facility compare. The implementation of the Medicare Access and Chip Reauthorization Act, or MACRA, will allow additional quality metrics to be added to physician compare overtime. While surveys indicate that consumers are interested in information that helps them evaluate and choose physicians, research indicates that a small proportion of consumers make use of physician rating sites that present detailed quality metrics, such as, physician compare, and those sponsored by states. As we mentioned earlier, HCAPS is a 32 item survey administered to people who have been hospitalized. Because the same survey is given to patients all across the US, it allows for valid comparisons. The raw data captured through the survey is used by CMS to create a consumer friendly website to compare hospitals. The website is called the Hospital Compare, and it allows consumers to look at the HCAPS data and also other data concerning safety, cost, and value. So that consumers can compare the hospitals in their region or city and see how other consumers felt about their experience. Let's look at a sample screenshot from the Hospital Compare website. The user selects the location to search, or up to three specific hospitals to begin the comparison. Tabs across the top show a variety of categories of information to compare, such as, overall patient satisfaction and value of care. This image shows how consumers reports takes HCAPS data and presents it so that it easily understandable and familiar. Red circles, under Patient Outcomes in the bottom portion of the screen, mean better than average. Half red circles are slightly better than average. Black half circles are slightly worse than average. And black circles are much worse than average. This type of information allows consumers to look at the hospitals in their region to see how they compare, and which ones they may want to go to. Information like this, whether provided through hospital compare or through consumer reports, allows informed consumers to research and find information about the cost and quality of care that hospital provide. The Robert Wood Johnson Foundation, or RWJF, maintains a directory of public reports focused on quality reporting. Of the 208 reports currently listed, 26 are national. The remainder have a focus on regional, state, or local providers. Most, but not all, of the national reports focus on hospitals. Aligning Forces for Quality, or AF4Q, a program funded by RWJF, partnered with Consumer Reports to publish special reports as inserts in three AF4Q communities to provide consumers access to performance data on local providers. A group known as the Healthcare Improvement Incentive Institute, or HCI3, does an annual report card on the transparency of quality and cost information. In 2015, for the third year in a row, most states received a failing grade for providing information to consumers on the quality of physician care. Although many states may currently be failing in these efforts, the report highlights a few communities and states as leaders including California, Colorado, Maine, Massachusetts, Minnesota, New Mexico, Oregon, Washington And Wisconsin. Both private not-for-profits and profit making entities are looking at the growth of the consumerist movement in healthcare and considering opportunities to either make money or serve the mission of their non-profit. On the right, is an image from healthcarebluebook.com. The site presents consumer friendly information that is easy to review and digest. As a consumer, the following resources can help to provide information on healthcare costs and quality. Healthcarebluebook.com, the Leapfrog Group which does a lot of work with hospital quality and safety, private sector rating sites that are often based on a small number of ratings per provider. Insurance companies offer tools that look at the various providers in an area. For example, United Health Group has a tool caused myHealthcare Cost Estimator. Patients as consumers present some real challenges. Consumers of healthcare are in a different position than consumers of cars or dry cleaning services or other things people buy. To start with, most consumers don't directly buy health insurance. This chart shows where people in the US got their health insurance in 2014. It shows that, only a small percentage of people, the 6% in the non-group pie wedge, bought insurance directly, 49% of consumers obtained their health insurance through an employer. Some employers offer employees a choice of plans and so, those consumers have some influence on the market. Medicare and Medicaid cover about 32% of the population. Another 2% buys insurance from public plans offered by municipalities or states to cover a limited number of people. About ten percent of people are uninsured. They either receive charity care, pay out of pocket or don't access healthcare services. Though 6% of the population adds up to millions of people who buy their own insurance, which is still a relatively small percentage who are able to directly impact the healthcare market through the purchase of insurance. Consumers are increasingly bearing more of the out of pocket cost of their care, which theoretically should drive selection of high value services. If we are paying for something we want to get our money's worth, right? Consumers are paying high deductibles in order to keep premiums lower. The percentage of healthcare consumers with a deductible in 2010 was below 70% but increased to 81% by 2014, a greater than 10% increase in 4 years. In 2009, only 27% of people had deductibles over $1,000. By 2014, that has increased to over 45%. Additionally, many health insurance plans require copayments and coinsurance. A copayment is a set amount of money paid for a healthcare visit. Coinsurance is a set of additional charges. For example, the insurance company pays 80% of the charges for a specific service and the consumer pays the balance. Copayments and coinsurance are becoming more common in employer sponsored plans. To gather current information about employer sponsored health benefits, the Kaiser Family Foundation, or Kaiser and the Health Research and Educational Trust or HRET, conduct an annual survey of private and non-federal public employers with three or more workers. Based on the 2014 data, the results showed that 68% of covered workers have some sort of copayment requirement for primary care visits, 23% have coinsurance. The average copayments for an in-network physician office visit ranges from $24 for a primary care visit to $37 for a specialist visit. And for hospital admissions, 65% of covered workers have coinsurance, 14% have copayments. The average coinsurance rate is 19%, the average copayment is $308 per hospital admission and the average separate annual deductible is $1,006. However, since most people don't purchase their health insurance directly and the most group health plans handle deductibles, copays and coinsurance differently, it is very challenging for consumers to track and analyze the implications of their healthcare decisions. As we have reviewed earlier, there is a lack of consistent information on provider quality and cost available to consumers that would allow them to compare their options. While there may be local or state efforts, such as aligning forces for quality, most consumers may not be able to name a source to identify high-value services and providers. There is also an issue of accessibility of information depending on health literacy, language, Internet access and other barriers. Deductibles, copays, and co-insurance are tools that can be used to minimize the overuse of medical care that we discussed in the previous lecture. Remember some of the differences between HMOs and ACOs and how they try to balance the delivery of health care services? We found that it is important to provide incentives to providers to lead to quality outcomes. However, how does consumer behavior, based on cost sharing, impact outcomes? Sometimes, a health plan's attempt to find the right balance between over and under use can backfire. A recent study found that, when an employer moved its employees from a plan that had no cost sharing to a high deductible plan, the employees cut back on high value, as well as low value care. Although high deductible plans are meant to encourage price shopping, the employees did not use the price shopping tool that was provided but simply reduced the number of services they received including preventive care. An extensive survey conducted by Families USA in 2015 found that, adults with high deductibles were more likely to forego needed medical care. 29.8% of adults with deductibles of $1,500 or more per person who were insured for a full year went without needed medical care because they could not afford to pay the deductible. As we look at value based care, it is important to include those factors, such as consumer cost sharing that might have significant implications for consumer behavior. And explore options to incentivize consumer selection of high value care options. In life threatening situations, consumers are unlikely to do the research to select healthcare options. For example, if you or a family member were experiencing severe chest pain would you stop to look up the best cardiac physician or best hospital for treating heart attacks? Or, would you call 911 and go directly to whichever hospital the ambulance went to? Even in non-emergency situations, elements including whether a provider accepts a consumer's insurance, location, accessibility and personal referrals can be weighted more heavily than quality ratings when making healthcare decisions. In spite of information being available on websites like Hospital Compare, the information is not universal or all encompassing. These are new efforts, so there isn't a tremendous amount of research. One survey article in Health Affairs, found the following about the use of these sites by consumers. These sites are mostly used by consumers who were white, college educated and over age 45. There was little use by vulnerable populations, and only about half of those visiting the sites indicated they were likely to use the data to choose a hospital. For consumers to be able to choose high value care, they need to approach healthcare decisions with clear and meaningful information about quality and caused. As we previously discussed currently their continuous to be a focus on process rather than outcome measures. And there's a lack of meaningful provider level measures that are comparable across providers. Providers are often concerned about public reporting that attributes quality scores at the provider level. Particularly if there isn't agreed upon methodology to account for more complex or sicker patients. Measures to track the quality and cost of care by specialty providers can be particularly challenging to compile because there is more work that is needed to be able to define and track meaningful measures for specialists. Measures also need to be given with context an explanation so consumers can understand the measures and meaning. It may not be immediately obvious with some measures whether a higher or lower rate is better, for example, consumer sometimes understand higher hospitalization rates for asthma to mean that there was good care because sick patients weren't prevented from receiving hospital care. The catalyst for payment reform, or CPRs 2013 national score card on payment reform revealed that 98% of health plans say they offer cost calculator tools. But only two percent of patient members actually used them. Therefore a growing number of purchasers and employers have turned third party vendor and search for tools and services that engage their employees and dependents and encourage them to shop. After the last several years independent vendors such as Castlight health, Truven Analytics, Change Healthcare and Healthcare Bluebook have made significant studies in developing price transparency products designed to help consumers shop for healthcare. Although the products currently available are improving in usability, for example, although some products may require consumers to search by current procedural terminology, or CPT code, increasingly, the products allow consumers to search by an episode of care. There are still problems with generating accurate price estimates because of problems such as varying and incomplete definitions of the episodic care. In most parts of our lives we have access to do huge amounts of information about the purchases we wish to make and we use that information to make rapid high quality informed choices. However when faced with healthcare purchasing decisions, consumers face some challenges. Some may be a lack of information as highlighted in a 2011 US Government Accountability Office or GAO report that was commissioned by congress, which stated that several healthcare and legal factors may make it difficult for consumers to obtain price information for the healthcare services they receive, particularly estimates of what their complete costs will be. However, Atul Gawande summarizes the issue differently. As a public health researcher and staff writer for the New Yorker, Gawande writes in the article Overkill, doctors generally know more about the value of a given medical treatment than patients. Who have little ability to determine the quality of the advice they are getting. Doctors therefore are in a powerful position. We can recommend care of little or no value because it enhances our incomes. Because it's our habit, or because we genuinely but incorrectly believe in it. And patients will tend to follow our recommendations. Even with a wealth of information, it may still be challenging for consumers to influence a move towards value-based care without incentives for providers to support the shift at the same time. In Overkill, Atul Gawande gives an example of how information and incentives can line up to promote quality high value care. He relates the story of a Walmart employee with an insurance plan with copays and deductibles. That would make his out of pocket cost for spinal surgery total over $1000. However, if the employee chooses care at an approved Center of Excellence, there is no out-of-pocket expense. These centers are selected based on the quality of care, low complication rates and pricing with a bundled payment approach. It has also been found that when the providers at these centers evaluate patients who are referred for care, they find that about 30 percent of the referred spinal procedures are unnecessary and that other less invasive treatment options will better meet the patient's needs. Gawande recounts the story of an employee who was incentivized because of the cost to pursue treatment at a Center of Excellence and finally got the right care. Gawande concludes, it isn't enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm, unnecessary care often crowds out necessary care. Particularly when the necessary care is less remunerative. Walmart of all places is showing one way to take action against no value care. Rewarding the physicians and systems that do a better job and the patients who seek them out. This concludes lecture B of outcomes and reimbursements. In this lecture we explored the concepts behind the consumers understanding of cost and quality as it relates to healthcare value. We explored the concept of having consumers bare more of the burden of costs through high deductibles and found that they reduce utilization, but that they also may have an overall reduction to overall health. We found that if people have to pay more for healthcare, they consume less of it. Just as there's needs to be incentives for providers kin the ACO model to provide quality care, there need to be incentives for consumers to choose high value care, so that they don't avoid necessary care. Putting off important medical procedures when the cost is too high. We examined the resources that consumers have available to find out about cost and quality. In spite of sites like Hospital Compare, it is still unknown whether there's adequate availability of information to help consumers make informed choices to increase the quality and value of the healthcare they access. These are new efforts without enough research available at this time to determine whether consumers can drive improvement toward value-based healthcare based on their actions.
