Since the Affordable Care Act is driving more employers to adopt high-deductible health plans, the challenge for consumers is to minimize their increasing financial burden. Within this context, the growth potential for health care transparency tools is significant.
Most of the conversation about this topic has been devoted to decision-support on price comparisons, says Marty Rosen, an executive VP at Health Advocate, a health care advocacy and assistance firm.
But just how valuable are these tools when shopping for health care services clearly isn’t as easy as filling a cart with everyday products in the supermarket or online?
About 90% of health plans submit data to the Department of Health and Human Services’ Healthcare Effectiveness Data and Information Set (known as HEDIS) but the trouble is that there are 71 measures, and “that’s a lot for patients to get their arms around,” says Rick Gundling, VP of health care financial practices for the Healthcare Financial Management Association. His suggestion is to narrow down the list to, say, five domains of care that patients consider most important.
Also see: “Consumers demand health care transparency.”
And while HHS incorporates quality data on hospitals and physicians into a transparency tool, Gundling says metrics outside of patient safety or other clinical issues may not mean much to most people.
The National Quality Forum has endorsed more than 750 measures but many are not intended to be used by consumers, suggests Elizabeth Mitchell, president and CEO of the Network for Regional Healthcare Improvement. What’s needed, she says, is “a small set of really high impact quality measures that everyone agrees are most important.”
Although more health care transparency tools for consumers will surely come to market, there’s a “limited uptake of the current products that are available,” says Mitchell, who’s also co-director of the group’s Center for Healthcare Transparency, an initiative created in partnership with the Pacific Business Group on Health. The chief culprits could be limited information or designs, information that’s hard to understand or not at the level of specificity that people need.
Marcia Otto, VP of pricing and transparency applications at Health Advocate, recalls seeing a study that noted while the vast majority of payers have pricing transparency tools on their websites, a very small minority of people have used them because they’re simply unaware of them or not yet on a high-deductible health plan, which is a driving force for such assistance.
“It’s not only about price,” she says, also noting the role of quality and value in this equation.
And as such, Otto has seen a push toward identifying centers of excellence and partnering with hospitals that are known for great outcomes.
When less isn’t more
Whittling down cost and quality measures for a more consumer-friendly presentation may improve employee uptake of such tools, but one industry expert with a medical background cautions that it could come at the expense of other important issues.
Jeff Levin-Scherz, M.D., national leader in Towers Watson’s health management practice, believes that favoring inclusion of many meaningful metrics is a better approach “because it probably drives quality improvement over a wider array of services.”
However, Mitchell laments that consistent, reliable and usable health care information is nearly unattainable at a time when employers are asking for relatively basic information. One explanation is the key measures that employers, patients and others need aren’t available in the form that people want or do not yet exist, she says. She also identifies other barriers relating to data access and governance, noting the health care industry’s resistance to make public certain information “because of how it might reflect on those being measured, or for business reasons.”
Be that as it may, Mitchell says consensus is building around the notion that quality is best determined with clinical data and patient-reported outcomes that can be understood or reported without any barriers. There will be a much greater emphasis on the latter, which she describes as “a priority for physicians, patients and purchasers” – but with a caveat: “We have to test those measures and get them more widely adopted.”
Encouraging doctor input
Another factor to consider is that health plans limit data access to their members, “and many times, you can’t adequately calculate a measure without a broader data set,” she notes. In addition, she says if physicians do not find any merit or credibility to the information being produced, it’s unlikely that their patients will trust and use it. The inclusion of physicians as a key stakeholder is critical, she says.
“We know of lots of public and private purchasers who say they want to move to value-based purchasing, but if they don’t know the relative quality or cost of a service, they can’t design a network or incent use of a practice or facility,” she says.
Also see: “Value-based insurance design gains momentum.”
This stands in the way of employees making responsible health care decisions and taking more financial ownership of their decisions, Mitchell says. She says it also hampers provider payment reform, noting that the Medicare Access and CHIP Reauthorization Act of 2015 presumed the right measures and transparent information were in place to reward physicians for quality and efficiency.
As a board certified internist, Levin-Scherz references an ambivalent reception to this issue in the provider community “in part because quality transparency almost certainly needs to include elements of risk adjustment, and those can be controversial.”
He lauds the growing number of efforts on quality transparency led by “very impressive not-for-profits” that have reserved a key role for physicians to increase fairness and the value of information imparted to patients.
Also see: “IRS definition of preventive services questioned.”
Public reporting is another major component in the quest for greater health care transparency that can have a positive impact, even if patients don’t move from one provider to another. Levin-Scherz says that after recognizing their cardiac surgery programs did not reflect their quality standards, many health care systems made substantial changes. For example, some hospitals in New York stopped doing cardiac surgery, while leadership changes in other organizations sparked substantial improvement in quality in the aggregate.
Better consumer engagement
There’s also a growing emphasis on incentives to ensure that group health plan participants are actively engaged in managing their health care, which Health Advocate’s Rosen considers a direct outgrowth of high-deductible consumer-driven health plans.
Mindful of this trend, Health Advocate helps prep patients and their family members for doctor appointments with guidance on how to ask the right questions. The organization offers an online tool called Medical Checklist Builder featuring algorithms that identify meaningful criteria and produce personalized reports that can be brought to appointments.
Another application helps people who require immediate medical treatment find the most appropriate avenue of care within the hierarchy of emergency rooms. For example, a community hospital would make sense for broken bones, while a trauma center handles gunshot victims or car-crash survivors. “Not all ERs are created equal,” Rosen says. Health Advocate also uses the Leapfrog Hospital Safety Score to grade facility performance within a 300-mile radius or beyond, if necessary.
Gundling believes that with more online tools and mobile apps coming to market, there will be superior filtering through information and customizable solutions that promote better decision-making and health outcomes. In some cases, he says patients might prefer to have a procedure done closer to home so that friends and family can easily visit, while others might choose a more prestigious academic medical center that’s farther away.
Employers, of course, can play an influential role in shaping their benefit design so that it rewards employees to look at high-value providers and use tools that help make the decision-making process more transparent, according to Gundling.
Yelp is on the way
While the current state of the industry may be marred in needless complexity, the future certainly looks bright. Levin-Scherz cites “huge improvements” in transparency aimed directly at patients driven by both Web and mobile-enabled products that present health plan enrollees an accurate estimate of the cost of discreet procedures and some indication of quality. He believes the latter category is easier for surgical procedures with widely agreed upon metrics.
Key developments include more efficient use of big data and an ability to scan many terabytes of claims data to identify multiple criteria. For example, cardiologists would be listed not only by ZIP code, but also their area of specialty (i.e., atrial fibrillation, coronary artery disease, congestive heart failure).
Also see: “HHS program targets patient safety.”
An emerging – and promising – area Mitchell calls “patient narratives” involves reviews posted on Yelp, Angie’s List, other websites or social media. “We know that patients want that, and we’ll probably see more of that soon,” she predicts. “But then, how does that fit in with other information about clinical quality and outcomes? So we’re going to have to marry that together to get the whole picture.”
Another level of health care transparency revolves around intermediary contracts. Levin-Scherz says Towers Watson, for example, helps secure on behalf of its employer-client base more transparent contracts for pharmacy benefits management – an area that’s prone to hidden pricing.
“If it’s for a specialty drug where there’s only one of that drug and there’s really no choice, it’s purely about contracts,” he explains. “But in instances like for hepatitis C, where there are multiple very highly efficacious medications, having a product design that steers people toward one or toward another can actually lead to substantially lower prices.”
Bruce Shutan is a Los Angeles-based freelance writer.
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