Proposed Agenda for Research and Action. Informing Consumers About Health Care Quality (continued)
Task 4: Identify the Market Characteristics and Purchasing Strategies that
Support Consumer Use of Quality Information
The utility of health care quality information clearly depends on the factors
discussed in the previous three tasks: the degree to which consumers are aware
of and prepared to use it, the ability of sponsors to communicate effectively,
and the salience of the quality measures for consumers. An often-overlooked
fourth factor is the environment in which sponsors are producing information
Despite some notable idiosyncrasies, the U.S. health care industry functions
much like a normal market, where the market refers to the ways in which services
are bought, sold, delivered, and regulated. The structure of this market is
defined by many things, including:
- The nature of competition among health care organizations and insurers.
- The number and size of purchasers.
- The presence of a dominant player of any kind.
- The mechanisms employed by regulators and purchasers to protect consumers,
ensure access, monitor quality, and establish minimum standards.
- The extent to which purchasers make choices.
- The amount of choice ceded to consumers.
- The degree to which consumers may influence either providers, plans, or
- The price sensitivity/immunity of health care consumers.
In light of the many ways in which structures can differ, one may surmise that
some of these features make the environment more amenable to the use of information
than do others. While there is no one "right" structure for a consumer
information strategy, it would be a valuable endeavor to identify the characteristics
of a market structure that would make the use of information compelling and
fruitful for consumers.
In particular, it would be useful to test the presumption that a consumer choice
model is fundamental to the use of quality information by consumers. We need
evidence to identify the extent to which consumer-level choice is both necessary
and sufficient for information to have value. Experience in the marketplace
suggests that choice alone is not sufficient because other factors are also
instrumental in determining whether consumers are able to use information to
make good decision. For example, in a structure in which all health plans offer
the same providers, information on the quality of the provider networks sponsored
by each plan will be of limited value to consumers in making better choices
among competing plans.
We also need to learn more about the necessity of choicei.e., whether information
on quality has value to consumers and patients in the absence of choice. Where
consumers cannot make choices, what features of the market may allow such information
to be useful? For instance, in an environment that provides strong consumer
protections, information that educates consumers about quality would give people
the knowledge they need to protect themselves, whether by seeking alternatives
to their current options or by obtaining redress from outside parties when appropriate.
Finally, beyond the issues of necessity and sufficiency, there is a need to
address practical questions about the nature of the choices that make information
valuable. What kinds of choices (e.g., among plans or among providers) should
consumers be making? How much choice is enough? And how much choice is too much?
The Current Situation
In the latter decades of the 20th century, the United States has played host
to a variety of health care markets. This lack of a common environment makes
it difficult to determine the functionality of consumer information. When information
does not appear to be effective, could the structure of the market be responsible?
That is, could the same kind of information work better in a different environment?
Even in the same geographical setting, purchasers may contract with different
kinds of health care organizations; consumers may have no choices or many choices,
choices at only one level of the health care system or choices at multiple levels.
Moreover, the structure of the market is constantly in flux; what seems to prevail
today may be barely noticeable tomorrow.
In light of the current emphasis on comparative quality information, it is
critical to note that opportunities for choice are not evenly distributed among
markets and population groups. This disparity is partially due to the nature
of the health care industry and the ways in which it has been evolving over
the past several years. The number and availability of competing plans and providers
varies significantly across regions of the country. In general, rural areas
have fewer choices of hospitals and doctors than do urban areas, and increasing
numbers of smaller communities are witnessing the closure of their hospitals.
Even in large metropolitan areas, which have a far greater supply of providers
and a greater degree of choice than rural markets, the trend toward increasing
consolidation of health care plans and delivery systems has eliminated effective
competition except among a very few suppliers.
Perhaps more importantly, the availability of choice is typically determined
not by market forces but by those who purchase or contract for care on behalf
of consumers. A 1997 survey sponsored by the Robert Wood Johnson Foundation
found that less than one in five private employers that offered health insurance
to their employees provided a choice among plans(4).
In general, the availability of health plan choices appears greater among public
employers (at the State, county, and city level) than private employers, and
among larger employers than smaller employers. According to a recent survey
commissioned by the Kaiser Family Foundation, 92 percent of small firms and
44 percent of larger firms (those with more than 200 employees) offered only
one plan in 1998(5).
This uneven approach to providing choice is echoed in the public sector. While
the Balanced Budget Act of 1997 was intended to move the Medicare program toward
a consumer choice model, certain changes in public policy resulted in a reduction
in choice for many beneficiaries. At the State level, increasing numbers of
state Medicaid agencies are starting to offer beneficiaries a choice of managed
care plans, but several are seeking freedom-of-choice waivers that will allow
them to offer only one managed care plan.
What We Need to Know: Priorities for Research
To create the structural environment necessary to provide consumers
with meaningful opportunities to use quality information to make better decisions
and choices about plans and providers, we need to learn more about the following
- What aspects of the market affect the salience of quality
information? In what ways?
- What kind of information about quality is useful to
consumers in a purchaser-choice environment?
What impact would a defined contribution strategy (where
purchasers contribute a flat amount to the cost of coverage so that consumers
bear the cost of choosing more expensive options) have on the salience of
quality information for consumers?
- What kinds of quality information, if any, are these consumers receiving?
- How can consumers use the information when purchasers make the choice?
What factors are likely to influence the impact of
the consumer choice model? What role does each factor play in the effectiveness
of the model? Examples of factors that might be considered include:
- Will this strategy make cost more salient?
- Will consumers embrace the idea of seeking "value" in their health
- How sensitive are consumers to changes in price?
- Number of choices (e.g., how many plans or providers?).
What evidence is there to suggest that the consumer
choice strategy actually works in practice to:
- Variety of choices (e.g., what different types of plans or providers?).
- "Distinctiveness" of choices (e.g., degree of difference in choice
- Choice at the plan level versus choice at the provider level.
- Differences in urban versus rural markets.
- Consumer characteristics (e.g., income, education, gender, race, etc.).
- Payer characteristics (e.g., commercial, Medicaid, Medicare).
- Type and mix of performance information (quality measures only, cost measures
only, quality and cost measures combined, etc.).
- Type of quality information (e.g., service quality, clinical quality, etc.)
- Type and extent of financial incentives for consumers (e.g., cost sharing
related to plan or provider cost levels).
- The availability of intermediaries to provide information and assistance
- The availability of sound risk adjustment methods to insure that cost and
quality performance measures are accurate and fair.
What are the roles that purchasers can play to both
complement and support consumers in driving quality improvement and system
What percentage of consumers making informed choices
is needed in a given market to drive improvements in quality and cost performance?
What percentage of purchasers making informed choices is needed?
Who is making the consumer choice when a caregiver
is involved (e.g., for a child, a senior, or someone whoís impaired)? How
does the surrogate make choices?
Is the consumer choice model appropriate for different
kinds of markets and different communities?
- Drive improvements in health plan and provider quality and cost performance?
- Drive improvements in overall health system quality, affordability, and
- Empower consumers to make choices that better meet their health care needs?
- Drive enrollment in health care organizations that offer demonstrably better
quality or value?
In the absence of choice, does the public reporting
of comparative cost and quality information by itself have a positive impact
on provider behavior and quality improvement (e.g., providing public information
alone in situations where choice is not available or not offered to consumers)?
- Specifically, what is the impact of a competitive approach based on quality
and cost performance on safety net providers and the public health infrastructure?
- Do people value data on the quality of health plans and providers from the
perspective of increasing public accountability?
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Task 5: Evaluate the Utility and Impact of Consumer Information Efforts
How will we know if consumer information initiatives are successful? First, there must be agreement on what the project is meant to do. As noted earlier, a consumer information strategy may have any number of different but related goals. Some projects may be more oriented towards long-term system-level change, while others are focused on short-term behavioral changes at the level of individual consumers or provider organizations. At this point in the development of this field, it is particularly important that those tasked with the evaluation pay more attention to the prospects for reaching reasonable, short-term objectives than to the unlikely possibility of detecting broad changes in the marketplace.
Once the objective has been stated clearly, the next step is to conduct a scientifically valid evaluation of the projectís impact. This requires an understanding of the appropriateness and limitations of evaluation methodologies. It also means that sponsors of quality information projects must have the funds and the resources to conduct evaluations when they are most likely to result in useful information.
Finally, we must have a mechanism for sharing the lessons from evaluations and incorporating them into ongoing and future projects. To move this field forward as efficiently as possible, sponsors of quality reporting projects will need an easy way to learn from the experiences of others.
The evaluation phase of quality information projects tends to be overlooked and underfunded. To the extent that sponsors have taken the time to assess their progress, their results are often discouraging, but that is primarily because many sponsors have expected too much too soon. Another common scenario is that the evaluation is too unfocused or incomplete to be of much use to future iterations of the project. That is, it does not help the sponsor determine what could be done differently in order to achieve better outcomes. And because the results are not useful or even negative, the sponsor has little motivation to tackle an evaluation in the next round.
Thus, the biggest problem with evaluations today is that they simply are not happening. Few people understand how to structure the process so that it results in useful information, and no mechanism exists to train people in the skills they need to handle this key part of a consumer information project. Our ability to overcome these obstacles may determine how quickly we are able to move beyond the current spate of information initiatives to develop programs that can get closer to the goals of the consumer information movement.
What We Need to Know: Priorities for Research
In order to conduct effective evaluations that result in useful information,
we need to develop a better understanding of the following issues:
- What expectations are realistic, based on the experiences
What practical and affordable evaluation methods can
be applied to help assess the overall impact of consumer information efforts
in the following areas?
- What can sponsors reasonably expect to deliver to the market in the short
- What can they hope to accomplish?
What is the optimal timeframe for conducting an evaluation in order
to capture the impact of a project?
What methodology can be used to conduct a cost/benefit analysis of
consumer information efforts?
How can sponsors quantify the return on their investment in cases where
the impact of their information projects is quantifiable (e.g., they can identify
changes in enrollment that favor lower-cost, higher-quality providers or plans)?
- Improvements in data collection and integrity.
- Consumer satisfaction with their ability to make choices.
- Consumer satisfaction with their choices.
- Consumer ability to use plans and providers effectively.
- Market share and member retention.
- Plan and provider behavior.
- Population health status.
- Improving health care system quality, cost, access.
What We Need to Do: Priorities for Action
To make evaluations both more effective and more feasible, we need to develop
ways to make them easier for sponsors, possibly by creating a few models for
implementing and interpreting evaluations that they could adapt to their projects.
The Work Groupís "TalkingQuality" Web site is one way to offer relevant
advice and resources to sponsors. We also need a mechanism for disseminating
the findings from evaluations that could be useful for other sponsors so that
the evaluation effort has a larger impact.
1. Develop a strategic consensus on what sponsors and
researchers can accomplish in the next few years.
- Generate realistic expectations of an intervention and what can be documented.
- Consider teaming researchers with sponsors up-front to enhance the rigor
of sponsor project designs that can be usefully evaluated.
2. For comparison purposes, develop and implement a national
survey monitoring system for tracking trends in consumer knowledge, attitudes,
and practices related to quality information.
- Build on the 1996 and 2000 KFF/AHRQ national consumer surveys to establish
an ongoing system for routinely tracking these issues. Such a system could
be modeled after similar public health survey programs, such as the behavioral
risk factor survey sponsored by the Centers for Disease Control and Prevention.
3. Identify and promote opportunities for sponsors and researchers to
share the lessons learned from their evaluations.
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Addendum A. About the Work Group on Consumer Health Information
Purpose of the Work Group
The purpose of the Work Group on Consumer Health Care Information is to provide
information and assistance to support a variety of public and private sector
efforts aimed at improving the communication of health care quality information
Sponsorship and Background
Initial funding for the Work Group was provided by the Health Care Financing
Administration (HCFA). Administrative coordination for the Work Group is provided
by the Agency for Healthcare Research and Quality (AHRQ, formerly Agency for
Health Care Policy and Research) with support from the Office of Personnel Management
(OPM). Funding has been committed by HCFA for two years (Fiscal Years 1999 and 2000), with
possible additional support to be provided by AHRQ and OPM.
The Work Group convened as a result of a national invitational conference in
December 1998 sponsored by HCFA with support from AHRQ and OPM entitled "Making
Quality Count: Helping Consumers Make Better Health Care Choices." Conference
summaries are available through the Work Group at 1-800-508-7453.
Work Group Members
The Work Group is an interdisciplinary group of researchers, purchasers, consumer
advocates, and government officials. Staff support for the Work Group is provided
by Westat and the Quality Measurement Advisory Service (QMAS). (Select Addendum
B for a list of Work Group members.)
Charge of the Work Group
The charge of the Work Group is to oversee the following tasks:
- Develop and Launch a Work Group Web Site: Provide a convenient and
effective tool to assist various audiences in identifying and gaining access
to multiple, current resources that can help them plan and implement consumer-oriented
health care quality information projects and related activities. The site
will provide links to many existing resources, include multiple examples of
"practice innovations," and provide directories and links to organizations
that can be of further assistance. It will not recommend any single "best"
practice but point to multiple successful innovations that can be illustrative
of effective methods of communicating health care quality information to consumers.
- Develop a Research and Action Agenda: Identify and prioritize topics
in need of further research and development, as well as specific actions and
initiatives outside of research that should be undertaken to advance consumer
health care quality information efforts. A second national conference will
be held to provide a forum for a focused discussion involving key opinion
leaders in the field about the recommendations presented in the Work Group
"Research and Action Agenda."
A byproduct of these tasks is for the Work Group to serve as a vehicle for
exchanging and disseminating timely information and updates among consumer health
care information research and applications leaders. Examples of additional information
that will be exchanged are:
- Inventory and regular updates on implementation projects.
- Contact lists and profiles of individuals and organizations engaged in implementation
- New consumer information research and evaluation findings.
The Work Group will recommend and oversee specific steps for functioning as
an exchange vehicle in the short term (e.g., internal Work Group web site, list
servers, information Help Line, a second national conference, etc.) as well
as a long-term strategy for formalizing this function on an ongoing basis.
Work Group Timeline
Date: December 10-11, 1998.
Item: "Making Quality Count" Conference.
Date: January to March 1999.
Item: Work Group planning.
Date: April 1999.
Item: Work Group Kick-off.
Date: May to August 1999.
Item: Initiate Work Group "Talking Quality" Web Site and Research and Action Agenda.
Date: September 1999.
Item: 2nd Work Group Meeting.
Date: October 1999.
Item: Launch Internal Work Group Web Site
Date: October 1999 to May 2000.
Item: Complete Work Group "Talking Quality" Web site and Research and Action Agenda.
Date: April 2000.
Item: 3rd Work Group Meeting.
Date: Summer 2000.
Item: Launch Web site.
Date: June to September 2000.
- Maintain and update web sites & Help Line assistance.
- Refine and package Research and Action Agenda.
Date: May to November 2000.
Item: Plan 2nd National Conference.
Date: December 11-12, 2000.
Item: "Informing Consumers About Health Care Quality: New Directions for Research and Action" Conference in Bethesda, Maryland.
Return to Contents
Addendum B. Members of the Work Group on Consumer Health Information
Sandy Robinson, Agency for Healthcare Research and Quality
David Miranda, Health Care Financing Administration
Ellen Tunstall, Office of Personnel Management
Members and Sponsor Participants
John Abraham, American Federation of Teachers
Laura Aiuppa, National Committee for Quality Assurance
Diane Archer, Medicare Rights Center
Christina Bethell, Foundation for Accountability
Abby Block, Office of Personnel Management
Patricia Drury, Buyers Health Care Action Group
Steve Findlay, National Institute for Health Care Management
Nancy Foster, Agency for Healthcare Research and Quality
Beth Ginzinger, Ford Motor Company
Judith Hibbard, University of Oregon
Sam Ho, PacifiCare of California
Howard Holland, Agency for Healthcare Research and Quality
Priscilla Holman, Centers for Disease and Control
Charles Inlander, People's Medical Society
Alan Levy, Food and Drug Administration
Jeanne McGee, McGee and Evers Consulting, Inc
Christine Molnar, Community Service Society of New York
Lisa Payne-Simon, California Health Care Foundation
Ruth Perot, Summit Health Institute for Research and Education
Prema Popat, Massachusetts Division of Medical Assistance
Dean Schleicher, Office of Personnel Management
Shoshanna Sofaer, Baruch College
Renee Turner-Bailey, Ford Motor Company
Christina Zarcadoolas, Brown University
Samantha Sheridan, Westat
Dale Shaller, Quality Measurement Advisory Service
Lise Rybowski, The Severyn Group
Kerri Yoder, Westat
(1) The conference, "Making Quality Count: Helping Consumers Make Better Health Care Choices", was sponsored by HCFA with support from OPM and AHRQ and held on December 10-11, 1998 in Arlington, Virginia. A summary of the conference and a companion analytic
report are available from the HCFA Web site at www.cms.hhs.gov. The analytic report, prepared under contract to HCFA by the Foundation for Accountability, provided the groundwork for the proposed research and action agenda presented here.
Performance: Report Cards Under Development But Challenges Remain (GAO/HEHS-99-178,
September 30, 1999).
(3) The Performance
Measurement Coordinating Council (PMCC) is a joint effort of NCQA, JCAHO, and
(4) The Robert Wood
Johnson Foundation, 1997 Employer Health Insurance Survey (Princeton,
(5) Henry J. Kaiser
Family Foundation, Health Benefits of Small Employers in 1998 (Menlo
Park, CA: February 1999).
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