November is not just the start of the holiday season; it’s the beginning of open enrollment. Whether you work somewhere that offers health insurance, or are purchasing insurance under the Affordable Care Act (ACA), people are spending the time to compare coverage and cost information between various insurance plans. There is more information than ever to review, such as the type of plan, services offered, co-pays, coinsurance, in and out-of-network providers, and cost information. It can be a very daunting purchasing experience; fortunately, resources exist, including access to consumer advocates and decision-support tools, to help navigate this complex benefits marketplace.
The key goals of the ACA were to extend health insurance coverage, improve quality of care, and to reduce the cost of healthcare spending, and efforts are already underway by the Centers for Medicare and Medicaid Services (CMS) and private insurers requiring providers to report information on provided quality of care for a variety of conditions and procedures. Insurers need this information to shift reimbursement from fee-for-service to value-based purchasing (VBP). Public reporting of this information is essential to achieving the goals of the ACA by driving consumer-purchasing behavior to high quality providers at a reasonable cost and by raising the bar for performance through provider benchmarking.
Consumers currently have little sight into quality of care information. Today’s publicly available reported data focuses on physician-level practice data, such as hospital or consumer websites that include information on board certification, years in practice, and areas of focus. There are websites to look up information on hospital mortality and complication rates for common conditions and websites that compare this information across hospitals (e.g., Hospital Compare, Healthgrades ®). Publicly reported data are generally lacking on the quality of outpatient care, where most patient care occurs. Over the next few years, the increase in the number of quality programs sponsored by CMS and private insurers across care settings and disease states will likely make more quality information publicly available.
The current quality measure landscape is crowded and disorganized, thus leading to potential confusion in the marketplace. CMS and private insurers use a subset of relevant measures to the various sponsored programs to assess quality of care. There are different types of quality measures including those used to assess the infrastructure supporting health care delivery, processes of care, patient experience with care, and patient outcomes. Each measure has detailed specifications on patient populations that include and exclude the type of data needed to calculate the performance metric. The intent is to standardize the collection and reporting of information in order to measure, report, and compare quality of care information. Today’s reality is that there is a lack of standardization in the choice of measures used in various programs even by the same insurer, and little to no standardization of measures used across insurers. In addition, there are gaps in assessing quality of care for many diseases and too few measures that are relevant to consumers.
The “devil’s in the details” when interpreting quality measure results, however. Consumers have a unique health profile, making seamlessly communicating quality information at a level that enables them to interpret its relevance very challenging. These challenges create roadblocks toward consumer-level success. There is a need for decision support tools to personalize the information, and most importantly to provide an integrated view of cost and quality information, which would enable consumers to make the best value-based healthcare decisions.
On November 18, 2014, the U.S. Government Accountability Office (GAO) released a report titled, “HEALTH CARE TRANSPARENCY, Actions Needed to Improve Cost and Quality Information for Consumers.” This Congress-requested report studied cost and quality information provided to consumers from CMS and private insurers. It focused on the type of information available to consumers, identified characteristics of effective transparency tools, and explored the effectiveness of CMS’ tools and efforts to expand information on cost and quality information. The report outlined 15 characteristics of effective tools to provide information to consumers. Over half of the characteristics relate to substantive quality and cost information for consumers, while the remaining characteristics focus on the display of information to enable consumer to understand the information’s usage.
The market-based transition to VBP is just the beginning, but the content and the presentation of quality and cost information will continue to improve with experience and advances in technology. Two activities in particular can facilitate these transitions: 1) expanding and aligning quality measures across programs, and 2) introducing consumer awareness campaigns; seldom discussed, but equally as important. We need more research in order to understand the value proposition of using quality and cost information. More importantly, consumers can respond to, or rationally interpret information about cost and quality, only if they are aware of its’ existence.
Debbie Lucas is the Director of ETI Practice at Avalere Health