Survey sponsors include physicians, consumer groups, and health plans. If used broadly in all settings of care, patient experience surveys will go a long way toward getting consumers to think about their health care from a value perspective. The greatest obstacle hindering the proliferation of patient experience surveys is the postage associated with disseminating and returning the surveys by mail. More research is required to see whether an electronic survey could replace the traditional hard-copy format, thereby driving down costs.
It is important, however, to ensure that whatever survey format is used takes into account ease of use by consumers.
2. Affordability of healthcare
Healthcare providers, too, in some cases impede the broader use of patient experience surveys. Non-physician stakeholders who sponsor reports should make every effort to engage healthcare providers in the process and to respond to any concerns they might have about particular measures or survey methodology.
Designing benefits to give consumers incentives to make truly value-based decisions is an additional strategy to sharpen consumer awareness about quality health care. It is important to ensure that consumers have access to information about cost and quality when redesigning benefits and that incentives are not designed simply to encourage consumers to choose the cheapest care.
Benefit design should also encourage consumers to seek out the primary and preventive care that will keep them well and support their efforts to effectively manage their chronic conditions. This can dramatically achieve both better health outcomes and lower costs. Efforts to generate consumer-friendly public performance reports and offer benefits that encourage value-based decisions are often thwarted by various stakeholders. In some cases, physicians oppose performance measurement in general, do not approve of the measures or methodologies used, or question the reliability of the data.
In other instances, consumers are angered that they must pay a higher fee to visit a doctor they have been seeing for decades. Engaging healthcare providers in these efforts may minimize their concerns. With consumers, it is crucial that changes in benefits be explained prior to roll-out to help them understand that the changes are based on value and are not punitive.
The Path to Continuously Learning Health Care
The strategies detailed above should be employed by consumer advocates and other stakeholders to help achieve this goal. People naturally want to be in the best health and have the lowest out-of-pocket healthcare costs. Having good health includes making optimal lifestyle choices, focusing on prevention, managing acute illnesses, and optimizing chronic illness management.
Individuals also face several layers of choice in striving to achieve or maintain their health: the choice of health plan; the choice of physician, hospital, or other provider of care; the choice of treatment; and the choice of lifestyle. Understanding where the variation exists and providing the best information available at the point of choice with appropriate incentives are critical to achieving better quality and making health care more affordable. Variation for some types of care occurs principally in the cost domain price for the item or service , with less variation for the majority of clinical circumstances in the quality domain.
Examples in this category include laboratory, high-tech imaging, ambulatory surgery, and pharmaceuticals. In each of these areas there will be a subset of clinical circumstances in which there are quality differences among providers.
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However, for the majority of clinical circumstances, the quality of care is both very high and equivalent among providers. Variation for other types of care, such as that provided by hospitals and physicians, occurs in both the total cost for the episode of treatment efficiency, a combination of the unit cost and utilization of service rate and quality domains over a broad spectrum of clinical circumstances as shown in the Table An estimate of the potential for improvement can be developed by first identifying the top-tier provider group and then calculating the theoretical improvement that would occur if everyone achieved the same results as those in the top tier.
When significant variation occurs in both quality and efficiency, the top tier must consist of those providers who demonstrate both superior quality and superior efficiency. For services such as laboratory, high-tech imaging, ambulatory surgery, and pharmacy, the primary variation occurs in price, and the potential impact of optimization is 0. For pharmacy, the optimal substitution of therapeutically equivalent generics for brand drugs would have an impact of 3 to 5 percent TMC.
For hospitalizations, we evaluated 29 different procedures such as coronary artery bypass graft [CABG] and medical conditions such as admission for pneumonia. The theoretical movement of all care to these facilities would reduce mortality and complication rate by more than 30 percent and cost per admission by 40 percent, resulting in a 0. For physicians, we initially focused on the care provided by 19 different specialty types, such as cardiology, endocrinology, and so forth.
We focused on specialists because they control the largest portion of the healthcare dollar. In addition, the patient-specialist relationship is often episodic, and therefore a greater opportunity exists to influence future choice. Again, the top tier was selected based on both quality parameters, such as adherence to evidence-based measurement standards, and cost efficiency as assessed by episode treatment groups.
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In this case, selecting about the top third of physicians based on both criteria and theoretically moving all care in a marketplace to those physicians improves cost by about 8 to 12 percent of TMC. Likewise, adherence to evidence-based medicine EBM standards would improve quality by about 5 percent, and the readmission rate would be lowered by about 20 percent. Achieving these theoretical potentials requires giving patients credible information that is easy to obtain and integrate into the healthcare experience.
CIGNA has found that when we provide information to people on the cost of high-tech imaging at the time the study is ordered by their physician, in 80 percent of cases the individual will choose the most affordable imaging center. Also, individuals must have reasonable access to preferred providers. Finally, benefit incentives are critical to encouraging people to consider quantitative quality and cost information in their decision making.
Larger incentives, such as a 20 percent coinsurance difference between in-network and out-of-network providers, influence choice.
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CIGNA has found that with carefully designed consumer-directed health plan benefits, individuals engage in reducing their total medical expenditures substantially—for example, by choosing generics more often—while maintaining or improving quality of care—for example, medication adherence, receipt of preventive health visits, and receipt of care in accordance with chronic disease guidelines Healthcare Effectiveness Data and Information Set [HEDIS] measures.
Barriers to progress include assisting individuals to transition from their customary reputation-based method of selecting a healthcare professional to one based at least in part on comparison of quality and cost information. Increasing the credibility of the information is critical. Physician ambivalence or reluctance to assist patients in these decisions must be overcome by full disclosure of conflicts and by payment reform with a transition to financial incentives to improve outcomes in both cost and quality for patients.
Enabling and rewarding individuals to choose the existing highest-value providers of care offers an immediate impact on the quality and affordability of health care for individuals today and stimulates all healthcare providers to improve in the future. The stimulus for future improvement based on consumer choice is limited by access issues and physician or hospital loyalty; thus, payment reform remains essential—paying for quality and efficiency total cost and not quantity—to improve future performance.
Reweaving the strands into a valuable fabric rather than cutting the entire knot is beyond the job description of most purchasers. Some employers focus on long-term gain via wellness programs, or on short-term gains, raising employee contributions and out-of-pocket costs. Others encourage expression of consumer preferences, sometimes at the risk of increasing already overused services.
Many purchasers have tried but few have been successful, year in and year out, in containing costs, advancing quality, and involving consumers. A limited number of successes have occurred, but with unknown potential for replication outside of the culture that fostered them. Kaiser, Geisinger, HealthPartners, Caterpillar, Pitney Bowes, and a few others come to mind; they are much admired, often cited, and rarely copied. Employees are provided with comparative data about individual physicians and hospital performance and then given financial incentives to use providers who are more highly rated.
The basic premise is that transparency is necessary, but not sufficient, without consequences. Also, although we have found the path to meaningful patient engagement on the comparative value of provider selection to be a steep one, we have also determined that it is a path well worth taking, for purchaser and enrollee alike. The GIC is the state agency that manages life, health, long-term disability, and other benefits excluding pensions for state employees, dependents, retirees, survivors, a small but growing number of municipalities, and most public authorities.
The GIC, unlike many state purchasing pools, also covers the entire state public higher education system. The GIC is self-insured for three-quarters of its enrollees and also offers three fully insured health maintenance organizations HMOs. The GIC does not negotiate benefits with employee unions; premium contribution splits between employees and the state are determined by the annual appropriation act.
However, premium levels and the benefit programs are determined by the commission itself. The GIC was an early adopter of mail order drugs, tiered pharmaceutical co-pays, mental health parity before it became law , intensive—and expensive—cardiac rehabilitation programs, and disease management programs. Its cost trends have consistently been below national or state trends.
Nevertheless, the trends are upward bound, except for the few years of HMO dominance before the backlash annihilated much of the management aspects of managed care. By , the GIC had tested all the conventional solutions, but still faced unsustainable increases in per capita health spending. Working with its consultants from Mercer Health and Benefits, the GIC decided to focus on pressing for faster improvement in overall physician performance.
Mercer consultant, Dr. Arnold Milstein, pointed out to GIC staff and its commissioners that since physician decisions are estimated to govern more than 80 percent of health spending and are associated with significant physician variation, motivating physicians to emulate peers who attain high-quality scores and use healthcare resources judiciously represented an opportunity to affect both.
In drafting its Request for Proposal for a new contracting cycle, the GIC required that health plans send their patient-anonymized book of business claims data to Mercer to enable comparisons of physicians on measures of quality and use of healthcare resources. Milstein attended a number of these meetings to explain to physicians the value for performance improvement of such comparisons linked to consumer involvement through the use of copayment differentials based on physician tiering.
At the same time, a quality-of-care comparison, not dependent on medical record review, was sought, since the GIC was committed to tiering decisions based on quality, not just cost. Resolution Health, led by Earl Steinberg, M. Using the aggregated database, Resolution Health looked for claims-based documentation that physicians performed the tests, prescribed the medications, and performed the examinations called for by major national standard-setting organizations such as HEDIS, the Agency for Healthcare Research and Quality, and specialist societies.
Adherence to guidelines and standards that could not reliably be determined via claims data was excluded. For example, annual flu shots cannot reliably be demonstrated by examining claims since they are often administered without generating a claim. Steinberg also made several visits to the Massachusetts Medical Society and attended multiple meetings to describe the measurement methodology and to gather suggested refinements.
The program went live in and is now in its fifth year of operation. The Clinical Performance Improvement CPI initiative, sponsored by the GIC in Massachusetts, again compares physicians on two dimensions of value and offers consumers lower co-pays when they seek care from higher-scoring physicians.
Several national insurance companies have mounted similar programs, but the CPI initiative is purchaser-driven rather than insurer-driven, aggregating claims data for six unrelated health plans. In Massachusetts, the passage of time since has brought more standardization and refinement of the CPI. The health plans, also unexpectedly, supported greater standardization of specialties to be tiered, quality measures to be used, and the elimination of supplementary plan-based measures. All plans now tier a core group of medical specialties, and only a few tier primary care physicians PCPs. The program is challenging to implement, requiring linking physicians across six plans, accurate identification of practice specialties, and appropriate attribution of accountability to physicians.
Each of these issues has proved complex and occasionally contentious. Response to physician complaints about incorrect tier placement proved challenging but was addressed by a probability analysis devised by a nationally distinguished bio-statistician. It attempts to factor in patient behavior and measure difficulty. Its statistical elegance is not easily appreciated by many physicians, but it does attempt to deal with some of their concerns.
- 1. Accessibility of healthcare!
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However, the communication with and buy-in from patients have been positive. The GIC used simple vignettes to explain how enrollees can use the program to select new providers or as an informational resource for discussion with their PCPs when they are being referred to hospitals or specialists. It got me thinking: while the needed interventions would be specific to India and would possibly vary for different regions within the country, the foundational realities which would drive these reforms in India are similar to those in other developing countries throughout the world, namely accessibility, affordability and availability of healthcare.
While there are many factors impacting how each country deals with these fundamental issues and their digital health strategies, in my view, there is a crucial need to develop, deploy and regulate digital health across the continuum of care. Healthcare providers need to scale up on IT applications to have a robust, accessible and affordable healthcare system available for all. Access to healthcare is a complex issue with unique problems for each country, and these problems need to be addressed in their entirety.
In the context of India, the first major issue is an inadequate and poorly maintained physical infrastructure and insufficient allocation of funds for properly running the existing healthcare infrastructure in the public sector. The second major issue affecting access to healthcare is an over-reliance on the private sector to provide healthcare.
Private sector healthcare is profit-driven and has thrived largely in large cities and only in tertiary care segments. These two factors combined have left a big gap in the area of primary and preventive care, especially in non-urban and remote areas.
Advancing real-time knowledge
Technology has a big role to play to improve accessibility of care. For example, telemedicine, if deployed systematically and holistically, is an excellent way to take healthcare to virtually anywhere, rather than patients having to visit a clinic or hospital. Telemedicine, in different forms, has existed in India for over a decade now. It has been reasonably successful in private institutions as an outreach medium, but not so successful at a population level.
The reasons telemedicine has not achieved the desired results include disjointed implementations in the public sector, poor mapping of the clinical workflows in telemedicine systems, and lack of training and empowerment of the care providers. Policy makers need to look at telemedicine in a fresh perspective by:. One of the most important elements is to ensure that the care delivery system is clinically relevant and aligned to the standard clinical workflows. This should further be augmented with the right kind of clinical decision support CDS tools to enable care providers deliver high quality, evidence-based and standardized care.
It is important to understand that the cost of healthcare in a system dominated by for-profit organizations is not just the price one pays for the services delivered inside the healthcare setup and buying medicines. There are many associated costs such as travel, hiring a full-time caregiver, and follow up visits, which eventually add up to a large sum of money.
To top that off, lack of longitudinal health records often necessitates duplication of diagnostics, thus creating a huge burden on the healthcare systems and further increasing the cost of care for patients, often driving not so fortunate families below the poverty line. While India spends a relatively small percentage of its GDP on health compared to other developing nations, we need to also think about where the country should spend the money allocated to healthcare in order to derive the greatest return on investment.
Fortunately, the basic economics of healthcare is opposite that of other industries because, unlike with other things we spend our money on, it is actually possible to reduce the cost of care by improving its quality. For example in a fee-for-service world, if a patient undergoes an operation and the surgeon does a poor job, and the patient has to undergo two more operations and spend two weeks the ICU followed by four weeks in a normal ward for four weeks, that costs a lot of money.
However, if the operation is done well and the patient is discharged in a week, it costs a lot less money. Investing in digital technology that gives healthcare professionals access to current, credible, evidence-based information not only elevates healthcare but helps reduce variability, which in turn will reduce the cost of healthcare while improving patient outcomes. As such, an early major investment should be in a combination of push and pull CDS solutions , which deliver current, credible evidence-based information to doctors, nurses, other traditional providers and patients.
It is unrealistic for developing countries such as India to rely solely on their limited number of trained physicians to drive impactful healthcare reform. The shortage of healthcare manpower and resources has two dimensions — quantity as well as quality. In my opinion, the greatest impact to improving the quality of healthcare can be made by empowering two critical non-physician provider groups: nurses and patients. For example, the quality of education and clinical training for nurses in the Indian education system varies widely. They therefore play a very crucial role in driving the impact of any population health measures.
With proper practice training and empowerment and appropriate incentive schemes, nurses can play a crucial role in providing safe, high-quality, cost-efficient basic care to patients in peripheral areas. This redistribution of clinical workload to nurses would also help the physicians by allowing them to focus more on patients who actually need their interventions.
Similarly, the nurse-specific CDS solutions, when implemented in an integrated fashion, would allow enable nurses in hospitals to deliver superior care. Until patients truly own and take responsibility for their health, any healthcare reform cannot realize its full potential. Such a monumental change in perspective requires investments in public education and easy-to —use, people-friendly CDS solutions, possibly in local languages, geared to engage and educate patients and their families about preventative and maintenance healthcare.