R. Galvin, A Historic Change, Modern Healthcare and The Commonwealth Fund, November 2007
Commentary on The Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey: Transparency of Health Care Quality and Price Information in the United States By Robert Galvin, M.D., director of global health care for General Electric and a member of The Commonwealth Fund Commission on a High Performance Health System.
Increasing cost pressures and compelling data documenting shortfalls in quality and efficiency have laid the groundwork for two powerful forces to coalesce: collaboration between private- and public-sector purchasers and the injection of consumerism into the health care sector. Employers and the Centers for Medicare and Medicaid Services are convinced that publicizing quality and price information would engage consumers, accelerate improvement and increase the value of their health care expenditures. Although this theory isn't proven, transparency has become interwoven into the concept of the public's right to know. Now we have to make this notion meaningful.
The degree to which transparency will lead to improvements in the health care system is dependent largely on how effectively it helps consumers and clinicians. Information has to be sufficiently relevant, accurate and understandable to drive improvement. And if patients are the "customers" of transparency, then providers are the key stakeholders. Engaging both parties is critical to success.
Since the system is still in the early stages of this transformation, it's an appropriate time to assess the progress to date and examine a few key issues.
There are several technical issues related to accuracy and fairness, among them case-mix adjustment, attribution, sample size and obtaining accurate clinical data. While there are few simple answers, the broad representation of groups working on solutions represents a solid foundation for consensus. The level of collaboration and good will to this point is impressive.
However, the social policy issues are potentially more important than the technical challenges. For the vast majority of measures, getting to absolute accuracy is not possible. The old policy saw, "not letting the perfect stand in the way of the good" is a suitable framing of the debate. Purchasers and consumers, eager for improvement and demanding their right to know, come down on the side of "pretty good, even if not perfect, information is OK by us." Providers, cognizant of the complexity of disease and treatment as well as what's at stake—i.e.. their reputations and potentially their livelihoods—and are understandably on the side of the "perfect." A recent event may shed some light on how this debate is likely to be resolved.
In August, New York State Attorney General Andrew Cuomo released what amounted to a cease-and-desist-order to several large health insurers that had released physician rankings or were planning to do so. He asserted that the health insurers were using imperfect data to increase their profits by steering people to cheaper providers. He was surprised, however, when the loudest voice in opposition to his order was that of consumers; what was done as protection was seen as paternalism. Consumer groups made it clear that they wanted information about doctors and hospitals and that they had already developed principles guiding public release of measures, with sign-off from important provider organizations, and that they would rather have imperfect information than none at all. Although the issue is not fully resolved, the compromise that is in the process of being hammered out looks like it will clearly lean towards "the good" not the "perfect," reflecting the importance of information—flawed though it is—to consumers. This is an indication that in areas of contention, patient-centeredness will take center stage.
Although there are data about a few conditions, patients needing information on common conditions like diabetes, cancer, and major orthopedic procedures still face a wasteland. GE recently held a "quality summit" at which we reviewed the current state of performance measurement. Two concerns emerged: the first is the number of metrics that, while measurable, aren't meaningful. For example, a recent measure approved by the Ambulatory Quality Association as a standard for quality uses the obtainment of an electrocardiogram for patients admitted with chest pain. Although no one disputes that this practice is indicated, it measures a "floor" for quality. Arrival-to-procedure time or even waiting times seem far more responsive to patient interests. There isn't a clear process by which consumers and payers have a voice equal to that of providers in measure development.
The issue of meaningfulness arises also with respect to the degree of differentiation being used in today's rankings. In examining the criteria by which several of the largest health insurers are constructing their "premium" or "select" networks, it turns out that that up to 70 percent of the doctors with whom they contract are being included. Clearly, when a consumer is looking for "the best," having no distinction between the top 10 percentile and those who rank at or below the average is insufficient. While both the paucity of data and the concerns of physicians are contributing factors, as stated earlier, patient-centeredness should be the guiding principle.
A second concern has to do with how well information is being communicated. It's likely that the degree to which consumers are using information is proportional to how well it is being presented to them. According to research by Judy Hibbard and others, the best we can say in this area is that we have a long way to go. At GE, in response to employee surveys that indicated that a large part of the population wants to talk to a person when they make important health care decisions, we developed a product called Health Coach. Using outside vendors, this model uses nurses who have been trained to help employees use data and other information to choose doctors and hospitals. While definitive data about program effectiveness awaits the results of a study led by Harvard researchers, qualitative data indicates that employees are finding that having health professionals help interpret performance data is very powerful.
In summary, the system's performance on transparency to date warrants a grade of "good start, but long way to go." As the measuring stick of success, I suggest that we'll deserve a high grade when the answer to "Who should I see for a spinal fusion?" is "You should consider Dr. Jones because she has some of the best outcomes and patients rate her highly on a personal level. Ask your primary care physician what he thinks. "
The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.