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Think Tank

Predicting Future of Ratings in Health Care

As a reforming health system evolves in California and the rest of the nation, getting reliable, up-to-date comparisons of services and service providers will become increasingly important for everyone involved — consumers, purchasers, providers and insurers.

The ratings landscape is growing. Nationally, there are Medicare report cards for hospitals and nursing homes.

Organizations long known for rating products and services in other industries — Consumer Reports, JD Powers, PricewaterhouseCoopers, Moody’s and others — are increasingly turning their sights toward health care. Other organizations, such as Healthgrades, are forming specifically for health care assessments.

In California, the Office of the Patient Advocate offers an array of report cards, including its own on HMOs, PPOs and medical groups. It also provides links to ratings of Medi-Cal managed care organizations, Medicare physician groups, hospitals and long-term care facilities and CalPERS health plans.

With the spread of electronic health records and the accumulation of data they will generate, making comparisons will become easier and more prevalent.

There is resistance to ratings. A Forbes story, “Why Rating Your Doctor Is Bad For Your Health,” posited that physicians — and presumably other providers — would change their practices to achieve better ratings, not necessarily to improve patient outcomes.

Ultimately, where is all this headed? We asked stakeholders and experts to weigh in on several questions: Will disparate rating mechanisms wielded by public and private groups continue to carve out pieces of the system to assess? Will there eventually be a recognized framework for comparisons? Will resistance to ratings grow or fade?

We got responses from:

Definitely Headed in Right Direction

Years ago, when I was the founding CEO of The Leapfrog Group, I engaged in countless heated conversations about the value of grading American hospitals on their quality and safety. Today, I am pleased to witness consumers researching rates of hospital mortality or health care-acquired infections, and using this information in choosing where to seek care.

The current debate around physician ratings is déjà vu. Despite the resistance, we are heading down a path — the right path — where our quality measures are improving and becoming more relevant and reliable. The challenge before us is to continue to develop and identify measures that matter to consumers and push for providers to accept them. It will also be important to balance consumers’ interest in patient satisfaction results with patient-reported clinical outcomes and other more clinically-focused measures and ratings. The good news is that groups like the Consumer Purchaser Alliance and Consumers Union are working to distill which measures — such as care outcomes — are truly meaningful, so that consumers aren’t left with a hodgepodge of “process measures” they can’t decipher, alongside consumer-generated reviews that can completely lack correlation to the clinical quality of care. 

Organizations like Catalyst for Payment Reform are playing a role in bringing the employer voice to the table, which can help give providers a business-case to submit to performance measurement, reviews, and ratings. Employers and other purchasers want consumers to be informed decision-makers, especially because the employer and consumer pay the bills.

As consumers learn more about how quality and prices vary in health care and become subject to health insurance benefit designs that give them incentives to shop around, they will gravitate toward websites and other resources that help them make smart decisions. Health plans and other technology companies are playing an important role in developing websites and other resources where consumers can easily find information in an understandable format, specific to their health insurance. In CPR’s recent review of some of the leading price and quality transparency vendors, we found many of these tools are rapidly evolving, showing consumers helpful information on both the price and quality of their providers.

I’m optimistic that within the decade we’ll have enough information to choose our doctors based on meaningful information. It’s certain to be better than the “pin the tail on the donkey” approach we have to use today.

Electronic Records Hold Promise for Future

The California Hospital Association supports the appropriate collection, validation and dissemination of publicly reported hospital quality and patient safety information. Transparency of hospital quality data can improve patient outcomes by promoting collaboration among health care providers, and enable consumers and payers to make better informed health care choices.

Publicly reported quality data should be derived from an assessment of evidenced-based quality measures that have been demonstrated to reliably assess meaningful aspects of patient care. The measures should be clinically and statistically confirmed, and relevant to the needs of health care consumers and providers.

It is important that quality measures are feasible to collect. The construction of comparative quality measures using exclusively administrative data remains challenging, and results may be more indicative of documentation practices than actual delivery of care. When utilized, it is important that administrative data incorporate all payer categories, rather than a single payer. Data should be risk-adjusted, using standardized, transparent statistical techniques that can be replicated.

Due to the challenges of administrative data, CHA believes a more effective approach to measure performance will utilize electronic health records in order to capture clinical quality and patient safety data.  Although this cannot be done in the short-term, electronic health records hold the promise of more robust data.

To assist in achieving these foundational goals, we support the National Quality Forum Measurement Application Partnership, which bridges public and private sector use of measures to help the nation use measures efficiently and reduce the burden of reporting data that are of limited value.

Finally, improving the quality and safety of care provided is an iterative and continuous process. Therefore, publically reported hospital quality and safety data represents a single snapshot in time. Even if the data are the most current available data, it will rarely represent present performance.

Core Measures, Sustainable Approach Are Key

The question is not whether to measure and report on the performance of the health care system — information on quality, cost, access, and health outcomes is critical for decision-making at all levels, from patient to policy maker. We regularly use volumes of information to support decision-making in virtually every other sector of the economy and should demand the same from health care. 

In our decade of experience measuring and reporting on performance in California, we have learned several lessons that inform our ongoing efforts to improve quality and reduce cost:

  1. Measurement must be tied to performance priorities. IHA’s efforts began squarely in the quality space — clinical quality, patient experience, and meaningful use of health information technology — and have expanded to include total cost of care and appropriate resource use. Each of these areas is essential to achieving value in health care — and sole focus on any one of them misses the broader picture.
  2. Coordination and standardization is essential to reduce measurement burden. The impetus for IHA’s Pay for Performance program in the early 2000s was the proliferating set of performance measures faced by physician organizations. Each health plan adopted a different approach, creating duplication, administrative hassle, and cost for the physician organizations required to respond. Under IHA’s leadership, 10 statewide health plans and 200 physician organizations now share the same set of measures, detailed specifications, processes, and timeline for reporting on the care delivered to over 9 million HMO/POS commercial enrollees across the state. A core program principle is to align and adopt existing measures, whenever possible, rather than create new ones. Efforts to measure physician organization performance are also in place for Medicare Advantage plans in California and in pilot stage for Managed Medi-Cal.
  3. Measures for public reporting must meet reliability standards. While data used for internal quality improvement purposes can be based on smaller sample sizes and less rigorous reliability standards, information used for payment and consumer decision-making must stand on solid ground — perceived as credible by all concerned. This approach can slow down the performance measurement process and restrict the number of measures for which adequate data are available, but the alternative is quick and comprehensive reporting of flawed data – and a loss of trust and credibility for the entire enterprise. 

IHA is engaged in ongoing efforts associated with the California State Health Care Innovation Plan which provides an opportunity to develop a statewide performance measurement framework, set targets and reach consensus on metrics to measure both quality and cost across payers and providers.  Developing a core set of measures and a sustainable approach to collecting and reporting on the data are essential ingredients if we are to deliver on the promise of a high-performing health care system.

Variety in Ratings Is a Good Thing

While there are multiple efforts — public and private — under way to provide useful information to consumers on health plans, hospitals, doctors and other providers, Consumers Union views that as positive. Getting these ratings right is still at an early evolutionary stage. We need to learn what consumers want to know and create systems to more easily gather, crunch, and display the data in a compelling way.

Different developers trying out different measures and displays generates a knowledge base that will allow us, collectively, to find the rating measures that will “take” with consumers– and move providers and plans to provide better care.    

With consumers bearing more and more of the cost of care, the public is entitled to know how to get the best value for their health care dollar. And the trend toward standardization of offerings ushered in by the Affordable Care Act makes it more important than ever. Since the ACA requires all health plans to offer ten “Essential Health Benefits,” which medical services are covered is no longer a significant differentiator among plans. Covered California, has further standardized benefit designs to make comparisons simpler. Measures that illustrate such features as safety of hospitals in the plan network, health improvement, and consumers’ experience of complaint handling can signal the differences among products aside from snappy advertising and name recognition. In fact, the ACA requires creation of a rating system for Exchange plans, and that development is underway by CMS and Covered CA.

Our research confirms that consumers really want to know which doctor will best serve their needs. Yet, physician ratings are hard to come by, and often more like a glorified popularity contest. Last month, as an insert to Consumer Reports California subscribers, we published comparisons of physician groups in California in conjunction with  The ratings, also reflected are based solely on patients’ experiences — measuring how well their doctors communicate, coordinate care, and provide access to routine and urgent care. Of course, patient experience is just one measure; clinical evidence is critically important too. But the patient experience is a start, and it can also affect clinical measures.

The ACA is built on the premise of transparency and the promise that we will all be able to choose health insurance and medical care based on “value,” taking into account quality and cost. We cannot do that without the data. And, in this era of ratings, consumers don’t even go to a local restaurant for a hamburger without checking Yelp ratings. For something as critical (and expensive) as medical care for oneself or loved ones, the need for quality, safety and cost information is indisputable. The train has left the station on ratings — the smart move is to get on board to meet consumer needs and foster health improvement.