Can consumers capture the essence of quality? - quality measures of health plans

Business & Health, Annual, 1997 by Lani Luciano

Not so long ago, quality-of-care researchers fretted mainly over technical barriers to comparing health plan performance. Incompatible data, inadequate risk adjusters and unreliable reporting by providers loomed dismayingly large. Now, the experts face a more daunting obstacle-consumer reaction.

Acceptance by these ultimate customers for comparative information is crucial to the future of external quality measurement. So far, however, consumers don't much like, understand or trust the fledgling measures they've seen. And, though demand for health plan ratings is so high that outsiders -- such as the American Association of Retired Persons (AARP) and even some popular magazines -- have jumped in with their own freelance judgments, progress on improved measures from the experts has been slowed by competitive jockeying over who can best meet consumer needs.

"I'm not surprised that consumers aren't impressed," says Susan Edgman-Levitan, director of the Picker Institute, a nonprofit organization promoting patient-centered care. "We haven't gotten to the level of information that really concerns them -- doctors' performance. And we're spending too much time arguing about what patients want."

At the moment, the patients aren't too sure themselves. Focus groups and surveys suggest that their ideas on quality are intuitive and highly personal. When the Agency for Health Care Policy and Research (AHCPR) and the Kaiser Family Foundation polled 2,000 people last fall, a majority said they valued informal advice on health plans, hospitals and individual doctors from family, friends and other doctors much more than reports issued by employers or outside evaluators. Consumers are impressed by easy access to care, particularly specialty care, and largely uninterested in indicators that don't relate directly to them. Pregnant women, for instance, are understandably interested in what percentage of babies are born underweight but fail to appreciate that the percentage of diabetics regularly screened for retinopathy also gives them a useful window on a plan's quality of care.

This demand for individualized -- and simplified -- measures may add up to big problems for quality advocates. "Policy makers are betting that giving consumers more and better information will lead them to seek value for their money, but it's far from clear that that's the case," says Judith Hibbard, an expert in decision analysis at the University of Oregon. "Quality data are complex, confusing and imprecise." To make meaningful choices based on quality, says Hibbard, consumers will need standardized benefits, comparative information in small, digestible bites and possibly decision support from personal advisers.

Making patient needs

a norm

Leading the drive to make quality measures more user-friendly are the Foundation for Accountability (FAcct), a consortium of purchasers, and the Consumer Assessment of Health Plans Study (CAHPS), a research project launched by AHCPR. Last year, FAcct released its first five measurement protocols -- for breast cancer, diabetes, depression, health risks and health plan satisfaction. Under development are measures for asthma and health status. Alcohol abuse, AIDS/MV, hypertension, pediatric/adolescent, reproductive health and end-of-life care are planned for the future.

FAcct's approach is to ask patients what they want to know, then look for existing measures that can answer those questions with data. For example, focus groups said that their most urgent question about breast cancer was the percentage of cases diagnosed at an early stage. To find out, FAcct's measure set mines data from tumor registries, claims/administrative records and self-reported questionnaires. It remains to be seen, however, whether the multifaceted data will satisfy consumers' desire for unambiguous answers.

"What matters to patients and the way they perceive care is often much different from the medical community's views," says FAcct spokesperson Judith Graham. "We think that's very important." The ideal has lagged behind reality, however. Because of the expense and political infighting by special interest groups slow to offer their support, Facct convened focus sessions only for the breast cancer measure set. The other four current sets rely on extrapolated information to surmise what patients want to know.

CAHPS, a joint effort by Harvard Medical School, RAND Corp. and the Research Triangle Institute, also uses consumers as a starting point. The project aims to create finely tuned surveys of how consumers view crucial aspects of their care, such as access to services, communication/interaction with providers and coordination/continuity of treatment.

Although CAHPS does not use purely clinical data, researchers expect survey results to provide a window on both clinical quality and satisfaction. Additional questionnaires will probe the views of specific populations, such as parents, the chronically in, Medicaid recipients and non-English speakers. The Health Care Financing Administration, which is also testing FAcct measures, plans to start using CAHPS surveys in March.