Wednesday, June 2, 2010

Comparison and Competition through Transparency


I strongly believe that a higher value for patients (the consumers of health care, so to speak) might in many cases only be achieved with more transparency. There are more and more institutions who become more an more transparent:
  • In a recent article, The Fiscal Times highlighted how hospitals in Wisconsin (among them the well-regarded ThedaCare health care system, famous for their ) publish their costs and compliances with best practice checklists through the Wisconsin Collaborative for Healthcare Quality.
  • In few areas, e.g. coronary artery bypass graft (CABG) surgery, there are in some States detailed and risk-adjusted rankings of the quality of  CABG programs available (often termed "report cards"). Early examples include New York State and Pennsylvania.  However, there might be adverse consequences from publishing such very detailed rankings, e.g. doctors avoiding high-risk patients and widening of disparities in health care utilization.
  • Medicare/Department of Health & Human Services offer a tool called "Hospital Compare". They publish patients' opinions about their treatment in six conditions and of 29 procedures in hospitals. 
  • The Commonwealth of Massachusetts has chosen a different approach: it publishes a composite index of quality and cost of care of procedures from different providers. On their website you can select in four different providers and compare their costs and quality compared to the state average (example). Importantly, as in Wisconsin, also costs (in terms of median, "low", and "high" charges) are being made transparent.
  • In his blog "Running a hospital", Paul Levy of Beth Israel Deaconess Medical Center in Boston has revealed more information than is available from their official hospital website, for example central line infection rates.
  • The Dartmouth Atlas is famous for the geographic comparison of different Medicare spending per enrollee. But they do have a few quality measures in their currently available analyses as well: patient satisfaction per HCAPHS survey, amputations and HbA1C as measures of ambulatory care, and the CMS Hospital Compare Score (another composite score, calculated with the Jha et al. method) for inpatient care:



Both typical health outcomes of different management strategies (or diagnostics, e.g. screening strategies) for a particular condition and the quality in which providers of health care offer them can only be put to real comparison if the health outcomes as well as the costs involved are clear. This is, at present, not necessarily given.

As Michael Porter and Elisabeth Teizberg write in their book "Redefining Health Care: Creating Value-Based Competition on Results", although a provider can also benchmark internally first, real competition between providers can only arise when both costs and quality of the health care services can be compared by the patient (disclaimer: I have participated in their week-long immersion program). I very much agree with the analysis of the current situation that Porter and Teisberg put forward, but not with all their "prescriptions" and the effects on the whole system that they predict.

How aware are patients of such a rankings? In a 1998 study by Eric Schneider and Arnold Epstein, only 12% of CABG patients in  Pennsylvania were aware of the report card before their procedure. This number could be MUCH higher today through the power of the internet.

These are just a few snippets of the discussion which is gaining speed. It will be very interesting to follow how this evolves over times. Will quality increase and costs decrease with more transparency and competition? Will all providers benefit from more referrals? Or will some be punished by lower revenues through, for example, lower rehospitalization rates? Will this all require different payment schemes, for example bundled payments for episodes of care, also known as capitation? Moreover, what effects will this have on the whole system, on referral practices and selection? Will less profitable or more complicated cases (which might be able to be treated as standardized and efficiently in integrated practice units) be treated differently? What do you think? You are welcome to comment!

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