Not so transparent: Health care data hard to define

These days there's a lot of talk about making the cost and quality of health care more understandable to patients. But this transparency, like beauty, is in the eye of the beholder. While physicians and insurers each express support for transparency, there is a battle over what measures and techniques should be used to achieve it. Even the definition is in flux.

Insurers trumpeting transparency say they make every effort to ensure that the price and quality information they release gives consumers the clearest picture of the best doctors, the least expensive doctors and the best combinations of both.

But there's concern among physicians that without their clear direction and input, transparency initiatives might mislead patients into thinking that plans are paying doctors more than they actually are and that physicians are overcharging. Physicians also worry that plans are not using the correct and most complete information to rate quality, thus misrepresenting doctors, particularly those who take high-risk cases.

"Cost and efficiency is so hard to define," said Molly Katz, MD, immediate past president of the Ohio State Medical Assn. and a Cincinnati ob-gyn. "Perception of those things is different in everyone's eyes. Physicians don't mind saying, 'This is what I charge.' But comparing what you charge to the next person is very hard to quantify."

The issue of transparency has gotten more traction as patients have become responsible for more of their health care costs through increased PPO deductibles or consumer-directed health plans.

Big employers also are demanding transparency as they try to find ways to put a lid on their ever-increasing health care costs. A report presented at the AMA Annual Meeting in June highlighted efforts by plans such as Aetna, Cigna and Humana to post physician price data on sites accessible to members and doctors. UnitedHealth Group in late May announced that it would offer hospital-specific cost and quality data to members in Colorado as part of an initiative that will be rolled out nationwide by year's end. The Blue Cross Blue Shield Assn. in June announced a program involving 17 Blues plans giving their members access to hospital pricing and quality data.

America's Health Insurance Plans supports many of the transparency initiatives already in place, but is also concerned about prices becoming widely available for public consumption, thus undermining plans' bargaining power. AHIP President and CEO Karen Ignagni said insurers want to work with the government to devise price publishing methods that won't conflict with health plans competing in the same market.

"Many health insurance plans already are leading the way by collecting and disclosing quality and price data and making personal health care information more available to their members," Ignagni said.

The federal government is following a similar course. An executive order issued earlier this year by President Bush requests federal agencies, including the Centers for Medicare & Medicaid Services, to start reporting cost and quality information to people enrolled in the programs. CMS recently began posting what it pays hospitals for 30 common elective procedures. A few state governments are getting into the transparency act as well. For example, on Oct. 18, Georgia Gov. Sonny Perdue signed an executive order to create an entity called the Health Information Technology and Transparency Advisory Board, which is supposed to advise the state's Dept. of Community Health on transparency issues.

Medicine seeks clarity

Organized medicine has shown general support for the idea of transparency but has reservations about some of the definitions. The AMA, for example, has policy that encourages physicians and others to post fees. But physicians worry that insurers' and government's efforts to post fees will result in inaccurate information getting to consumers. For one thing, doctors say, fees must reflect what insurers pay physicians. Even the "negotiated rate ... tells only part of the story," states an AMA Board of Trustees report released in June, because insurers often change what they pay physicians during the course of a contract.

"Gone are the days when a doctor posts fees and patients pay the doctor directly," said board Chair-elect Edward L. Langston, MD, a family physician from Lafayette, Ind. "If we want patients to become more prudent purchasers of health care, they need to be in greater control of their own health insurance choices and decisions and need price transparency from all insurers, not just the federal government."

Even with the federal government, physicians worry that merely, say, releasing what Medicare pays each doctor for each procedure would not give consumers comparable data.

Federal and state efforts are in early stages and have not codified what transparency means. Private insurers are further along, though the AMA and others continue to work with plans to help them refine transparency initiatives. The AMA House of Delegates in June approved a report stating the Association should monitor insurers' transparency plans and be involved in "ongoing discussions on improvements."

Aetna was one of the first health plans to post physician-specific prices of common medical procedures for its members in selected areas. That's largely uncommon for health plans who generally have posted regional averages of costs on their Web sites. What began as a pilot program in Cincinnati last year turned into a national program reaching nearly 15,000 physicians in Aetna's network. William Fried, MD, Aetna's medical director for the mid-Atlantic region, said the company posts the prices that it pays to physicians.

"The physician can see his or her own information, but this information is intended to be available to members. It's not available to the public," Dr. Fried said. "These services can promote discussions. We want [members] to have discussions with their doctors to complement their health care decisions."

Dr. Fried said physician reaction to their program has ranged from skepticism to support. The health plan took physician suggestions about how to frame the information by making it easier for patients to understand what they were viewing.

Still, even though an Aetna patient could find the cost of a certain medical procedure, that's not enough information, many physicians argue. A physician's fees alone don't speak to the continuum of care, such as drugs, labs and imaging costs. Physicians say transparency efforts won't progress until prices include the total cost of care for complex illnesses.

True transparency, physicians say, can be realized only if the plan's medical payment policies, claim edits, patient-cost sharing portions and benefit payment levels are embedded in the health plan fee schedules or price ranges.

Mary Jean Geroulo, a lawyer at the Dallas-based law firm Stewart Stimmel, said the whole concept of transparency in its current phase is out of whack largely because the charges patients are seeing are generated by what the government and health plans are paying, not by what it costs to provide the service. "For transparency to work, you not only need to have visible charges, but the charges need to be comparable," she said.

Insurers say they are not opposed to being more transparent, but are opposed to making public the rates negotiated privately with physicians.

Initiating quality

Then there's the question of quality transparency. President Bush's executive order includes a call to federal health plans to develop and identify quality measures and approaches. But there is no guidance as to how.

Meanwhile, physicians and insurers have tussled over early attempts at identifying "quality" physicians. For example, the AMA and local and state medical societies fought United HealthGroup, on behalf of the plan it manages for General Motors, to rate physicians on quality based on outcomes in claims data. United has since amended its plan, and physicians and the plan continue to talk about quality rating.

Part of this debate includes the creation of quality initiatives across the board. To that end, the AMA convened the Physician Consortium for Performance Improvement, which includes more than 100 specialty and state medical societies, as well as a few private practices, federal health groups and insurers, including United. Dr. Langston said the group already had developed 115 quality measures for conditions including adult diabetes, asthma and chronic obstructive pulmonary disease. An additional 55 measures are expected by the end of the year. As of yet, no federal or private insurer has announced plans to adopt these measures on any widespread basis.

But that vagueness can be an opportunity. In the quest to define what transparency is, physicians have the ability to shape the answer in a way they feel is the most accurate and the most beneficial to patients. But they need insurers to accept that answer, physicians say.

"Insurers don't render health care," said Nancy H. Nielsen, MD, PhD, speaker of the AMA House of Delegates and an internist in Buffalo, N.Y. "They cannot deliver the product without us. They can't really ignore us in this situation. Any concerns about cost need to be married to a concern about quality. We want insurers to be focused on quality to get the right outcomes."