Quality data have limited impact on patient behavior

The information is not always trusted, studies find, and matters more when patients are paying out of pocket for nonurgent care.

By Victoria Stagg Elliott — Posted July 13, 2009

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The growing body of quality data available to patients may not have much effect on their choice of physicians outside of certain situations, according to several studies presented at a recent research meeting in Chicago.

Researchers are discovering that changing patient behavior is not easy and that making quality information available is one thing, but making patients aware it exists is another.

"There are many questions that these studies spark," said Jessica Greene, PhD, MPH, chair of a panel on consumers and their health choices at the annual meeting of AcademyHealth, a society of professional health researchers. She also is an associate professor of planning, public policy and management at the University of Oregon. "How do we reach consumers with information that they trust? What level of financial incentive is needed to spark more cost-effective health use?"

One paper by Harvard University researchers presented at the June 28-30 meeting looked at the effect of a tiering program established by Massachusetts' Group Insurance Commission, a state agency overseeing health insurance for public employees.

The program divides physicians into three tiers with rankings based on efficiency and quality analyses of claims data. Patients who choose those who are top-ranked are allowed discounted co-payments.

Critics argue it is designed to control costs rather than improve quality because physicians are not given the opportunity to review the accuracy of the data, understand why they were given a particular ranking or figure out the steps needed to improve. Five physicians and the Massachusetts Medical Society filed a lawsuit to stop tiering on the basis that patients were being misled and physician reputations were being harmed.

"It's a poorly designed construction that does not help patients," said MMS President Mario Motta, MD.

The American Medical Association strongly opposes tiered or narrow physician networks that deny access to or steer patients toward physicians primarily based on cost-of-care factors. The organization also states that rating systems should be transparent and based on evidence-based quality measures, rather than cost. In addition, the AMA urges health plans to allow physicians to review the data behind such ratings and have the ability to appeal them.

Data on the Group Insurance Commissions' program after the first year, however, indicated that many patients were not aware of the rankings and did not trust the information.

"They were more likely to trust their doctors as opposed to their employers or their health plan," said Anna Sinaiko, who presented the data at a June 30 session and is a health policy doctoral student at Harvard.

Researchers surveyed 4,200 randomly selected participants, finding that nearly 50% had not seen information about tiering. Almost 32% knew about tiering but didn't know where their own physician stood. Of those who were aware of their doctor's ranking, nearly 84% did not know this information until during or after the first visit.

Most patients also didn't trust the health plan as a source for this kind of information, with most preferring recommendations from a medical society, consumer organization or a personal physician. Only 3% would consider switching physicians in response to these rankings, and experts suspect that the financial incentives may not have been great enough to make a difference.

"This underscores the challenge of educating people about the tiered networks and how they work," Sinaiko said.

A different situation for in vitro patients

Another paper suggested, however, that publicly posted quality measures can have an impact on the physicians patients choose to provide in vitro fertilization. Researchers are interested in this procedure because patients usually will undergo it more than once, and they can illuminate the decision-making process for similar situations.

"A lot of health policy questions boil down to: Are patients good consumers?" said David Howard, PhD, associate professor of health policy and management at Emory University in Atlanta, who presented the paper. "But in many health care situations, patients are making one-shot decisions."

The Centers for Disease Control and Prevention is mandated to collect and publish success rates of fertility clinics. The study suggests that this information does make a difference, at least initially. Because those who undergo the procedure tend to be highly educated and from a high socio-economic status, and are paying for this procedure out of pocket, much research usually goes into choosing a clinic. Clinics with higher success rates do attract more first-time patients. Women who start out at lower-quality clinics also are more likely to switch to those that they perceive as higher quality.

Quality information makes less of an impact, however, on subsequent decisions about where to go for fertility treatment. The authors suspect this is because patients seeking the service are more likely to be influenced by the community of others in the same situation.

Effect of high-deductible plans

Scientists also are looking at the link between quality, health care costs and increasingly popular high-deductible health plans. A study by researchers with the Rand Corp. followed 39,795 people enrolled in such plans through 31 employers and compared them with 785,876 case-matched controls who were not offered this option.

The hope is that these plans will lead to lower health care costs, because patients will make more judicious decisions about their care. Researchers found that in the first year of enrollment, families with a deductible of more than $500 did reduce total health care expenses. There was no impact on emergency department use, and less of a difference was seen among families who also had a health savings account and an employer that was contributing significantly to it.

Researchers plan to investigate further whether these plans reduce costs over the long term and the plans' impact on health outcomes. Experts are concerned that preventive care, which is often a fully covered service not considered part of the deductible, may be underutilized, because patients may not understand the terms of using it. This could offset cost savings by leading to an increase in preventable hospitalizations.

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