Does anyone really believe quality scores change referral patterns or the doctors patients choose?

This question was posed by an audience member to speakers at the 3M Value-Based Care Conference. The answers were all “yes,” but not without qualification about how data transparency changes behavior.

Precisely, the question was, “Does anybody really believe that putting up a quality score changes referral patterns or makes a patient go someplace different?” The asker explained, “In New York, we’ve had the Cardiac Report Card forever and forever . . . I have never seen a badly reported cardiac surgeon come off that list or not do cases.” Furthermore, states and private health plans have invested in public reporting and web-based consumer tools on price and quality. Has it made a difference?

Consumer expectations

It has made a difference in satisfying patient advocates, according to Sheryl Terlouw, director of network innovation at Wellmark Blue Cross Blue Shield. “The market demands that you provide consumer transparency,” she says. Even so, consumers don’t take full advantage of the quality rating tools her health plan offers. The use rate is what she describes as very, very low. “Not that we shouldn’t do it or that we shouldn’t keep trying,” she adds.

Data transparency satisfies consumer expectations for public accountability, even when members don’t access the information or fully understand it. Terlouw observes that quality information can overwhelming to patients. “We have to make it simpler to understand,” she says, “More like a Consumer Reports kind of thing rather than HEDIS measures that people don’t necessarily [understand.] People go to physicians because they like them, not because the doctors control hemoglobin A1Cs. Many people don’t know what that is. The measures are complex, and we need to make them consumer friendly.”

Among other stakeholders, data transparency offers more obvious benefits. Terlouw says that sharing information “among providers and to employers is probably now far more effective than sharing it with consumers.”

Referral patterns

Jamie Dudensing, executive director at Texas Association of Health Plans, agrees on the value of data transparency with providers. “Where I see the impact is where primary care docs refer patients,” she says. “The quality data changes where they send the consumers.”

She says a health plan may use quality scores to influence behavior changes from “a macro standpoint.” For example, Superior Health Plan in Texas shares quality reports and other analytics with its providers in the state foster care program. “Just showing providers that they were overprescribing psychotropic drugs to kids when there was an alternative, just that data alone made an impact,” she says. When the health plan added payment incentives based on the quality data, it changed physician behavior and improved quality outcomes a little more.

Finally, a health plan might offer a bonus payment to a medical practices based on the quality metrics of all its clinicians. Dudensing says, “Say they have a practice of ten physicians. Nine of them are performing well in how they are watching quality of care and utilization patterns. And they have one that’s not. The plan may tell all ten of them, you’re not going to get your bonus payment, because you have one guy that’s not performing well.”

But how does the risk of losing a bonus change referral patterns? Dudensing says the poor-performing physician is going to pay closer attention to his or her referral patterns, to “the quality of care down the line of specialists and the hospitals” where he or she sends patients. “That’s where you see it really change the volume, driving consumers to a particular provider group that’s performing better. It’s those referral patterns.”

Systematic change

Public reporting prompts other types of changes in the healthcare system, including the behavior of doctors, according to Barbara DeBuono, director of market development at 3M, who once worked as the commissioner of health for the State of New York, including with the quality reports on cardiac care.

“We closed certain cardiac programs down [in New York], because their mortality rates were unacceptable,” says DeBuono. “They changed—had to change—their processes and their systems to raise their scores and get back on the list of programs that were allowed to do bypass surgery and other things in the state.”

According to DeBuono, raising their quality scores meant the physicians had to understand the factors that affect the score. “They looked at their anesthesia. They looked at post-op recovery, looked at pre-op,” she says. “What’s interesting is the number of times we saw hospitals and cardiac programs dig deep, try to understand their entire process from the time that the patient is diagnosed until the time that they are in recovery. And with some modest changes we found that, in fact, scores changed and programs were able to move up in the system.”

For more on healthcare data transparency, check out this blog and presentation from Paul LaBrec.

Kristine Daynes is marketing manager for payer and regulatory markets at 3M Health Information Systems.

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