557514
research-article2014
AJMXXX10.1177/1062860614557514American Journal of Medical QualityCantor
Commentary
Health Care Quality: A Question of Supply and Demand
American Journal of Medical Quality 2015, Vol. 30(5) 491–492 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614557514 ajmq.sagepub.com
Michael N. Cantor, MD1 Providing quality health care is the goal of every provider in the system, from individual physicians to large integrated networks. In spite of all the resources and personhours put into developing and implementing quality improvement initiatives, one major issue persists: those who benefit most from increased quality—patients—just do not seem to care. We have a major imbalance in the supply and demand for quality in the US health care system, and we need to improve patients’ understanding of and ability to act on quality measures to bring the situation back into balance. The emphasis on the supply side in quality improvement is notable for programs that lead to improvements in quality measures (eg, Get with the Guidelines1) or reducing low-value interventions,2 both of which should ultimately improve outcomes and care for patients. These initiatives become more important as quality and cost data become publicly available. Unfortunately, most patients do not pay attention to public reporting data when choosing their health care providers, mainly because they believe the data are not relevant to them or, more importantly for the supply side, because the data are not presented in a meaningful way.3,4 A recent report revealed that most patients focus on bedside manner and personality traits rather than quantitative outcomes when defining quality, and that they trust word-of-mouth recommendations over publicly reported data when choosing health care providers.5 As doctors, we base our referrals or recommendations on subjective criteria such as relationships and reputations, so it is not surprising that patients take a similar approach. Along this line of reasoning, one could question whether quality even matters at the patient level. Obviously the concept of health care quality and the intention of quality improvement programs matter to patients—the expectation of high-quality care is at least implicit in all patient interactions with the health care system. However, in addition to their complexity, current quality measures have the challenge of being population-based, while patients base their health care decisions on individuallevel characteristics. In reality, most patients likely will have similar outcomes no matter which doctor they see because most patients have common manifestations of common diseases and most doctors are competent. The
differences in how they get to the outcomes may be more costly or take longer, but most patients will not know any better because they do not have any alternative for comparison. When many negative individual outcomes coalesce into a trend, reputations, ratings, and patients may suffer; however, the lack of market forces in health care allow even the lowest quality providers to stay in business. If we care about quality and want patients to make educated decisions when choosing their health care providers, we must make the vast supply of quality measures meaningful and important. We have to create demand for objectively high quality care. To accomplish this goal, we must focus on 2 areas: transparency and communication. Health care is like no other market, and at least in the United States, it suffers from a major lack of transparency. Although quality information is available, as already noted, it is often difficult to find, incomprehensible, or not applicable to patients, which is why patients go to informal sites such as Yelp.6 Luckily, we have 2 excellent models to build on to help fix quality reporting in the United States. One highly successful model is that of fantasy sports. The Internet has allowed fantasy sports leagues to take off, and their success has spurred an entire industry and a slew of new “advanced metrics” to measure player performance. These advanced metrics are often the results of highly complex statistical manipulations based on multiple inputs, but as millions of fantasy owners can attest, they are packaged in a way that is meaningful and understandable. Health care quality reporting agencies could learn from sports statistics suppliers such as the Elias Sports Bureau to figure out new ways to make quality numbers accessible. People who have grown up on PER (player efficiency rating) and VORP (value over replacement player) and know the minute details of the performance of their favorite quarterback should have the same quality of information about the internist treating their 1
New York University School of Medicine, New York, NY
Corresponding Author: Michael N. Cantor, MD, New York University School of Medicine, Population Health, 227 E 30th Street, #645, New York, NY 10016. Email: [email protected]
492 diabetes or the surgeon repairing their anterior cruciate ligament. Another model that combines transparency and communication is the letter grades given for restaurant inspection results. In several cities, the Department of Health’s results are given in letter grades and posted publicly, both at the restaurants themselves and on Web sites. Though health care quality information may be more complex, distilling a provider’s overall performance into a letter grade would be a direct, easily understandable, and transparent way to communicate information to patients. While building on these 2 models would make data more accessible and understandable, it will have little impact if patients do not incorporate the data into their decision making. A nonprofit modeled after environmental advocacy groups, such as the Sierra Club, could make a difference here by designing a targeted campaign to increase demand. The Sierra Club has grown into a 2-million member organization and has helped pass milestone environmental legislation. A similar organization focused on health care could help promote patient engagement and educate patients to change the national mind-set around what health care quality looks like, leading to monumental changes in health care delivery, especially if patients started “voting with their feet” away from lower quality providers. The organization also could help spread the effects of well-intentioned but top-down campaigns such as Choosing Wisely, which are currently targeted at physicians. Imagine if patients thanked their doctors for not overprescribing antibiotics or not ordering unnecessary tests. Providing high-value, high-quality health care is a universal goal, but the goal is difficult to achieve when patients and their health care providers have different definitions of its fundamental constructs. Much as enthusiasm for supply-side economics has waned, it is now time to take a more Keynesian approach to improving health care quality. Focusing on the demand for quality
American Journal of Medical Quality 30(5) by educating and communicating effectively with our patients will lead to improved outcomes, better engagement, and could ignite the move to a truly high-performing, learning health care system. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
References 1. American Heart Association. Get with the guidelines. http:// www.heart.org/HEARTORG/HealthcareProfessional/ GetWithTheGuidelinesHFStroke/Focus-onQuality-HomePage_UCM_306348_SubHomePage.jsp. Accessed August 18, 2014. 2. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign. Acad Med. 2014;89:990-995. 3. Agency for Healthcare Research and Quality. Public reporting as a quality improvement strategy. http://www.ahrq.gov/ research/findings/evidence-based-reports/gapqistp.html. Accessed August 18, 2014. 4. Milstein A, Kocher R. Widening gaps in the wall obscuring physician performance differences. JAMA Intern Med. 2014;174:839-840. 5. The Associate Press—NORC Center for Public Affairs Research. Finding quality doctors: how Americans evaluate provider quality in the United States: research highlights. http://www.apnorc.org/projects/Pages/HTML%20Reports/ finding-quality-doctors.aspx. Accessed August 18, 2014. 6. Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311:734-735.
research-article2014
AJMXXX10.1177/1062860614557514American Journal of Medical QualityCantor
Commentary
Health Care Quality: A Question of Supply and Demand
American Journal of Medical Quality 2015, Vol. 30(5) 491–492 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614557514 ajmq.sagepub.com
Michael N. Cantor, MD1 Providing quality health care is the goal of every provider in the system, from individual physicians to large integrated networks. In spite of all the resources and personhours put into developing and implementing quality improvement initiatives, one major issue persists: those who benefit most from increased quality—patients—just do not seem to care. We have a major imbalance in the supply and demand for quality in the US health care system, and we need to improve patients’ understanding of and ability to act on quality measures to bring the situation back into balance. The emphasis on the supply side in quality improvement is notable for programs that lead to improvements in quality measures (eg, Get with the Guidelines1) or reducing low-value interventions,2 both of which should ultimately improve outcomes and care for patients. These initiatives become more important as quality and cost data become publicly available. Unfortunately, most patients do not pay attention to public reporting data when choosing their health care providers, mainly because they believe the data are not relevant to them or, more importantly for the supply side, because the data are not presented in a meaningful way.3,4 A recent report revealed that most patients focus on bedside manner and personality traits rather than quantitative outcomes when defining quality, and that they trust word-of-mouth recommendations over publicly reported data when choosing health care providers.5 As doctors, we base our referrals or recommendations on subjective criteria such as relationships and reputations, so it is not surprising that patients take a similar approach. Along this line of reasoning, one could question whether quality even matters at the patient level. Obviously the concept of health care quality and the intention of quality improvement programs matter to patients—the expectation of high-quality care is at least implicit in all patient interactions with the health care system. However, in addition to their complexity, current quality measures have the challenge of being population-based, while patients base their health care decisions on individuallevel characteristics. In reality, most patients likely will have similar outcomes no matter which doctor they see because most patients have common manifestations of common diseases and most doctors are competent. The
differences in how they get to the outcomes may be more costly or take longer, but most patients will not know any better because they do not have any alternative for comparison. When many negative individual outcomes coalesce into a trend, reputations, ratings, and patients may suffer; however, the lack of market forces in health care allow even the lowest quality providers to stay in business. If we care about quality and want patients to make educated decisions when choosing their health care providers, we must make the vast supply of quality measures meaningful and important. We have to create demand for objectively high quality care. To accomplish this goal, we must focus on 2 areas: transparency and communication. Health care is like no other market, and at least in the United States, it suffers from a major lack of transparency. Although quality information is available, as already noted, it is often difficult to find, incomprehensible, or not applicable to patients, which is why patients go to informal sites such as Yelp.6 Luckily, we have 2 excellent models to build on to help fix quality reporting in the United States. One highly successful model is that of fantasy sports. The Internet has allowed fantasy sports leagues to take off, and their success has spurred an entire industry and a slew of new “advanced metrics” to measure player performance. These advanced metrics are often the results of highly complex statistical manipulations based on multiple inputs, but as millions of fantasy owners can attest, they are packaged in a way that is meaningful and understandable. Health care quality reporting agencies could learn from sports statistics suppliers such as the Elias Sports Bureau to figure out new ways to make quality numbers accessible. People who have grown up on PER (player efficiency rating) and VORP (value over replacement player) and know the minute details of the performance of their favorite quarterback should have the same quality of information about the internist treating their 1
New York University School of Medicine, New York, NY
Corresponding Author: Michael N. Cantor, MD, New York University School of Medicine, Population Health, 227 E 30th Street, #645, New York, NY 10016. Email: [email protected]
492 diabetes or the surgeon repairing their anterior cruciate ligament. Another model that combines transparency and communication is the letter grades given for restaurant inspection results. In several cities, the Department of Health’s results are given in letter grades and posted publicly, both at the restaurants themselves and on Web sites. Though health care quality information may be more complex, distilling a provider’s overall performance into a letter grade would be a direct, easily understandable, and transparent way to communicate information to patients. While building on these 2 models would make data more accessible and understandable, it will have little impact if patients do not incorporate the data into their decision making. A nonprofit modeled after environmental advocacy groups, such as the Sierra Club, could make a difference here by designing a targeted campaign to increase demand. The Sierra Club has grown into a 2-million member organization and has helped pass milestone environmental legislation. A similar organization focused on health care could help promote patient engagement and educate patients to change the national mind-set around what health care quality looks like, leading to monumental changes in health care delivery, especially if patients started “voting with their feet” away from lower quality providers. The organization also could help spread the effects of well-intentioned but top-down campaigns such as Choosing Wisely, which are currently targeted at physicians. Imagine if patients thanked their doctors for not overprescribing antibiotics or not ordering unnecessary tests. Providing high-value, high-quality health care is a universal goal, but the goal is difficult to achieve when patients and their health care providers have different definitions of its fundamental constructs. Much as enthusiasm for supply-side economics has waned, it is now time to take a more Keynesian approach to improving health care quality. Focusing on the demand for quality
American Journal of Medical Quality 30(5) by educating and communicating effectively with our patients will lead to improved outcomes, better engagement, and could ignite the move to a truly high-performing, learning health care system. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author received no financial support for the research, authorship, and/or publication of this article.
References 1. American Heart Association. Get with the guidelines. http:// www.heart.org/HEARTORG/HealthcareProfessional/ GetWithTheGuidelinesHFStroke/Focus-onQuality-HomePage_UCM_306348_SubHomePage.jsp. Accessed August 18, 2014. 2. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign. Acad Med. 2014;89:990-995. 3. Agency for Healthcare Research and Quality. Public reporting as a quality improvement strategy. http://www.ahrq.gov/ research/findings/evidence-based-reports/gapqistp.html. Accessed August 18, 2014. 4. Milstein A, Kocher R. Widening gaps in the wall obscuring physician performance differences. JAMA Intern Med. 2014;174:839-840. 5. The Associate Press—NORC Center for Public Affairs Research. Finding quality doctors: how Americans evaluate provider quality in the United States: research highlights. http://www.apnorc.org/projects/Pages/HTML%20Reports/ finding-quality-doctors.aspx. Accessed August 18, 2014. 6. Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311:734-735.
