Transparency: Some Fundamental Questions

Is it possible to represent and present prices in a transparent way?

One can argue that most plans and approaches obscure pricing and that little substantive progress can be made without a more standardized pricing approach.

Is it possible to represent and present meaningful quality metrics?

Early attempts are that - early. They are bounded by limitations in the type of data collected, by the difference between the available data and how an individual describes "health" and the lack of longitudinal information essential for long-term approaches and measurements.

Will affected individuals understand what is presented?

Consumers believe price and quality information is important but find the current resources inadequate.

Will they change their behavior?

There is evidence that early hospital quality metrics do not change behavior but that pricing changes - particularly in prescription drugs - do change purchasing decisions.

Can the process be continually improved and simplified?

Some argue that our limitations in data will lead to a "dead" end and that further progress will require a re-thinking of the role of consumer judgement, health, and the very type of information collected to represent health and behavior.

Can the effort start small with ‘quick wins” and evolve to realize its larger aspirations?

The challenge is to find a population or area where self-pay markets predominate and pure competition over the right things is taking place.

What kind of coalition can foster the community-wide commitment required for long-term success?

There will be some parties early on who "win" and others who "lose." Success requires all to realize the failure of the current system - something difficult to do since by and large the majority of the population is satisfied with their health care as it is today.

Transparency: Selected Web Sites

Transparency Sites

Ambulatory Care Quality Alliance (ACQA)

AHA Hospital Quality Alliance (HQA)

Blue Cross - Blue Shield Association transparency site

Blue Cross - Blue Shield of Massachusetts: How Consumers Make Decisions

Business Healthcare Group (Wisconsin / Humana)

California Health Care Reform

Florida AHCA Consumer Information

Florida Compare Care

FloridaHealthStat.com

Florida - myFloridaRx.com

FloridaInformedPatient.com (Florida Hospital Association)

Florida State Consumer Health Information and Policy Committee (AHCA)

Florida: Choosing a quality health plan: HMO reports

Florida: 2005 Florida Snapshot (2-28-07: Penny Walker Bos PowerPoint)

HHS value-driven health care home

HHS Hospital Compare

HHS price standards

HHS community leaders for value-driven care criteria

HHS value-driven care definition and charter criteria

Humana transparency tools

Maryland Price Compare (Rx)

Massachusetts Health Care Quality and Cost Council

Minnesota Quality Site

Missouri Price Compare (Rx)

National Conference on State Legislatures (NCSL): State Legislation Relating to Disclosure of Hospital and Health Charges

New York Price Comparisons (Rx)

Pacific Business Group on Health

Pennsylvania Health Care Cost Containment Council

Quality Alliance Steering Committee - comprised of the ACQA and the HQA

Quality Counts - mock consumer report

WorldChanging.org Transparency Links. These are not health-care related.


Transparency Readings

Top Transparency Reads

California Health Care Foundation. Price Check: The Mystery of Hospital Pricing (2005). This study used "mystery shopers" to inquire about prices for common procedures in 64 hospitals. In most instances, it was difficult if not impossible to find this information. Of note is mention of legislation in California (and similar legislation in other states) that requires hospitals and pharmacies to provide

Florida's AHCA State Consumer Health Information and Policy Advisory Council
This site has the current and past activities for this critical group within Florida. It includes comprehensive presentations on the state of health care.

Florida Senate: Review of Medicaid Prescription Drug Pricing: Interim Project Report 2005-141, November 2004.(pdf) This article reviews Florida's pharmacy reimbursement mechanism and changes made to the methodology during the 2004 legislative session.

Follow the Pill: Understanding the U.S. Commercial Pharmaceutical Supply Chain. Health Strategies Consultancy for the Kaiser Family Foundation (March, 2005). An outstanding review of the nuances of drug pricing.

Public Reporting and Pay for Performance in Hospital Quality Improvement. Lindenauer et. al. NEJM 356:486-496, February 1, 2007. Conclusions Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.

From "Soak the Rich" to "Soak the Poor": Recent Trends in Hospital Pricing. Anderson. Health Affairs 26 (3): 780-789, 2007. Abstract: In 2004, the rates charged to many uninsured and other "self-pay" patients for hospital services were often 2.5 times what most health insurers actually paid and more than three times the hospital’s Medicare-allowable costs. The gaps between rates charged to self-pay patients and those charged to other payers are much wider than they were in the mid-1980s, and they make it increasingly more difficult for some patients, especially the uninsured, to pay their hospital bills. This has triggered lawsuits and some recent government efforts involving price transparency. Three specific policy options that could lower the markups are a voluntary effort by hospitals, litigation, and legislation.

Blue Cross - Blue Shield of Massachusetts: How Consumers Make Decisions.
Summary:
  • Choosing the right doctor and hospital is one of the most important health care decisions people make, and Massachusetts adults face these decisions often. Approximately half make health care decisions for someone else in their family, and most have chosen a doctor or used ahospital within the last five years.
  • Not surprisingly, consumers are eager for information to help them make more educated health care decisions, with more than three in four saying they would be interested in different types of information (e.g., hospital infection rates, information on the doctor’s experience) to help them compare doctors and hospitals.
  • Massachusetts consumers are hungry for this kind of information because they are keenly aware that problems with quality and safety exist. Nearly two in three believe medical errors happen often, and one in four have personal experience with medical errors.
  • But the kinds of relevant information consumers seek, such as the kinds of information they use for other major purchasing decisions (like buying a car or appliance), are not currently available.
  • In light of the dearth of credible information for making health care decisions, consumers often choose doctors and hospitals rapidly and with little information.

Health Care Price Transparency: A Strategic Perspective for State Government Leaders
Produced by the Deloitte Center for Health Solutions. Good overview document emphasizing consumer surveys. This article emphasizes Secretary Leavitt's four cornerstones:
  • Connectivity
  • Measuring and publishing quality information
  • Measuring and publishing pricing information
  • Creating positives incentives
Of FloridaCompareCare.gov, the report states:

The Florida Agency for Health Care Administration’s (AHCA) redesigned web site is the first step in an ambitious program. This site ultimately will give Florida’s health care consumers, purchasers and professionals an unprecedented degree of easy-to-access and understandable information on quality, pricing and performance. Florida Compare Care consists of two adjoining web sites that disseminate comparative health care information to consumers. The MyFloridaHealthStat web site displays price and quality information for hospital services based on risk-adjusted DRG codes. The MyFloridaRx site conveys information on prescription drugs, and anecdotal evidence shows that it is working to lower costs. For example, in Miami-Dade County there was a dramatic decrease in the range of retail prices for the drug Neurontin since the introduction of the price comparison web site. Florida has plans to begin reporting comparative information for health plans and individual physicians in the near future.

Could U.S. Hospitals Go The Way Of U.S. Airlines? Altman et. al. Health Affairs, 25, no. 1 (2006): 11-21.
Abstract:
The market for hospital services, like global markets in general, is becoming more competitive. Increased price transparency and focused competition can squeeze out inefficiencies, restraining prices and making some consumers better off. But competition can have a dark side. U.S. hospitals can treat Medicare and Medicaid patients at less than cost, care for the uninsured, and provide other money-losing services because they can cross-subsidize. By 2025 the need for general hospitals to cross-subsidize will greatly in-crease, but their ability to do so will be diminished. U.S. hospitals could begin to resemble U.S. airlines: severely cutting costs, eliminating services, and suffering financial instability.

Sometimes What's Needed is a "Nudge" - David Leonhardt - NYT - 16-May, 2007
Quoting (subscription required):
"This same sort of complexity has plagued Medicare Part D, the new prescription drug benefit. Almost one-quarter of low-income people eligible for a subsidy aren’t getting it because they have not signed up for the program at all. “It’s sufficiently complicated that people sort of throw up their hands and say, ‘I can’t deal with it,’ ” said Joseph Newhouse, a Harvard economist.

Likewise, there are almost seven million children without health insurance who are eligible for the State Children’s Health Insurance Program but are not in it. A few proposals to make it easier for children to be signed up are now working their way through Congress. In every one of these cases — school choice, Medicare, health insurance — the government can help people make good choices by tearing down bureaucratic hurdles."


National and International Trends in Health Care Financing and Delivery

The Uninsured: A Primer (Kaiser Commission on Medicaid and the Uninsured, 2006)

Consumer-Driven Health Care: Lessons From Switzerland. Herzlinger and Parsa-Parsi. JAMA 292 (10): 1213-1220 (September 8, 2004).
Abstract: Switzerland's consumer-driven health care system achieves universal insurance and high quality of care at significantly lower costs than the employer-based US system and without the constrained resources that can characterize government-controlled systems. Unlike other systems in which the choice and most of the funding for health insurance is provided by third parties, such as employers and governments, in the Swiss system, individuals are required to purchase their own health insurance. The positive results achieved by the Swiss system may be attributed to its consumer control, price transparency of the insurance plans, risk adjustment of insurers, and solidarity. However, the constraints the Swiss system places on hospitals and physicians and the paucity of provider quality information may unduly limit its impact. The Swiss health care system holds important lessons, including evidence about its feasibility and equity, for the United States, which is now embarking on its own consumer-driven health care system.

The Swiss Health System: Regulated Competition Without Managed Care. Reinhardt. JAMA 292 (10): 1227-1231 (September 8, 2004).

AHRQ Information Collection Activity (Federal Register Vol 72, no. 88, May 8, 2007, p 26117)
This Comment request deals with "Chartering Value Exchanges for Value-Driven Healthcare." This project proposes to twice annually post a public call for parties interested in becoming chartered as Value Exchanges for Value-driven Healthcare. Anticipated benefits of being a chartered Value Exchange include (1) participation in an AHRQmanaged Learning Network and (2) eligibility to request Medicare-inclusive multi-payer patient de-identified individual physician-level performance measurement results.

To be eligible, interested parties must first be recognized by HHS Secretary Michael O. Leavitt as a Community Leader for Value-driven Healthcare. Follow this link for additional information on Community Leader recognition.

Florida Demographics

Florida Population Statistics (US Census)

Florida County Map

Florida Trends in Financing and Delivery

Highlights from the 2004 Florida Health Insurance Study (2004)

Florida Insurance Statistics (Kaiser Family Foundation)

Florida Office of Insurance Regulation- Reports

Florida Hospital Association (FHA) Nurse Staffing Survey Findings (2005)

Analysis of Nurse Licensure Data in Florida: Methods and Statewide Results (Florida Center for Nursing, January 2007)

The Southern Regional Educations Board’s 2006 Annual Survey of Nursing Education Programs (Florida Center for Nursing, November 2006)

Quality

A Checkup on Health Care Markets (RWJ, Powers and Painter)

Your Guide to Choosing Quality Health Care (AHRQ) . A comprehensive (some would say encylopedic) 44-page document that includes definitions, advice on choosing health plans, hospitals, and doctors, and some advice on maintaining personal health information.

Are Consumers Influenced by Quality Metrics?

The Predictive Accuracy of the New York State Coronary Artery Bypass Surgery Report-card system. Jha and Epstein. Health Affairs 25, no 3 (2006); 844-855. Abstract: We examined the impact of New York State’s public reporting system for coronary artery bypass surgery fifteen years after its launch. We found that users who picked a top-performing hospital or surgeon from the latest available report had approximately half the chance of dying as did those who picked a hospital or surgeon from the bottom quartile. Nevertheless, performance was not associated with a subsequent change in market share. Surgeons with the highest mortality rates were much more likely than other surgeons to retire or leave practice after the release of each report card

Public Reporting and Pay for Performance in Hospital Quality Improvement. Lindenauer. NEJM 356 (February 1, 2006); 486-496. Conclusions Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.

What Happens to Prescription-Drug Use After Consumer-Directed Health Plan Enrollment? Fairman et. al (Express Scripts). Summary.CDHPs produce considerable savings, both in total drug cost and net-payer cost. These savings are achieved by 1) payment of a greater proportion of cost by the enrollee and 2) reduction in brand use, which is only partially offset by increases in generic use. The chronic-medication-persistency differences observed in the first quarter of the year had mitigated, but not disappeared altogether, by the third quarter. This finding suggests that members may have anticipated the change to CDHP and stockpiled medication prior to the end of 2005, making early (first-quarter) estimates of CDHP impact somewhat misleading.
.....Finally, they curtailed medication use instead of consistently substituting generic for brand medications.

Are providers influenced by quality and performance metrics?

Pay for Performance at the Tipping Point. Epstein. NEJM 356:515-517 (February 1, 2007).

Consumer-Directed Health Care And The Courts: Let The Buyer (And Seller) Beware. Jacobson and Tunick. Health Affairs, 26 (3),:704-714 (2007).
Abstract:
In consumer-directed health care, patients will be expected to exert greater control over their spending decisions than before. As consumer-directed care gains market acceptance, courts will inevitably be involved in resolving challenges to the new arrangements. We anticipate that courts will be generally favorable toward consumer-directed care, but the new legal doctrine will not uniformly favor medical professionals and insurers. The information demands inherent in consumer-directed care will present particular legal challenges to physicians and insurers. Even as courts provide flexibility to reflect the new market realities,

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An Interview with Representative Holly Benson

The National Conference of State Legislators recently published an interview with Florida Representative Holly Benson - an advocate of health information exchange. In this brief interview, she summarizes some of the efforts in Florida.

Regional Efforts in Florida

Northwest Florida RHIO (Pensacola)
Big Bend Regional Healthcare Information Organization (BBRHIO)
Jacksonville RHIO
Pinellas RHIO: Diabetes and Pediatric Asthma Health Information Exchange
The Humanna/Blue Cross Blue Shield, Availity.Care Profile
Tampa Bay RHIO
Central Florida RHIO (CFRHIO)
Brevard County Health Information Network
Western Palm Beach County Health Information Infrastructure Operations and Evaluation Project
South Florida Health Information Initiative

Florida Privacy and Security Work Group (Selected Postings)

Florida Health Information Infrastructure

Medicaid

Florida has an aggressive Medicaid reform agenda.

Selected State Legislation

Florida HB 1155 - AHCA's role in e-prescribing outlined

Section 3. Section 408.0611, Florida Statutes, is created to read:

408.0611 Electronic prescribing clearinghouse.—
(1) It is the intent of the Legislature to promote the implementation of electronic prescribing by health care practitioners, health care facilities, and pharmacies in order to prevent prescription drug abuse, improve patient safety, and reduce unnecessary prescriptions. To that end, it is the intent of the Legislature to create a clearinghouse of information on electronic prescribing to convey the process and advantages of electronic prescribing; to provide information regarding the availability of electronic prescribing products, including no-cost or low-cost products; and to regularly convene stakeholders to assess and accelerate the implementation of electronic prescribing.

(2) As used in this section, the term:
(a) "Electronic prescribing" means, at a minimum, the electronic review of the patient's medication history, the electronic generation of the patient's prescription, and the electronic transmission of the patient's prescription to a pharmacy.
(b) "Health care practitioner" means an individual authorized by law to prescribe drugs.

(3) The agency shall work in collaboration with private-sector electronic prescribing initiatives and relevant stakeholders to create a clearinghouse of information on electronic prescribing for health care practitioners, health care facilities, and pharmacies. These stakeholders shall include organizations that represent health care facilities; organizations that represent pharmacies; organizations that operate electronic prescribing networks; organizations that create electronic prescribing products; and regional health information organizations.

Specifically, the agency shall, by October 1, 2007:
(a) Provide on its website: Information regarding the process of electronic prescribing and the availability of electronic prescribing products, including no-cost or low-cost products; Information regarding the advantages of electronic prescribing, including using medication history data to prevent drug interactions, prevent allergic reactions, and deter doctor and pharmacy shopping for controlled substances; Links to federal and private-sector websites that provide guidance on selecting an appropriate electronic prescribing product; and Links to state, federal, and private-sector incentive programs for the implementation of electronic prescribing.

(b) Convene quarterly meetings of the stakeholders to assess and accelerate the implementation of electronic prescribing.

(4) Pursuant to s. 408.061, the agency shall monitor the implementation of electronic prescribing by health care practitioners, health care facilities, and pharmacies. By January 31 of each year, the agency shall report on the progress of implementation of electronic prescribing to the Governor and the Legislature. Information reported pursuant to this subsection shall include federal and private-sector electronic prescribing initiatives and, to the extent that data is readily available from organizations that operate electronic prescribing networks, the number of health care practitioners using electronic prescribing and the number of prescriptions electronically transmitted.

Selected Federal Legislation