Many health plans and other consumer groups have advocated consumer empowerment in healthcare – i.e., there is a push to encourage consumers to take more control of their healthcare spending and interactions with the health system. The belief is that more consumer engagement and responsibility that exists, the more likely consumers are to make decisions that lead to a more efficient healthcare system.

            For consumers, however, or anyone for that matter to exercise effective agency, there is a need for reliable, frequent, and sufficient data to inform the decision-making process. An investor may pour over 10K and 10Q statements and price charts before making a decision; much of this information is, furthermore, required by authorities to be made public. The story with healthcare is, however, markedly different. While there are many public data sources – CMS is increasingly requiring public reporting and one’s health plan also possess significant data about healthcare providers and some plans are also adding incentives for patients to use their health plan portal to identify the best value for a procedure (especially for expensive imaging procedures or for surgeries).

            That said, provider data is not necessarily public in large numbers. For example, health plans often have significant quality data on providers due to their need to collect it for their HEDIS quality metric reporting; moreover, through claims analysis, health plans can determine provider readmission rates. This data, typically, is not made available to patients and, therefore, patients cannot rely necessarily on relatively objective criteria to determine if a provider is a high-quality, low-cost provider or not.

            The situation, however, is not completely negative. CMS has provided data on its physician and hospital compare portals to empower patients, and, as stated previously, some health plans have made data available to their members. The Physician Compare website provides information on a provider’s participation in Medicare, their acceptance of Medicare fees, and whether or not a given provider takes part of CMS initiatives designed to improve the quality of care. Accompanying the Physician Care website is the Hospital Compare website which providers even more detail about items such as death rates, surgical site infection rates for certain procedures, and readmission rates. Such information can assist consumers in determining whether or not a given hospital – all things being equal – is a good fit for a specific procedure for a patient. In essence, it can be used – to a degree – as a shopping tool for patients – especially those in high-density geographic areas that may have significant hospital competition. Unless one plans on traveling a significant distance for a procedure.

            Data from sources such as these, can be combined with other information such as the NPI directory, other CMS data sources, and privately acquired data to build comprehensive directories for patients to assist them in choosing the providers and locations for their care. The meshing together of such data sources is necessary if patients are to be empowered to make informative decisions about their healthcare and to take responsibility – or partial responsibility – for choosing the best providers and locations for their care. That said, tremendous challenges persist especially the reticence on the part of many in the healthcare system to allow for quality data to be made public. Many physicians are concerned that they will be effectively penalized for taking more complex or challenging patients on through lower quality scores – indeed many are currently penalized through incentive programs already – and therefore, there will be an incentive to dump sick or challenging patients rather than meeting them where they are and providing the best possible care they can receive.

Categories: Healthcare

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