Transparency of health care data has become widely accepted over the last few years, says Steven A. Spaulding, CLU, CHC, PAHM, Executive Vice President and Chief Health Management Officer for Arkansas BlueCross BlueShield. And he sees trust developing between payers and providers in sharing performance data.
“Maybe 5 years ago, providers would have fought tooth and nail to have that information not be made accessible to others, because at that point they felt it was being used as a weapon by health plans against providers,” he says. But today, “there’s a general understanding that the information has gotten better, and incentive programs have arisen that help providers understand the need for transparency.”
In a recent NEJM Catalyst Insights Report on transparency, only 5% of Insights Council respondents consider the concept of patient-facing transparency to be very mature at their organizations; another 33% admit that it is not mature at all.
So, despite the improvements, respondents recognize that transparency efforts are a relatively recent development and that there is room for improvement.
“I am more focused on provider-facing transparency than I am on patient-facing transparency,” Spaulding says. “I have long thought there is limited value to transparency from the patient-facing side simply because a lot of the decisions that a patient should have the ability to participate in are at the very low-acuity levels of the system, and when you get to more sophisticated problems, it’s very difficult for a patient — other than just to look for general quality ratings or general directional cost ratings — to participate in the care plan itself. It doesn’t surprise me that there’s not a lot of patient-facing transparency because it doesn’t represent value in a lot of situations.”
The impact of transparency on elements of value also points to areas for improvement, especially aspects related to cost. Just 31% of survey respondents expect that transparency alone can have a strong impact on lowering costs — notably lower than the 52% who say transparency will have a strong impact on improving quality.
Nancy Girard, DO, is a rural solo primary care practitioner in Alexandria Bay, New York, a Health Professional Shortage Area at the Canadian border. Many of her patients have chronic conditions that require long-term management with prescription drugs.
“One of my greatest problems with transparency has to do with prescribing medications, and not having a clue what drugs the insurance company is going to cover when I’m trying to get my patient’s medication in order.”
Even if a drug is part of the payer’s formulary, the out-of-pocket cost for the patient can spike unexpectedly. Girard sees cases where the drug is no longer covered.
“That is not very transparent. The pharmacy tells the patient all they have to do is get the doctor to do an authorization. You can spend an hour trying to get the patient their drug, or finding an equivalent — then in 6 months, it changes again,” she says.
“I talk to my patients about everything that I am doing with them. I spend a lot of time with patients, and that is a function of being in a small town,” Girard says as she describes her commitment to being transparent. “You need to be able to confidently tell a patient what a price of something is going to be.”
Mike Noonan, DO, practices family medicine at Salud Family Health Center, a Federally Qualified Health Center in Commerce City, Colorado, an industrial suburb of Denver. He, too, cites the importance of cost-related transparency for patients, but says some aspects of transparency are not needed.
“I think there are parts of transparency that are very important, for example, the costs that patients will incur for various treatments. But I think that some of the inner workings of health care are irrelevant to patients,” he says. “I feel we have a strong duty to society, and sometimes that is to protect people from themselves. Does a person need to know I feel that they have addiction risk factors, and that’s why I won’t prescribe them hydrocodone? I don’t believe so. What I believe they need to know is that this medicine is not safe and appropriate for most people.”
Noonan also addresses the importance of transparency to impact cost. “We waste money like it’s just tissue paper to throw into the fire. I understand from the point of view of policymakers and the patient’s point of view that an annual CBC [blood test] ordered for screening is insane. We say that as physicians, but we order it all the time. That’s the transparency that is important: that I’m doing this for no reason.”
Randal S. Weber, MD, is Chief Patient Experience Officer at UT MD Anderson Cancer Center in Houston. He describes the organization’s concept of the value proposition as not just outcomes divided by costs, but as the outcome achieved from care, plus the patient experience and the provider experience, divided by the cost of care.
Eventually, those clinical outcomes should be reported and transparent at the provider level, he says.
“For me, as a head and neck surgeon, it would be things like mortality rate, readmissions, return to the operating room,” Weber says. But, he cautions, “These also have to be risk-adjusted. I may see a different cohort of patients than you do. My patients may be sicker, have a more advanced disease stage. It is tricky when you get to that level of reporting.”
Despite the challenges and caveats, the multipronged transparency effort is essential. “The ultimate upside [of transparency] is to improve the patient experience globally, but it’s also reporting on quality and safety and cost of care. That really feeds right in to the value proposition,” Weber says. “The federal government has already implemented compensation based on outcomes and value. Insurers and payers of insurance premiums in the not-too-distant future will look at these data and channel patients to institutions and providers of the best outcomes and patient experience as part of that decision-making process on where to allocate your dollars to pay for health care.”