New Marketplace

New Marketplace Survey: A Slow Path to Transparency for Patients

Insights Report · July 5, 2018

Analysis of the NEJM Catalyst Insights Council Survey on the New Marketplace: Transparency for Patients — Demand vs. Reality. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

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Advisor Analysis

By Robert C. Pendleton and Namita Seth Mohta

There is national momentum to empower patients with actionable health care information. But how well is the health care industry faring with this push to improve patient-facing transparency? In a new NEJM Catalyst Insights Council survey, only 5% describe their organization as very mature in transparency initiatives, and one third acknowledge their organization is not mature at all.

Transparency Initiatives Are Maturing But Have Far to Go

From the New Marketplace Insights Report: A Slow Path to Transparency for Patients. Click To Enlarge.

At first blush, one might find this bleak, but the truth is that patient-facing transparency efforts are still in the early stages. Following the stages of the diffusion of innovation, the health care industry is already past the few innovators and well along the way toward an early majority of maturity, and actively pushing forward in applying transparency.

In 2012, the University of Utah went live with patient experience data on its website for individual providers (including patients’ comments) when no one else was doing that. Today, individuals and organizations are increasingly aware of the need for this type of transparency; the Insights Council survey shows broad acknowledgment that transparency is important for a host of reasons. The pronouncements coming out of Washington, D.C., will almost certainly accelerate this progress. The data in this Insights Report represent a snapshot in time, and as we in health care adopt and adapt on this pathway to transparency, the trustworthiness and maturity of the information provided will grow.

Difficulty Defining the Value of Transparency

So what does transparency for patients mean to health care providers? Most Insights Council members point to sharing quality and outcomes data (88%) and cost-of-care information (85%) for procedures or services. But, while cost and quality data are critically important, there are precious few examples today of organizations harnessing actionable information from that data. Meanwhile, components that relate more to the patient’s experience are cited by smaller shares of respondents as being meaningful for transparency: open sharing of health information, such as provider clinic notes (62%), and sharing patient experience performance (61%).

There is sometimes a disconnect, however, in how health care providers and patients define transparency around quality, cost, service, and other attributes. If the intent of transparency is to help patients make better consumer-oriented choices and to improve patient engagement, then health care providers are only going to be successful if we work more with our patients to understand what information they think is valuable.

Insights Council members — who are clinicians, clinical leaders, and health care executives — show strong optimism about the ability of transparency to have a strong or moderate impact on improving quality (say 96% of respondents) and, to a slightly lesser extent, to lower costs (85%).

There are considerable challenges to realizing these outcomes, and so far a paucity of evidence. Indeed, the Council members recognize this: more than two-thirds (69%) of respondents say gaming the system (such as “cherry-picking” patients) is a potential negative consequence of sharing data more broadly, and nearly half (47%) are concerned about increased staff or provider burnout. These issues persist because there still are not adequate data standards for the health care industry, and we do not have adequate science on the best path of how to present cost, outcomes, and performance measurements in a way that best helps providers improve and leads to better patient-driven decisions.

The Need for Better Data

Data limitations such as collecting, risk-adjusting, and disseminating data are cited as the top barrier to successful implementation of transparency initiatives (by just over half of respondents). These inadequacies tie into concerns about adverse selection (cherry-picking) and clinician burnout because providers may not trust the data and often lack the ability to fully control or influence many of the metrics that we currently collect.

There is a great need for team-based data. It is encouraging that Insights Council respondents make clear that for transparency data to be meaningful, it needs to have granularity at the team/procedure/condition level, such as for a joint replacement team. That is the top choice of respondents, with 44%, followed by provider-level performance, 28%, and system-level performance, 18%.

A single provider cannot control the overall outcomes for cost, quality, or experience. For example, a hospitalist’s patients are interacting every day with numerous different nurses and clinicians, each of whom can have a profound effect on outcomes. A surgeon may perform the same procedure with different surgical team members at different facilities. Health care is not delivered by doctors in silos, and we are seeing a paradigm shift in how we think about the granularity of data and about who is accountable to help the patient to get better. The survey data reflects the evolution in medical thinking toward the importance of team-based care.

Survey respondents cite barriers to implementing transparency, but these are not insurmountable and should not be viewed in isolation, as if they are discrete items on a checklist. If we start addressing one, the rest will follow. If we start getting better provider buy-in, for example, that puts pressure on investing in the human capital and technology that we need. This survey shows the need to invest in the appropriate tools and resources to effectively, and sustainably, improve transparency to realize better outcomes.

VERBATIM COMMENTS FROM SURVEY RESPONDENTS

An example of a transparency initiative that your organization has implemented.

“Patient access to the majority of their health records through online tools; ready access to the cash prices of visits, tests and procedures; compliance with Medicare-mandated Advance Beneficiary Notification about uncovered tests.”
— Clinician at a large nonprofit large health system in the West

“Emotional journey mapping — mapping a clinical process with the real-time input of patients to better understand improvement opportunities.”
— Chief of service line at a large nonprofit academic medical center in the South

“Transition coordination with family present.”
— CEO for a large post-acute care facility in the Midwest

“Physician rating is visible to patients.”
— Clinician at a large nonprofit hospital in the South

“We are working on internal transparency — breaking down our own self-created silos. So, we share outcomes across service lines and in leadership meetings, and now in peer review. We are also having more patients and families involved in committees either formally or as guests.”
— Executive for a large nonprofit health system in the Northeast

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about transparency for patients in the health care marketplace. The survey explores the importance of transparency for patients, its definition, its impact on quality and costs, the level of detail needed for meaningful transparency, the level of maturity of transparency, and barriers to implementation and potential negative consequences. Completed surveys from 783 respondents are included in the analysis.

Insights Council respondents say that transparency for patients includes multiple elements. The top tier of responses — cited by more than 80% of respondents — is for clinical quality and cost-of-care elements. The second tier of responses focuses on the patient experience. In written comments, some survey respondents express a need for informing patients about errors and being open about conflicts of interest. Others stress that information should be put in context; for example, a clinician could tell a patient that medication can cut stroke risk in half but should further explain that the risk may be low in either case, such as dropping to a 2% risk from 4%.

Transparency Means Sharing Quality and Cost with Patients

From the New Marketplace Insights Report: A Slow Path to Transparency for Patients. Click To Enlarge.

Council members clearly accept that transparency is important, but agree on no single dominant reason. They cite patient-oriented factors, changing care delivery, and improving overall outcomes and costs. In written comments, respondents say transparency will drive corrections in the health care market (“eventually will improve overall costs and outcomes — a long term proposition,” says one) and will transfer power to patients (“shift the balance of ‘ownership’: patients are sovereign. We are CONSULTANTS,” writes another).

Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.

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