Final Contract
Report (continued)
Special Populations
Question 17. Are certain types of consumers more
responsive to financial incentives than others?
There has been some research into the characteristics that make a consumer
likely to respond to the information provided in an incentive plan (Table
5).
When the aim is to encourage the selection of high performance health plans
or providers, an important issue is the extent to which the information about
the performance of providers or plans offered through the incentive program
is considered new information.5
Studies
have shown that sometimes consumers already have an informal sense of health
plans' or providers' performance,
and that the addition of a report card merely confirms those impressions. In
such a case, a new report card may have little impact on consumers' behavior.4-5 One
implication of this finding is that consumers who are new to a market, and
have no prior information about providers or plans, may be particularly likely
to respond to information—and also to
incentives.4,8,115
For all the approaches to establishing incentives discussed in this Guide,
a major factor determining whether people become engaged in, and effective
managers of, their health care decisions is the extent to which they are "activated
consumers." Hibbard and colleagues116 have
developed a tool to measure consumer activation—the general concept is
that a consumer needs to have the confidence and knowledge to step into the
decisionmaking role.
Patients who are female, younger, and better educated
are more likely to be activated consumers, but these readily measured variables
account for relatively little of the variation in activation.117 Rather,
personal behaviors like asking questions and reading medication labels are
better markers of an activated consumer.
Some patients may not want to be activated consumers. In fact, a national
survey found that some people—although they are happy to discuss options
with their physicians—actually do not want to be decision makers in their
own health care.118
Patients
who are elderly or very sick—those who have the highest health care costs—are
less likely to want to make their own decisions. In terms of using information
for reducing disparities in health care delivery, it also was found that African
American and Hispanic patients were less likely than others to prefer an active
role in decisionmaking.118 Consequently, consumer responses to incentives are
likely to vary widely, both among people within a group and among groups. Special
efforts will be needed to ensure that all patients benefit from performance
measurement and incentive programs.
Question 18. What special accommodations, if any, should be made for
lower income, underserved, or sicker consumers?
Socioeconomic factors and health status clearly have an impact on consumers' responses
to incentives. This has been most carefully studied with respect to consumer
incentives to use fewer or less expensive drugs. It has been shown that even
among patients with chronic diseases, patients with a lower income and those
who are sicker are more likely to stop medications because of cost.57
The impact of income and health status on the response to incentives can be
mitigated through the design of the incentive program. If, as in the example
of Aetna's HealthFund program, first-dollar coverage for certain necessary
care is part of the benefit design—for example, people with diabetes
in HealthFund get their diabetes medications at no cost—so then there
is much less reason to be concerned about the negative impact of cost-sharing.26
Whatever incentive approach is used, it will be important to consider the
possible impact of limited health literacy. Descriptions of the program should
be sufficiently simple that consumers can understand them, even if their educational
level is low. If this is not achieved, large segments of the population may
fail to understand how the incentive functions and therefore cannot be expected
to respond as desired.
A relatively novel approach to assisting patients with their health care and
health care decisionmaking is the use of "patient navigators"—health
care professionals who help patients navigate the complex health care system
and the myriad potential barriers to accessing high quality care. Such barriers
can range from a patient's mistrust of providers, to a patient's
lack of child care, to cultural barriers.119
An
example of this approach is the National Cancer Institute's program to
use patient navigators to address disparities in care affecting underserved
populations.120 The
results of the studies funded under this program should be available soon and
should help us understand when and how navigators are needed and what navigation
assistance is most important.
Question 19. Is there a role for consumer financial incentives in
an overarching disparities-reduction strategy?
There are at least two ways in which introducing incentive programs also could
reduce disparities in health care delivery. The first is the simple act of
disseminating information about the quality of providers' health care
performance to populations negatively affected by disparities. Research has
shown that, before providers' report cards are released, minority groups
seem to have less access to information that defines which providers perform
better based on the available, measurable quality indicators.
Before the institution
of public reporting of surgeon-specific rates of mortality from bypass surgery
in New York State, there was no relationship between surgeons' mortality
rates and the probability that an African American patient would choose a particular
surgeon. Among white patients, however, those from ZIP codes associated with
a high education level and a high or middle income level were more likely to
choose a surgeon whose surgical mortality rate was low. After 1 year of
public reporting, African American patients from ZIP codes with a high education
and a high or middle income level were also more likely to choose a surgeon
who had a low mortality
rate.5
The second way incentive programs could reduce disparities is that information
about disparities can be included in the set of measurements collected and
reported.68 For
example, patient experience (patient satisfaction) scores for
hospitals could be reported by race and ethnicity. This would give providers
an incentive to reduce disparities and provide culturally sensitive care, while
helping minority-group consumers identify hospitals in which they would be
most comfortable receiving care.
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Evaluating a Consumer Financial
Incentive Program
Question 20. What unintended consequences should we seek to avoid?
In addition to the hoped-for effects of an incentive program, purchasers will
need to monitor, and try to minimize, unplanned negative consequences. Earlier,
we described potential, unintended responses from consumers, especially skipping
or delaying important treatment to avoid out-of-pocket costs. There also may
be important unintended consequences in terms of providers' responses to
tiering, which by definition includes public reporting of quality ratings, and
the concern those reports may raise. Three unintended consequences to look for
are: providers' selection of patients, "cherry picking" the
healthiest patients; diversion of attention away from important aspects of
care that are not measured in quality ratings; and widening gaps in performance
among providers.
- Selection of patients. Providers may avoid treating
sicker patients in the belief that adjustments made for severity of illness
in quality ratings are not adequate and that caring for such patients will
reduce their measured performance. Surveys done after New York instituted
public reporting for coronary bypass surgery showed that two thirds of cardiac
surgeons admitted to avoiding referrals of the most severely ill
patients.121 One
approach that might reduce the probability that an incentive program
would experience this problem would be to include, among the performance
measures, some structural or process measures of quality that apply equally
to all patients, regardless of their severity of illness. Risk adjustment
of outcome measures like mortality rates will also minimize selection incentives,
as long as providers believe the risk adjustment is adequate. In addition,
including explicit reporting of case-mix data that show which providers are
avoiding or accepting the more difficult cases—or providing differential
rewards for meeting performance goals with more difficult patients—might
increase providers' willingness to take on those cases. Another possibility
would be to collect and report information about patients who change from
one provider to another. A provider who is avoiding sicker patients would
be identified by the high case-mix scores of patients leaving his
practice.69
- Diverting attention from aspects of care not included in quality
ratings. Incentive programs may focus providers' attention
on the aspects of care for which there are quality performance measurements,
to the detriment of performance in other
areas.122 This
potential problem highlights the importance of selecting measures judiciously
and of paying attention to interrelationships among targeted and untargeted
domains of performance. Using some broader measures of outcome, such as
patients' experiences or decubitus ulcer (bed sore) rates and pain
scores in hospitals, may mitigate this problem as well.
- Widening performance gaps among providers. This problem
is most likely to occur if a program is designed to reward only providers
that meet a high standard of performance or that are the highest ranked among
peers. If this approach takes substantial resources away from other providers,
their performance may actually get worse. The problem is of particular concern
if it has an impact on safety-net providers and/or if there are not enough
alternative options for those patients who receive care from providers with
poor performance. If these adverse consequences are anticipated or noted,
purchasers can adopt auxiliary programs to help safety-net providers improve
their performance.
Question 21. How can we tell if consumer financial incentives are
working?
Assessing the impact of a consumer incentive program is challenging because
so many other factors simultaneously affect the quality and cost of patient
care. Ideally, purchasers would implement the incentive program in one market
or submarket and track the same performance measures on a set of comparison
providers in another area. Some large employers, the Federal Centers for
Medicare & Medicaid Services, and state Medicaid programs may be in a
position to pilot consumer incentives in this way, but most purchasers cannot
set up their programs as controlled trials. Therefore, special effort is needed
to disentangle the effects of the program from other trends.
At a minimum, purchasers using strategies that target provider or plan choice
should collect baseline data on the targeted performance measures before the
program begins. This will be a critical part of program implementation because
consumers and plans or providers need to learn about the measures and current
level of performance. Baseline data about provider or plan market share also
must be obtained. As the program is implemented, its effects can be evaluated
in terms of the change in performance and market share for high and low performance
providers, preferably relative either to a comparable but unaffected population
or to the trend in performance and market share existing before the program's
implementation.
For programs targeting selection of treatment options or reducing
health risks, the key baseline data relate primarily to consumers' choices
among treatment options or health risk behaviors. Assessment of the program's
impact, then, involves re-measuring the baseline variables to determine the
magnitude of change achieved.
To understand the impact of any type of consumer financial incentive program,
consumers and providers can be surveyed for feedback about unexpected problems
with the measures used, including difficulties with access to care. Similarly,
purchasers can track a set of performance indicators that are outside of the
incentive program to better understand both negative and positive spillover
effects from the program on untargeted clinical domains. Evaluation of the
program also can include assessing not just average performance but also the
effects of the program on different parts of the delivery system, including
patients from low and high income levels and providers with high and low baseline
performance ratings.
The Agency for Healthcare Research and Quality (AHRQ)
and the Commonwealth Fund have recently collaborated on establishing priorities
for research into the impact of consumer-oriented programs on clinical
outcomes—proceedings are available at
http://www.ahrq.gov/qual/qpayment.htm.
Purchasers have to decide how rigorous an evaluation needs to be in order
to ascertain whether a program is working and how to improve it. To adhere
strictly to scientific standards of evidence may be too costly and may produce
evidence too late to be useful for decisionmaking—but erroneous conclusions
that may be drawn from anecdotal or incomplete information may have substantial
costs as well.
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