What You Have to Explain

To help consumers understand and use the information on quality that you are sharing with them, your report should touch on the following four topics:

• Purpose of the Report. What is this document? Why should consumers read it? How can they use the information?
• Today's Health Care System. What do consumers need to understand about their health care system in order to make sense of this information?
• Reasons to Focus on Quality. What do consumers need to understand about the quality of health care? How will this information help them?
• Other Factors that Affect Health Care Decisions. How can the consumer weigh considerations of quality with other important factors, especially the costs of care?

Purpose of the Report

To get your audience's attention, you will need to convince them that the information you are providing is both interesting and beneficial to them. Can you establish a strong link between the questions that readers want answered and the information the document provides? Depending on your relationship with your audience, you may also need to explain why you are giving them this information and where the data come from. For employers, in particular, it is important to reassure readers that your purpose is to help them get higher-quality care and that the source of the information is reliable and unbiased. Finally, since most performance reports are intended to help the reader take an action (as opposed to those reports whose purpose is purely educational), you must explain not only what the information is but also how they can use it to make better decisions.

To help ease your readers into the report, incorporate material that answers most if not all of the following questions:

• Why should consumers be interested in this information? Why is it important?
• Where did the information come from? What methodology did you use?
• How is the information relevant to questions they are interested in or actions they need to take?
• How is this document similar to something your audience is already familiar with? How and why is it different from other materials they may get?
• How does the information from this document fit with other pieces of information they may have or need to get, such as a comparison of benefits?
• How is the information in the report organized?
• How can they use the information (e.g., to compare plans so that they can make the choice that's best for them and their families)?
• How can readers organize all of the information they have to help them make the decisions that are best for them?

For details on methodology, go to Other Information You Can Share.

To learn about integrating quality information with other information, go to What You Have to Explain.

Today's Health Care System

In order for consumers to be able to understand and use quality information appropriately, they need to appreciate—at a basic level—how their local health care system works, how different components of the system interact, and how these things influence the quality of care they receive. In particular, they should be aware of the nature of the relationships between the insurers and providers available to them, especially health plans and the physician groups with which they contract.

To help your audience develop a better understanding of their options, your report could include a brief discussion of the following topics:

• How Managed Care Works in Your Market (including the "ground rules" for health plans and provider organizations).
• Different Kinds of Products Available to Your Audience.
• Differences Within the Same Kinds of Products or Organizations.

How Managed Care Works in Your Market

Your explanation of managed care largely depends on how much your audience already understands and the kind of comparative information you're providing. If managed care is still relatively new to your market, try to explain its purpose in as balanced and neutral a way as possible. Be sure to acknowledge the following points:

• Managed care is a strategy for lowering costs by providing timely health care services and reducing unnecessary and inappropriate care. This can lead to better quality as well as barriers to care that is necessary and appropriate.
• Under managed care, when consumers choose a source of coverage (i.e., a health plan), they are also choosing the providers and facilities from whom they will get most health care services.
• Because it integrates health plans and providers into identifiable groups, managed care makes it easier for purchasers to hold health care organizations accountable for the quality of their care.
• While managed care has its problems, it is not the cause of poor quality. Quality is a concern throughout our health care system.  Reports on quality tend to focus on managed care plans not because these entities are inherently flawed, but because their size, structure, and technical sophistication make it feasible to collect the data needed for quality measures. When comparable and reliable data on the quality of traditional insurers and smaller provider groups can be reported, they will be.

Select to learn Why Quality Measures Focus on Managed Care Organizations.

Since the implementation of managed care varies, be sure to tailor your explanation to the practices common in your audience's local market. In particular, explain some of the key "ground rules" for local health plan products and provider organizations, including such things as whether the primary care provider functions as a gatekeeper, how to get emergency care, and how to appeal denials of care. Consumers who understand the rules have a better basis for making an informed choice and are likely to have better experiences with plans and providers. In addition, you can use the rules to highlight the relevance of the data in your report.

For details, go to Making the Connection to the Ground Rules.

The Medicare & You 2002 handbook (PDF file, 583 KB; HTML) explains some of the ground rules for beneficiaries who enroll in Medicare managed care plans.

If your audience is well-acquainted with the practices of managed care and the structure of their local health care system, you may want to keep the discussion very brief, or even to eliminate it entirely. Another reason to avoid this topic is if an explanation is readily available elsewhere. For example, in its performance report, the Twin Cities-based Buyers Health Care Action Group doesn't feel compelled to include information about managed care, since 85 percent of the people belong to some kind of managed care plan and HMOs have been around for 25 years. The report also does not explain the coalition's unique care system model because the purchasers have distributed other consumer-oriented materials that explain how the model works.

Different Kinds of Products Available to Your Audience

If your audience can choose among different kinds of organizations, the report should clarify those options and the differences between them. For instance, if readers have access to different types of health plan products (HMOs, PPOs, POS plans, and/or fee-for-service plans), explain how those choices differ. To do this in a neutral way, talk about the features of each option so that consumers can understand the trade-offs they would have to make. It is especially helpful to consumers if you can spell out the differences in costs and access. There's nothing wrong with using explanatory text that has already been tested with other audiences, but be sure to edit the text to make it accurate for the organizations you're including in your report.

The CAHPS® 2.0 reporting template (PDF file, 170 KB; HTML) offers text for explaining HMOs and PPOs.

Medicare Rights Center's traffic light chart (PDF file, 387 KB; HTML) uses graphics to show differences between coverage options for Medicare beneficiaries.
© Copyright 1999. Medicare Rights Center. All Rights Reserved. Used with Permission.

The 1998 New Mexico Consumer Guide to Selecting a Managed Care Health Plan (PDF file, 1 MB; HTML) explains how different types of plans work.
© Copyright 1998. New Mexico Health Policy Commission. All Rights Reserved. Used with Permission.

You may also want to remind your audience of important differences across products when you present your data on quality. One way to do this is to group organizations by type; for instance, present results for all PPOs in one table and all HMOs in another table. Another approach is to indicate the type of organization in one column of a comparison chart.

The CAHPS® 2.0 reporting template presents results grouped by product type (PDF file, 49 KB; HTML).

Differences Within the Same Kinds of Products or Organizations

Depending on which health care organizations are included in your report, you might want to explain that even organizations with similar structures and policies can differ from each other in significant ways, and that those differences affect how care is delivered. For instance, HMOs have different criteria for selecting providers and use different incentives to retain them, which can affect quality. Also, while some HMOs have a great deal of influence with providers, some newer managed care organizations are more loosely structured and have less control over providers.

The booklet, Thinking about joining a Medicare HMO? (PDF file, 905 KB; HTML), notes some of the ways in which Medicare HMOs can vary.
© Copyright 2000. Baruch College School of Public Affairs. All Rights Reserved. Used with Permission.

Reasons to Focus on Quality

The idea of comparing the quality of health care organizations is new to most people. To make comparative quality data meaningful for your audience, your report must help them understand why quality is a concern and what the data tell them about the quality of health care organizations. It should also help readers make the link between the choices they make and the quality of care they receive. If consumers don't grasp this connection, they are unlikely to see how the information you give them is relevant to their lives.

Select links below to read about:

• Conveying Important Messages About Quality.
• Framing Messages About Quality.
• Addressing Common Misconceptions.
• Making the Connection to the Ground Rules.
• Explaining the Relevance of Population-Based Measures.

Conveying Important Messages About Quality

In your report, consider sharing the following messages:

• Quality can vary from one health plan to another.
• Quality varies within health plans (i.e., among provider groups within the plan).
• Quality is often not as good as it can be.
• Many aspects of quality can be measured accurately and fairly.
• The plan you choose can influence the quality of care you get.

This last message is especially important because people tend to attribute the quality of care they get to their doctors. Similarly, they assign responsibility for preventive care to themselves and their doctors. They often don't realize how health plans can affect various aspects of quality, other than by restricting access to care.

Consequently, you must explain that health plans can make quality both better and worse by influencing the physician's behavior and the ways in which care is delivered. It is also useful to repeat this point in the context of specific measures. That is, in addition to explaining why a measure is important and what it shows the reader about the plan, you can explain how the health plan can affect the measure. For example, a health plan can influence the mammography rate by letting physicians know which of their female patients are due for their exams and by reminding female members to schedule appointments. 

  Ford Motor Company's pre-enrollment flyer for employees, Taking Charge of Your Health Care, (PDF file, 705 KB; HTML) contains many messages about quality.
© Copyright 1999. Ford Motor Company. All Rights Reserved. Used with Permission.

To reinforce the importance of quality as a consideration in coverage decisions, remind consumers that when they select a managed care plan, they are choosing the providers who will deliver their care. This reminder is especially important for those who are new to managed care, which still includes a majority of Americans. But even people who have been in managed care for a long time don't always make the connection.

Select for Suggested Readings on What Consumers Understand About Quality.

Framing Messages About Quality

You can express, or frame, messages about quality in a positive way or in a negative way.

An example of a positive frame: "Use this information to choose the health plan that will offer the best care for you and your family."

An example of a negative frame: "Use this information to avoid the problems that can arise if you pick the wrong health plan for your family."

Researchers are currently investigating whether the way sponsors frame a message makes a difference. One hypothesis is that the nature of the frame can affect how well consumers understand health care quality information, how much they value that information relative to other factors, and how willing they are to make trade-offs to get higher-performers. And in fact, their preliminary findings suggest that when quality information is framed in terms of risk avoidance, people do understand it better, do value it more, and are more willing to make tradeoffs.  This suggests that by speaking directly to your audience's concerns, you can motivate them to pay greater attention to quality information.

Addressing Common Misconceptions

Your report is also a good place to discuss any misconceptions that consumers may have about managed care and quality. For instance, many consumers believe that:

• Health care is pretty much the same wherever you go (or "All health plans are alike.").
• Health plans can't do anything about quality.
• Good quality is defined by good service and customer satisfaction.
• I like and trust my doctor, so I know I'm getting good quality.
• Health care's too complicated to measure or understand.

Finally, depending on your audience and the information you are offering, you may want to dispel the common belief that managed care is the source of all quality problems. Because quality reports usually focus on managed care plans, consumers often assume that the problem is limited to those plans only. But the truth is that it is simply easier to measure and report the quality of managed care organizations than that of traditional insurers and providers.

Select to learn Why Quality Measures Focus on Managed Care Organizations.

Educate your audience by making the following points:

• Quality is not just an issue in the context of managed care, but a concern throughout our health care system.
• Quality varies at every level of the system.
• Information about quality in other systems of care is likely to become available over time.

Making the Connection to the Ground Rules

The "ground rules" of health care organizations have consequences for people; the information you provide should help them deal with those consequences. Moreover, people are more likely to find meaning in quality information if you can link it to their day-to-day experiences with a health care organization.

For these reasons, you may want to supplement general messages about quality by explaining how the ground rules can affect quality of care, and how the information in your report can help consumers obtain good quality care within the boundaries of those rules.

Explaining the Relevance of Population-Based Measures

Quality measures are based on the experiences and opinions of large numbers of people, often referred to as populations. The purpose of relying on populations is to ensure that the measure accurately reflects the probability of a certain level of care. But this is very different from the way that many consumers are accustomed to gauging quality, which is to consider the experience and opinions of a few trusted individuals, such as family members and friends.

The problem is that one person's experience may be influenced by events that may never be repeated; when you look at the experiences of many people, unique factors cancel each other out. For example, if your neighbor reports a poor experience with the nursing staff during her stay at Hospital X while your brother-in-law was pleased with the nurses at Hospital Y, that tells you nothing reliable about the kind of experience you can expect at either hospital. If, however, only 60 percent of patients treated in the past three years at Hospital X were highly satisfied with their nursing care, versus 95 percent at Hospital Y, you can make some predictions about where you are more likely to have a positive experience.

However, many people believe that measures based on a population have little relevance to them and their experiences—especially if that population doesn't seem to include people like themselves. If you want consumers to look seriously at your data, you will have to help them understand what the information means for them as individuals. In your report, explain how looking at the experiences of other people can give your readers an idea of what they can expect from a health care organization. One expert suggested the following analogy:

Reviewing population-based data is like reading about the repair history of different car models before buying one. The model's repair record may or may not predict what the consumer's experience will be, i.e., the average won't reflect any owner's exact experience. But it does give an indication of the relative performance of different cars. And the consumer can be fairly confident that a car that requires relatively fewer repairs is a less risky purchase.

Other Factors that Affect Health Care Decisions

A performance report must acknowledge that quality is only one of several dimensions that your audience will assess when making a decision. For example, research has shown that when choosing a health plan, consumers consider the following factors to be very important:

• Costs (both premiums and out-of-pocket costs).
• Recommendations of family and friends (which may serve as a proxy for quality measures).
• Whether their doctor is in the plan.
• Convenience of location.
• What benefits are covered.

While your report should convey how information on quality can contribute to better decisions, be careful not to imply that this data is all readers need to know. If you overstate the value of quality information, you may lose credibility with your audience.

In addition, a quality report should acknowledge the need for trade-offs and help guide readers through their decisions. For example, consumers need to know whether choosing the health plan with the best quality scores means that they will have to travel farther or spend more. They also need a way to keep track of the factors that are important to them; a worksheet, for instance, may help them see that they can select a health plan that is less expensive, more convenient, or more comprehensive in its coverage and still get the same or even better quality.

In order for this to happen, your audience will need access to information on the various factors they value and a tool that will help them use this information to make decisions. Here's how you can assist readers:

• Find Important Information.
• Use the Information They Have.

Find Important Information

From the perspective of the consumer, it would be ideal to find all the information needed to make a decision in one place. While you may not be able to offer a comprehensive source of data, there are two things you can do to help your audience:

Give them the information they are most likely to need.

A handful of sponsors are spearheading efforts to present different kinds of information in a single set of materials. The Twin Cities-based Buyers Health Care Action Group, for example, offers both cost and quality information in a single report; by sorting care systems (which are large provider groups) into "cost groups," the coalition is able to present comparisons of the quality of systems that have similar costs. Another approach to this challenge is represented by the Medicare Quality Information Project, which uses a set of linked booklets to provide data on quality as well as information on prescription coverage, premiums, and covered services.

Buyers Health Care Action Group's report (PDF file, 640 KB; HTML).
© Copyright 1999. Buyers Health Care Action Group. All Rights Reserved. Used with Permission.

Identify the sources of any other information they may want.

Depending on the circumstances, it may be too complicated to present different kinds of information in one package. A coalition, for instance, cannot create a single report that presents the various benefit plans offered by every individual employer. Also, when a good source of information is readily available, it is probably best to keep your report as focused and simple as possible.

In these cases, what you can do is to help consumers find what they need on their own. For example, you may want to refer employees who need information on costs or coverage to specific benefits materials distributed by their employers. Or you can help readers find the health plans that offer convenient provider locations by providing links to Web sites maintained by the plans.

Use the Information They Have

Whether you actually provide consumers with much of the information they may need or help them find it on their own, you can do them a great service by helping them understand how to use whatever they have to make the decision that is best for them. The simplest way to do this is to offer some basic guidance. For example, you could suggest that they first identify the health plans they can afford, or the ones that offer access to their doctors, then pick the one that scores highest in the measures or categories that are most important to them.

An increasingly common alternative is to provide readers with a tool that guides them in organizing and analyzing the information that will influence their decision. This tool can be anything from a simple worksheet that prompts users to enter important pieces of information to a complex computer program that helps them focus on whatever is most important to them and determine which of their options best meets their needs.

The Maryland Health Care Commission's interactive version of its 1999 guide Comparing the Quality of Maryland HMOs (PDF file, 219 KB; HTML) provides a worksheet for gathering and organizing different pieces of information.
© Copyright 1999. Maryland Health Care Commission. All Rights Reserved. Used with Permission.

Comparing Texas HMOs 1998 (PDF file, 19 KB; HTML) offers consumers instructions and a worksheet.
© Copyright 1998. Texas Office of Public Insurance Counsel. All Rights Reserved. Used with Permission.

To learn more, go to Supporting Consumers in Using the Information.