Health care transparency: Just what the doctor ordered

How do you know which hospitals are doing the best job? Patients, insurers and employers all have a stake in the answer to this question, but up until now factual information on hospital and nursing home performance has been scanty, and what is out there is based on differing criteria. A new program designed by the Ambulatory Care Quality Alliance called "Quality Health Improvement" (QHI) is a strong first step in bringing transparency to healthcare. Arizona and five other states have been chosen to pilot the project, which will rate hospitals on 26 "quality measures." Arizona HealthQuery, a database of health information on more than seven million people, will be the foundation of the state's project. Arizona HealthQuery was created at ASU's Center for Health Information and Research.

Your orthopedic surgeon says it's time to fix that knee, but he leaves the choice of hospital to you, since he practices at three local facilities. Which one do you choose? The easy answer is the hospital that performs tons of knee surgeries with the lowest post-surgery complication rate and best mortality numbers. Obviously this information is crucial to you, owner of the knee in question.

It's also likely of interest, indirectly, to your employer, who pays the lion's share of your health insurance premiums and wants you back at work as soon as possible. And it's also important to your health insurance company. If the hospital staff doesn't get you up and walking the day after surgery, you may require more rehabilitation sessions in the weeks to come. Or if you pick up a staph infection, your inpatient stay could stretch past the anticipated two days. Either situation costs the insurer money.

Through a glass, darkly

Right now, factual information on hospital and nursing home performance is scanty, and what is out there is based on differing criteria, so the available data may compare apples to oranges. For example, a handful of Web sites offer limited forms of healthcare transparency. One is Quality Check, a site sponsored by the Joint Commission on Accreditation of Healthcare Organizations that lists hospitals and nursing homes quality findings.

Then there are businesses specializing in healthcare performance reporting via the Internet, such as HealthGrades, founded in 1999 and based in Golden, Colo. Spokesperson Scott Shapiro, M.D., says HealthGrades provides healthcare-quality reports for consumers on doctors, hospitals and nursing homes, along with cost information on 55 medical procedures. Consumers like the cost breakdown, which details out-of-pocket costs, average negotiated rates (insurance plan rates) and list price (non-insured rates), Shapiro says.

Some information is free, while for-fee reports range from $9.95 to $14.95 each. Still, the ability to immediately compare complete, up-to-date "report cards" grading hospital, nursing home and physician performance using standardized criteria — part of a concept often referred to as "healthcare transparency" — is still a dream.

Making the dream a reality

But according to W. P. Carey research professor Mary Rimsza, a physician, that dream moves closer to reality this year, thanks to a new program designed by the Ambulatory Care Quality Alliance called "Quality Health Improvement" (QHI), that will funnel grant money to six states — Arizona, California, Indiana, Minnesota, Massachusetts and Wisconsin. Based on 26 "quality measures," hospitals will be rated on cost and effectiveness of care, length of stay and overall patient outcomes for various conditions such as cardiovascular disease or asthma.

"The information will be shared with the hospitals, employers and insurers," said economist William G. Johnson, who with Rimsza co-directs the Center for Health Information Research. "These participants will then use the information to develop a mutually acceptable public reporting system."

Besides QHI's designer, the Ambulatory Care Quality Alliance, there are a host of powerful players collaborating in the project, including two federal agencies — the Center for Medicare and Medicaid Studies and the Agency for Health Research and Quality — and a local coalition of national health plans, employers and non-profit healthcare groups called the Phoenix Health Care Value Measurement Initiative. They all hope the QHI pilot will reveal the most basic and telling bottom-line results essential if consumers are to make sound healthcare decisions, says Rimsza.

Arizona HealthQuery: Arizona's healthy head start

Arizona HealthQuery, which began as a pilot project six years ago, is often called the nation's best patient-information data warehouse. The Ambulatory Care Quality Alliance determined that HealthQuery, which already houses healthcare information on more than seven million people statewide, would be the logical home for Arizona's QHI pilot.

Arizona HealthQuery, founded in 1999, gives Arizona a head start on the QHI pilots in the five other states, where grant recipients are scrambling to build or consolidate data warehouses to house their patient healthcare information. Here's how Arizona HealthQuery works: more than 50 "data partners," including hospitals and clinics, AHCCS (Arizona’s version of Medicaid), other health systems and private physician practices, send in de-identified patient healthcare information recorded on tapes or disks every three months. (In the next month or so, patient information on Arizona's 700,000-plus Medicare patients will be added to the database.)

Using custom software, database administrators generate a variety of health trend or forecasting reports for researchers. Data partners can also request reports from the Arizona HealthQuery, even custom reports based either on their own organization’s patient information or on aggregate data minus information that would identify a competitor's business details. Right now, the valuable information generated through Arizona HealthQuery is available to data partners in the form of reports on their operations.

In addition, community-wide information on health status and health care is made available to the public. Once the $4.5 million QHI project gets underway, however, it will create a basis for the dev. of a cooperative public reporting system on provider performance. Long-term pilot goals include incorporating patient surveys in the outcomes information, and even documenting related data such as when patients are able to return to work. Rimsza hopes that "patients will get better faster, and stay healthier" as a result.

Michael Leavitt, U.S. Secretary of Health and Human Services, who met with Rimsza and other Phoenix healthcare leaders recently, shares that hope. Because healthcare transparency gives consumers essential quality and cost information, Leavitt considers it a critical element of health care reforms. Armed with this information, consumers are more likely to take control of their health care and make better personal decisions, which in turn will help decrease overall medical costs.

It's not just for doctors anymore

The pilot project is a little controversial, according to Elizabeth McNamee, associate director of community innovation and development at St. Luke’s Initiatives, a Phoenix non-profit organization and funding source for Arizona HealthQuery. Why? Because QHI’s structure will illuminate how patients' lifestyle choices, physical environment, level of community support and access to medical care affects their health, McNamee explains.

Until now, healthcare transparency efforts were confined to measuring how well doctors follow evidence-based medical "best practices." But even though the doctor might have done his job by prescribing the correct medicine and ordering the right tests in the "best practice" protocol, other factors may impact the patient's recovery. These other factors — did the patient adhere to a three-times weekly exercise regime, or did the hospital offer free classes in heart-healthy cooking? — were never considered.

Following through with doctors to assure that they adhere to best practices can boost outcomes by about 20 percent, McNamee says. But she and others involved in the QHI pilot say that measuring, then improving, patient lifestyle choices, etc., can improve public health significantly more than best practices alone.

Insurer report cards get poor grades

Many health insurers already issue their own report cards grading the best-practices performance of physicians working within their systems, according to Bruce Bethancourt, M.D., medical director for PrimeCare Physician Network, a Phoenix group practice. However, many physicians ignore the report cards, because they're often inaccurate, drawn from haphazardly gathered data and based on shifting criteria that differ from one insurer to the other, Bethancourt says.

"I recently got [a report card] from a top health plan, reporting on 50 of my patients. Ten of the 50 individuals weren't even my patients. They're going to grade me on people who have never stepped in my office!" Bethancourt relates. "Most physicians are beyond being upset by these. Now, they just throw them in the trash."

McNamee and Bethancourt agree that the QHI pilot is a departure even from the best insurer-initiated physician report card, which evaluates doctors based on how closely they follow "best practices," or established treatment protocols. (An example of a best practice for cardiovascular disease is that every patient arriving in the emergency room complaining of chest pain be given an aspirin).

Corporate health

Implementing QHI will bring notable local employers into the Arizona HealthQuery: Honeywell, Intel, IBM and General Electric, along with major insurers Humana and Cigna, all are members of the Phoenix Health Care Value Measurement Initiative, says Steve Wetzell, vice president of health care initiative for the HR Policy Association.

Based in Washington, D.C., Wetzell's group represents 260 chief human resource officers at leading companies. "We got involved as part of our healthcare reform efforts, because there's great value in helping move along a regional demonstration project like QHI. We came down to Phoenix with Cigna, and bumped into the Arizona HealthQuery. Once we learned that an infrastructure existed, we went from there," Wetzell notes. Look for more free-market and government participation in healthcare transparency in the future, Shapiro says, as employers increasingly struggle with the growing cost of health coverage for employees.

Bottom Line:

• Patients, insurers and employers all would benefit from the ability to compare complete, up-to-date "report cards" grading hospital, nursing home and physician performance using standardized criteria — part of a concept often referred to as "healthcare transparency."
• Currently available information is scanty, based on differing criteria, and often inaccurate.
• A new program designed by the Ambulatory Care Quality Alliance called "Quality Health Improvement" (QHI) is a strong first step in bringing transparency to healthcare. Based on 26 "quality measures," hospitals will be rated on cost and effectiveness of care, length of stay and overall patient outcomes.
• For the pilot project, QHI researchers will gather data on hospitals in six states — Arizona, California, Indiana, Minnesota, Massachusetts and Wisconsin — in 2007, then issue public report cards soon after.
• Until now, healthcare transparency efforts were confined to measuring how well doctors follow evidence-based medical "best practices." QHI’s structure will also illuminate how patients' lifestyle choices, physical environment, level of community support and access to medical care affects their health.