Last week’s New England Journal of Medicine had a Perspectives piece by Meredith Rosenthal, “Beyond Pay for Performance — Emerging Models of Provider-Payment Reform.” Rosenthal does a reasonably good job of summarizing progress thus far but she omits an important consideration in structuring reimbursement to encourage the provider behavior we desire.

Not nearly enough has been done thus far to encourage and hold providers accountable for communication with, and engagement of, their patients. We know that high-quality health care is partially (and substantially) based on effective communication, patient understanding, and consumer engagement (several posts on this blog have cited relevant studies in support of this fact). However, most pay-for-performance (P4P) models don’t explicitly try to address this issue.

To provide an instructive example of an exception that proves the rule, look at the MedEncentive approach. It provides two types of incentives. It rewards physicians for prescribing information therapy (Ix) and following evidence-based guidelines (or explaining why they don’t in specific circumstances).

Second, and unlike other P4P approaches, it also offers incentives to patients for filling their information prescriptions (going to the URLs where relevant evidence-based information is provided) and for confirming through a brief survey that their clinicians communicated appropriately and effectively with them. Preliminary results from MedEncentive suggest not only significant cost savings and high patient satisfaction but also a shift in payment from more intensive to less intensive settings, one of the goals of payment reform noted by Rosenthal.

In her article, Rosenthal summarizes the P4P/payment reform body of research, “There are, fundamentally, no ‘new’ methods of health care payment.” On the other hand, she didn’t describe the dual-incentive (patient as well as provider) approach and didn’t discuss much about how to enhance patient-physician communication and consumer engagement.

As payment reform initiatives evolve, particularly with the renewed popularity of the old idea of the patient-centered medical home (known by other names in the past), it’s important that these patient perspectives on performance are measured and rewarded.

It appears that at least the first phase of personal health record (PHR) certification from CCHIT (Certification Commission on Health Information Technology) will focus on a narrow set of attributes. CCHIT Chairman Mark Leavitt told a group earlier this month that the first set of PHR standards will focus primarily on privacy, security and interoperability.

Leavitt indicated that functionality standards would initially only address what functions are needed to support privacy, security and interoperability. I asked him the following question: Given that what many consumers need to know is how useful would different PHRs be to helping them and their families manage their health, wouldn’t it make sense to include a broader assessment of functionality in CCHIT’s PHR certification?

Leavitt didn’t say that they wouldn’t consider that in the future, and that they intended to continue raising the bar over time.

The concern that some industry insiders have voiced in response to my question is that they are concerned that a more robust assessment of PHR functionality might stifle innovation by mandating adherence to a too-narrow set of specifications.

There are several ways to address that concern, and we can learn from other consumer markets. For example, think about how Consumers Union provides guidance via Consumer Reports.  CR evaluates consumer products along multiple dimensions. Although some people may just look at the overall ratings or the “best buy” in a category, CR explains the different dimensions and why each may be important to particular users and allows consumers to understand performance along each of them.

I agree that privacy and security concerns need to be addressed at the outset. There’s no doubt that’s consumers’ number one concern at this point. As I have said before, however, part of the reason for that primacy is because we haven’t done enough to: 1) Understand consumers’ health needs–and how HIT tools can help address them; and 2) Provide guidance to consumers regarding how existing PHRs may actually serve useful functions.

By focusing PHR certification exclusively on privacy, security and interoperability, CCHIT is basically playing defense. These attributes address consumers’ real concerns but they don’t give them reason to get excited about using new tools.  In other words, we’re not guiding consumers to products that they want to use–just on products that they don’t want to use.

Some inside the industry have told me that they don’t think it’s CCHIT’s role. Perhaps that’s the case. But the need is definitely there. If CCHIT doesn’t address it, then I presume before long CU or some other consumer organization will develop a PHR consumer guidance tool that is much more useful and has CCHIT certification as just one of its components (regarding privacy, security and interoperability).

Beginning next Monday, September 29, public comment will be open here.  I know what I’ll be telling them. What do the rest of you think?

The new Informed Patient Institute has launched a beta site for guiding consumers to the best resources for selecting high-quality providers. The beta site focuses on nursing home rating tools and they plan to next tackle physician ratings.

IPI’s Executive Director, Carol Cronin, has been a national leader in guiding consumers to high-quality care for much of the last decade and a half (or perhaps more), and you can see just from this beta site that it holds great promise for helping consumers navigate the really messy terrain of provider rating systems. It is systematic, user-friendly, and well-designed.

Of course, since it is so badly needed for all kinds of providers, I’m only concerned that the other provider evaluative guidance can’t get here soon enough. I’m eagerly looking forward to the roll-out of the physicians guide and those that follow.

I was in an interesting roundtable discussion on patient-centered care yesterday (more on the main content of it some other time) when the usual dance about what to call “people who use health care services” led to the consistent use of the conjoined term “patient/consumer.”

As I heard this term being thrown around, it struck me that flipping the word “patient” from noun to adjective — as a modifier of “consumer” — characterizes part of what’s wrong in our health care delivery system. Americans for the most part are too [expletive of choice] patient with the absurd care that they get for more than $2 trillion a year.

For that much money, we shouldn’t be patient that: we can’t get access to timely information about our health; we can’t store that information securely to help us manage our health; and we can’t communicate when and how we need to with our clinicians about our health. (And a whole lot more.)

It’s not just a big problem. When you think about it, it’s downright ludicrous. It’s not that “patient consumers” are not upset at the care, service, quality, and access issues they face, but — for the most part — there is a certain level of acceptance.

I don’t know how long our society will tolerate this lack of attention to people’s real health care needs, but I hope that we begin to see the rise of the “im-patient consumer” to spark the care delivery system with a new sense of urgency about the need for deep reform on many levels.

The New York Times Well blog launched a new section yesterday called “Patients and Doctors Start Talking.” In yesterday’s premiere column, surgeon Pauline Chen explains that she hopes her new blog can become a vehicle for helping consumers and clinicians to mutually “bridge the gap between patients and doctors and remedy the disconnect.”

Chen points out:

“In 1966, a Harris Poll found that almost three-quarters of Americans had ‘a great deal’ of confidence in their health care leaders. That number has steadily dropped over the last four decades, so that today only slightly more than a third feel the same way, the same poll shows.”

Chen is absolutely right that we need creative solutions for remedying the problems with the clinician-patient relationship, and I think that an online community is a good vehicle for generating discussion. I hope that it ulimately addresses many of the issues that have been raised on this blog under the Patient-Clinician Relationship heading.

There was an essay by Sandeep Jauhar, MD, in yesterday’s New York Times about the perils of pay-for-performance (P4P). Specifically, Dr. Jauhar discusses how P4P may have unintended consequences and create perverse incentives due to poorly designed performance measures. The point is well taken, but it’s important not to confuse the merits of P4P with the measurement issues that exist.

With respect to the latter, back in my days as Director of Measure Development for the National Committee for Quality Assurance (NCQA), I co-authored a paper with Partners’ cardiologist Tom Lee, Jim Cleeman from NHLBI, and others working with us at NCQA on the development of new HEDIS cholesterol management performance measures. In the JAMA article, “Clinical Goals and Performance Measures for Cholesterol Management in Secondary Prevention of Coronary Heart Disease,” we tried (among other things) to communicate the difference between quality improvement measures and comparative performance measures.

Although the multi-stakeholder Cardiovascular Measurement Advisory Panel and NCQA’s measurement policy-making body, the Committee on Performance Measurement supported the goals of NHLBI’s practice guidelines, we believed that there are signficant differences “between a clinical goal for the management of individual patients (LDL<100 mg/dL) and a performance measure used to evaluate the care of a population of patients (LDL<130 mg/dL).” We described several reasons including: gaps in reasearch; drug efficacy; realistic performance measures; simplicity; and implications of physician failure.

Measurement systems designed for internal quality improvement may very well be different from those used to compare provider quality for a diverse population of patients, and we should make sure to consider the differences in establishing the criteria by which clinicians are compared and reimbursed.

However, we can make those distinctions and we need to in order to drive different kinds of quality improvement forward. If we don’t create fair measures that differentiate provider performance, we will continue to lack ways of adequately compensating those who deliver care for anything but the quantity of what they produce (i.e., number of services provided).

I came back from two weeks away in August to find a flurry of new data (here and here, for example) about how consumers are using the Internet for health care information searching. There also is more discussion in the ongoing debate about giving consumers access to information to make health care purchasing decisions, highlighted in the last few days by a proposal (not yet enacted, as best I can tell) from Alaska Governor Sarah Palin to set up a state-run health care information office for this purpose.

As explained by Center for the Advancement of Health President Jessie Gruman more eloquently than I ever could, the health care information tools just aren’t sophisticated enough yet to make this model work effectively. As suggested by the essay’s title, “So Many Choices, So Little Information!” consumers’ information demands are not being met.

It may not quite be a supply-and-demand problem given that it often is not a case of too “little information.” In fact, many health information seekers experience an “information overdose.” In many cases, it’s just not the right information–whether it be inaccurate or not comprehensive (such as what I summarized years ago in a white paper based on my own dissertation research), or it lacks specificity to the consumers’ actual needs.

Ultimately, the test for any information is whether it:

1. Answers a consumer’s question directly, accurately, and comprehensively
2. Provides that answer in a way the consumer can understand
3. Can be remembered or internalized at least for the purposes of the immediate need
4. Have sufficient resonance to guide decision making, stimulate sustained behavior, and/or provide comfort/support to the individual in need
5. Be contextualized for that individual’s particular circumstances

No doubt that’s a tall order for any information. That’s why even with the increasing sophistication of technology and information tools, we’re probably going to be more successful if we can integrate the best information we can find into the care delivery process.

Amid more data released that consumers are not using personal health records (PHRs) or don’t even know what they are, the state of West Virginia has launched a Web site designed to convince consumers of the merits of health information technology (HIT).

As best I can tell from eHealthWV Web site, here’s the plan: “To ensure consumer input and involvement in the process of health information exchange and electronic health records, WVMI and its partners launched a new phase to the project in mid 2007.  It involves educating consumers about electronic health records and health information exchange.”

I’m sure they mean well, but it would be helpful if one of these state efforts “ensured consumer input and involvement” by actually soliciting their input before designing their outreach. Right now, most states and health information exchange activities are focused on addressing consumers’ fears about data rather than their needs about health care.

Given survey data that highlights consumer concerns about privacy and security, it’s reasonable to ask: Why are consumers so focused on these issues with respect to health information exchange? It’s probably, in part, because consumers don’t care about data. How many consumers do you know who are passionate about data?

In contrast, consumers do care about their health…and resources that help them manage it. But most consumers have not experienced an electronic tool that facilitates the flow of appropriate information to them in a timely way.

Education can be bidirectional (or multidirectional or collaborative). Rather than framing the question as “how do we get consumers to understand why this is important to them?” we could start outreach and engagement by better understanding consumers’ needs with respect to managing their health.By taking a more proactive, user-centered design approach, such as used by the health system PeaceHealth in the Pacific Northwest, they could design tools and health information exchange plans that meet consumers’ needs rather than try to convince consumers about what they should care about with respect to management of their health. After asking consumers what health tasks they wanted to accomplish, developers created electronic shared care plans and other tools that met those specific needs.As I have blogged about before (and is described in an excellent New York Times Magazine article from 2007) this is the approach that pioneering companies like Toyota have taken to understand consumer needs. This is where the intersection of patient-centered care and HIT has so much promise. But we can’t get there unless we start by observing and talking to the consumers themselves.