Quality, With a Dash of Affordability

Healthcare is unlike any other business model, so it isn’t easy to manage or evaluate for innovation. Innovation is occurring but happening in a framework that is difficult to modify in short periods (generations). Moreover, the Medical Loss Ratio should not abdicate health insurance companies from providing quality and pricing transparency that patients can expect within their defined plans. This article will attempt to synthesize tools consumers can use when evaluating healthcare providers’ potential cost and quality. Along the way, we will highlight how several household names in the healthcare ecosystem provide transparency into the black box of healthcare cost and quality.

The Leapfrog Group is a nonprofit watchdog that provides transparency around the quality outcomes patients can expect from healthcare systems. Suppose a healthcare consumer has choices for their local or regional care. In that case, The Leapfrog Group provides a hospital compare tool that runs qualitative searches across several different metrics that Leapfrog Group captures in their annual surveys. There are 10 sections spanning 28 specific measures that make up these surveys. There are two main tenants that these surveys focus on:

  • Outcomes (readmission rates, infection rates, etc.)
  • Structural and process related measures (efforts towards creating safer care)

In 2018, more than 2,600 hundred hospitals participated in this survey. These surveys exclude DoD/VA hospitals, critical access hospitals, specialty hospitals, children’s hospitals, outpatient surgery centers, etc. The VA has its quality reporting structure through the Strategic Analytics for Improvement and Learning (SAIL) Metrics, and that is probably a topic for another conversation in the future. Leapfrog is an excellent resource for anyone looking to take a Consumer Reports-type approach to the potential healthcare provider they are evaluating for their care.

Medicare.Gov is a site run by the Centers for Medicare and Medicaid (CMS) that houses everything you would ever want to know about CMS’ role within our healthcare system. Within CMS, the National Health Safety Network (NHSN) is a lesser-known entity that requires hospitals to provide their Medicare infection data annually. 1% of eligible healthcare organizations’ Medicare reimbursement is dependent upon meeting specific criteria of safety through the Hospital-Acquired Condition (HAC) Reduction Program. CMS reduces the reimbursement of healthcare systems payments by 1% if they are in the bottom 25% of hospital-acquired infection rates for Medicare patients. The NHSN provides the infection data they capture through a Hospital Compare Tool that healthcare consumers can use to evaluate their prospective healthcare providers’ outcomes data. The data tends to show outcomes on a 15-month +/- trailing basis and is an excellent lagging indicator of quality. While it’s not perfect, in Atlanta, for instance, comparing the patient populations of a Grady Hospital to a WellStar Kennestone, it does provide some perspective on what sort of harm your prospective healthcare provider has caused previously.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is another lagging indicator type survey that provides consumers with content around the experience other patients had while in a particular facility. CMS developed this tool in conjunction with several other quality-focused organizations to help set expectations with patients from the perspective of the patient’s around the quality of the experience they can expect within a particular healthcare system. These surveys also drive reimbursement metrics through the Value-Based Purchasing Program’s Patient Experience of Care portion portion of the Value-Based Purchasing Program. There are 27 questions that patients fill out after they are discharged to rate their experience within a particular facility. 10 Measures are currently reported at Medicare.Gov for this survey. A given healthcare system must capture at least 300 surveys per reporting period to be considered compliant across the required reporting measures.

Clear Health Costs is a journalism-based organization from New York City creating true pricing transparency within states that tend to have patient-friendly billing practices. CEO Jeanne Pinder gave a Ted Talk recently on the topic and her role in developing the organization. Currently, their reach is limited to select markets, but it feels like they will continue to expand their reach; patients (a.k.a., people, as Jeanne mentions) and providers alike are becoming more willing to share their experiences. This website relies on data; there is no better way to price out your potential healthcare expenses than throughpatient data. While exposing charge masters is a sign of the consumerization of healthcare, does anyone pay MSRP of a car they are about to purchase? More importantly, given the complexities of providing care for populations, procedure and service-related expenses become even more fragmented when insurance is introduced. It’s important to know your options with cash, health-savings accounts, and through insurance benefits.

The reality is, father time undefeated. Why not act and prepare accordingly?

Published by Miers Q.

This website is a testament to the importance of our healthcare system and the importance our choices have on that system. I have worked in the health information technology software space since hanging up my baseball cleats. Hopefully this information can offer some unique perspective in a notoriously ambiguous industry.

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