Becoming an Educated Health Care Consumer
in an Information-Filled World

In the pre-internet age, identifying the best health care was not a matter of research and comparative study. Consumers did not “log on” to find the latest public report card on hospital performance. They did not arrive at their physician’s office armed with information from the latest advertisement on a particular purple pill. Instead, they visited their family physician—the one their parents visited. Or they asked a neighbor for the name of the surgeon who performed their neighbor’s gall stone operation. They went to the hospital where that surgeon had privileges—whether that hospital typically did one gall stone operation a year or hundreds.

Educating Consumers to make Multiple Care Decisions

Times have changed and, many would argue, for the better. Over the last several years, efforts to educate today’s health care consumer have exploded. Not only is more information available, but there are more loci of decision-making. Consumers must select among a variety of health plans with different benefit packages. Within health plans, there is a choice of multiple providers. Finally, consumers often must select among several treatment options. Each decision should be fully informed to ensure the consumer is making the most appropriate choice and is getting the highest quality of care. But, informing the consumer is a challenge.

HCFO-funded researcher Judith Hibbard and colleagues examined the use of report cards to provide quality information to health care consumers making decisions about health plan choice. She discovered that the actual presentation of data greatly influences a consumer’s ability to absorb comparative information about plans. The researchers also noted that alternate presentation techniques could be required depending on the population examined. The highly educated, employed adults taking part in this study were likely to respond differently than elderly Medicare beneficiaries or other vulnerable populations.¹

Picking the right provider is another health care decision facing consumers. HCFO researchers Katherine Harris and Janice Blanchard examined this decision making process. They looked at a population of individuals between the ages of 21 and 64 with employer-sponsored health benefits. The study generally confirmed the fact that health care consumers tend to be passive with regard to choice of physician. The findings underscored the need for effective decision-support tools to promote consumer activism, particularly in light of the development of consumer-driven health plans.²

Consumers may believe that treatment decisions fall only within the provider’s purview. In fact, information is available for consumers who want to take an active role in selecting the best treatment options. For example, the Dartmouth-Hitchcock Medical Center houses the Center for Shared Decision Making.³ The Center provides counseling, videos, and other decision aids to assist health care consumers in making informed choices about their care.

Efforts to Educate Consumers

Recently, employers have started offering consumer-driven health plans among their benefit options. These are high deductible health plans that give employees more choice and responsibility. While the jury is still out on whether there will be widespread adoption of these plans, there are many who believe that increasing employees’ role in the selection and payment of health care will inevitably result in savings and higher quality care. One key feature of consumer driven plans is the availability of information, typically offered via the internet, which may include provider qualifications, hospital performance measures, prices, and health promotion steps. Armed with this information, consumers become active participants in managing their health care. A number of HCFO researchers, identified below, are exploring the consumer driven health plan phenomenon. Their findings will help to determine whether the information tools in these plans are working.

As the employed population ages, they face new information challenges in the Medicare program. Medicare beneficiaries are inundated with multiple public and private Information resources to explain the program generally and, most recently, the new prescription drug legislation. But, volume does not necessarily equate with quality. And information is only as good as the delivery mechanism. One of the most fundamental challenges of becoming an educated health care consumer is that of wading through information and making judgments about reliability. A challenge for the “information brokers” is creating user-friendly, multi-format systems to ensure that the message gets to the right audience.⁴ This is particularly true for seniors who find the program’s new prescription drug options bewildering.

The Information Path is Challenging

Educating consumers to seek out high quality care is a promising approach to help reduce health care costs. However, successful education of the health care consumer has numerous challenges:

• The digital divide is a large barrier for financially vulnerable and elderly populations.⁵
• Consumers must be convinced that a quality problem exists before they will take action to educate themselves and use quality information to make better choices. ⁶
• Information must get the attention of the consumer to be effective.
• Cognitive deficiency will likely create a significant barrier for some individuals.⁷
• Cultural and language variation must be considered as part of any education program.

Conclusion

Historically, consumers have taken a rather passive role in the management of their own health care. The success of information campaigns depends in large part on how willing consumers are to exchange a passive approach for one in which they are called upon to embrace a variety of decision support tools to help them make informed choices about their care. Simple inertia and the power of that which is familiar will make this transformation challenging.

The challenge to policymakers —to deliver information to consumers in the most effective way; to encourage consumers to use health care information in their decision making process; and ultimately, to improve the quality of care. Educating consumers to enable them to make informed decisions may cure many health care ills —not the least of which is rising costs. Time will tell.

HCFO has funded research that directly informs these issues:

Title: An Early Portrait of Consumer-Directed Health Benefits: Design, Integration, Penetration, and Effects
Grantee Institution: Mercer Human Resource Consulting
Principal Investigator: Arnold Milstein, M.D
Grant Period: May, 2003 – May, 2004

What is the prevalence of consumer driven health benefits (CDHBs) in the market and what is the early evidence about how the movement toward CDHBs has affected cost and quality? The analyses will include three categories of CDHBs: health retirement accounts, tiered or flexible benefit design products, and tiered network or treatment option models. Specifically, the researchers are working to: 1) assess the enrollment in and features of different types of CDHBs, 2) assess the effects of these newly-introduced products, 3) generate hypotheses about the longer term prospects and impact of CDHBs, and 4) derive policy recommendations aimed at maximizing the value of CDHBs. The objective of the study is to provide purchasers and other private and public decisionmakers with early information about what consumer driven health benefit plans are and how they affect cost and quality.

Title: The Impact of Performance Reporting on Consumer and Physician Organization Behavior
Grantee Institution: Harvard School of Public Health
Principal Investigator: Meredith B. Rosenthal, Ph.D.
Grant Period: March, 2003 - October, 2004

How are public “report cards” on consumer and physician behavior being disseminated? The researchers are evaluating PacifiCare’s Quality Index report cards which provide a relative performance assessment of provider groups in selected areas of clinical, service and administrative quality. The researchers are testing (1) how new and continuing health plan enrollees use comparative quality information to select a physician group; (2) how mobilization of consumer choice based on comparative quality information drives physician group performance improvements; and (3) how physician groups are responding to performance measurement when data are used for confidential benchmarking only while other dimensions of quality are reported to consumers. The objective of the project is to fill an information gap concerning the value of publicly reported quality information and to provide guidance to public and private decision makers on the measurement and dissemination of provider quality information.

Title: Evaluation of Defined Contribution Plans on Health Insurance Choice and Medical Care Use
Grantee Institution: University of Minnesota
Principal Investigator: Stephen T. Parente, Ph.D
Grant Period: November, 2002 - October, 2004

What is the service use and adverse selection of consumers who select a consumer-driven health plan (CDHP) and what is the experience of “early adopters” from the employer and employee perspective? The researchers are conducting a two-part evaluation of Definity Health, a consumer-driven plan. The following research questions comprise the framework of the evaluation: 1) Who chooses to join CDHPs? 2) Do these plans attract the healthier employees in an employer’s health insurance risk pool? 3) How do cost and use differ among people in CDHPs versus other plans? 4) Do patterns of service use and medical care change for enrollees in CDHPs after enrollment? 5) How do employees and employers assess their experience in the plan? The objective of the study is to provide private and public decisionmakers unbiased information on the effects of CDHPs in their early stages.

Title: Assessing the Impact of a Public Report on Hospital Quality: A Controlled Experiment in the State of Wisconsin
Grantee Institution: University of Oregon
Principal Investigator: Judith Hibbard, Dr. P.H.
Grant Period: September 2001 - August 2004

How do hospitals react to public reports of their quality and how do such reports influence consumers’ perceptions of hospital quality? This study, conducted by researchers at the University of Oregon, will assess whether public reports of quality lead to improvement efforts within hospitals. The researchers also are studying whether the public reports create a general impression among consumers about the quality and safety of hospitals in the community. Hibbard and her colleagues are working with The Alliance, a large purchasing group based in Madison, Wisconsin, that will disseminate the public report. The researchers are conducting a controlled experiment in which hospitals will be assigned to one of the following three groups. Hospitals in The Alliance, 25 in the region surrounding Madison, will be included in the public report. The remaining 100 hospitals in Wisconsin will be separated by size (large and small) and randomly assigned to either the other treatment group or the control group. The second treatment group will receive a report of their own performance compared with other hospitals that will not be made public. The control group will not receive any reports. The objective of the study is to assess whether public reporting of hospital quality motivated improved behavior and performance and how public reporting affects consumer perceptions of hospital quality.

Hibbard JH, Stockard J, Tusler M. "Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts?" Health Affairs, March/April 2003, 22(2): 84-94.

Title: The Impact of Quality Information on Consumer Plan Choices: Does Health Status Matter?
Grantee Institution: RAND Corporation
Principal Investigator: Katherine M. Harris, Ph.D./Janice Blanchard, Ph.D.
Grant Period: July 2001 - June 2002

What is the impact of health status on consumers’ use of quality information in making health plan choice? Using an Internet-based survey, researchers at RAND built on a dataset collected as part of an AHRQ-funded small grant to include a series of health status and service use measures. They addressed the following research questions: What is the effect of health status and experience with the health care delivery system on (1) the overall impact of quality information on plan choices, (2) the relative impact of various forms of information on plan choices, and (3) the trade-offs between provider access and quality that consumers make in choosing health plans? The objective of the study was to inform policy makers and employers whether the substantial investment in the collection and dissemination of plan performance measures, which are designed to support consumers’ plan choices, also meet the needs and concerns of those in poor health status for whom the consequences of plan choice are the greatest.

Harris KM, "How do Patients Choose Physicians? Evidence from a National Survey of Enrollees in Employment-Related Health Plans"
Health Services Research, April 2003, 38(2).

Title: Methods to Present Quality Information to Assist Consumers to Make Health Plan Decisions
Grantee Institution: University of Oregon
Principal Investigator: Judith Hibbard, Dr. P.H.
Grant Period: January 1999 - March 2001

How can information on health plan quality be most effectively presented to consumers? Researchers at the University of Oregon used laboratory studies to examine how consumers process and integrate information in making choices about health plan. While there are many health plan "report cards" available to consumers, little is known about how consumers actually use the information they are given to make decisions. Consumers in a cognitive laboratory situation were presented with different types of information on health plan quality, in different formats, and asked about how they use the information in their decision-making process. The researchers also assessed how specific pieces of information are used and weighted in decisions. The objective of the study was to help determine how best to present information on health plan quality so that it is valued and understood by consumers, and so that consumers can make the maximum use of information on quality when choosing a health plan.

Hibbard JH et al. "Strategies for Reporting Health Plan Performance Information to Consumers: Evidence from Controlled Studies." Health Services Research, April 2002, 37(2), 291-313.

Hibbard JH, et al. "Is the Informed-Choice Policy Approach Appropriate for Medicare Beneficiaries?" Health Affairs, May/June 2001, 20(3), 199-203.

Hibbard JH, et al. "Making Health Care Quality Reports Easier to Use. "The Joint Commission Journal on Quality Improvement, November 2001, 27(11), 591-604.

Title: Evaluating the Use of Performance-Related Information and Financial Incentives in Employer Health Care Purchasing
Grantee Institution: Economic and Social Research Institute
Principal Investigator: Jack A. Meyer, Ph.D.
Grant Period: January 1997 - March 1999

What impact does the dissemination of report cards of health plan performance or linking reimbursement to plan performance have on consumer selection of health plans? Researchers conducted the second phase of an evaluation of "value-based" purchasing efforts, where purchasers attempt to measure and compare providers and health plans and hold them accountable for achieving cost and quality goals. The first phase of this project was completed under a prior HCFO grant, Evaluating Business Initiatives in Health Care Purchasing. The project expanded beyond private employer coalitions to include state government purchasing and to evaluate the use of performance-related information and the impact of financial incentives. The researchers assessed five purchasing initiatives which provide report cards to consumers or tie reimbursement to performance, selecting a combination of initiatives by private business coalitions, states as employers, and state Medicaid programs. The objective of the project was to help public and private policymakers better understand the effects of disseminating performance information to consumers and of tying payments to plan performance.

Title: An Evaluation of the Current and Potential Impact of Consumer Survey-Based Report Cards on the Health Care Market Place
Grantee Institution: Institute for Research and Education
Principal Investigator: Jinnet B. Fowles, Ph.D.
Grant Period: June 1996 - March 1998

How do consumer-based report cards affect institutional behavior in the health care market? This study was designed to complement work currently underway to evaluate the impact of consumer information on consumer choice. Through a series of case studies and structured interviews, the researchers studied a natural experiment in Minneapolis and St. Paul where one group of employees receives a consumer survey-based report card during annual health plan open enrollment while another group of employees, with the same health plan benefits and choices, does not receive report card information. The objective of the study was to provide further information on how consumer information affects behavior in the health care market.

Knutson DJ et al. "Impact of Report Cards on Employees: A Natural Experiment." Health Care Financing Review, Fall 1998, 20(1), 5-27.

¹ Hibbard JH, et al., Strategies for Reporting Health Plan Performance Information to Consumers: Evidence form Controlled Studies, Health Services Research, April 2002, 37(2): 291-313.

² Harris K, How, Do Patients Choose Physicians? Evidence from a National Survey of Enrollees in Employment-Related Health Plans, Health Services Research, April 2003, 38(2): 711-32.

³ dhmc.org/webpage.cfm?site_id=2&org_id=108&gsec_id=0&sec_id=0&item_id=2486

⁴ Tu, HT and JL Hargraves, Seeking Health Care Information: Most Consumers Still on the Sidelines, Center for Studying Health Systems Change, Issue Brief No. 61, March 2003.

⁵ Fox, S, Older Americans and the Internet, Pew Internet & American Life Project, March 25, 2004.

⁶ Shaller D, et al., Consumers and Quality-Driven Health Care: A Call to Action, Health Affairs, March/April 2003, 22(2):95-101.

⁷ Hibbard JH, et al., Is The Informed-Choice Policy Approach Appropriate For Medicare Beneficiaries? Health Affairs, May/June 2001, 20(3):199-203.