Shaller, Dale

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VBP Interview with Debra Ness

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Value Based Purchasing  May 2007,  Volume 1 Issue 1 VBP Interview with Debra Ness  Dale Shaller, Editor, VBP  Debra Ness is President of the National Partnership for Women and Families, anonprofit, nonpartisan organization based in Washington, DC that promotes fairness in the workplace, quality health care, and policies that help women and men meet the dual demands of work and family.  Ms. Ness has helped position the National Partnership as one of the nation's most influential consumer groups advocating health policy reforms based on transparency, choice, and accountability.  She holds advisory positions with numerous health care groups such as NCQA, JCAHO, IOM, the National Quality Forum, the Leapfrog Group, and the American Board of Internal Medicine.  This interview was conducted in August 2006 with grant support from the California HealthCare Foundation.  VBP:  What are the key drivers or forces that have led to the increasing role of consumers in health care decision-making? Ness: I think there are numerous forces converging to increase the role of consumers in health care decision-making.   First and perhaps most influential at this time is the change taking place in health care benefit design.  We are just at the tip of these changes, as purchasers and plans provide incentives for consumers to use information about cost and quality when choosing providers.    To the extent that good, comparative information about both quality and cost is available, such incentives may help steer consumers toward better quality care and help them spend their health care dollars more effectively.  Benefit design that encourages consumers to choose high quality, cost-effective care—what might be called “value-based decision-making”—can also positively impact the way care is delivered.  Many consumer groups, however, are skeptical of so-called “consumer-directed” health plans because they appear to be more about cost-shifting than consumer empowerment.  Plans that simply incentivize consumers to choose cheap services, or to use less care, will ultimately backfire.    A second major factor is that we are increasingly an information-based and information-seeking society.  We see more informed consumer decision-making in all types of services.  People are getting used to, and in many ways have come to expect, the ability to evaluate quality and performance in all kinds of products and services.    Even something as simple as the purchase of a cup of coffee is now a more “informed” and “value-based” decision.  Another factor is the increasing awareness among consumers that there are real differences in quality, efficiency, and safety among health care providers.  We still have a long way to go, but there is growing awareness of variations in the quality, safety, and cost in health care.  Value Based Purchasing  May 2007,  Volume 1 Issue 1 Finally, there is just more information available now on quality and cost.  It’s still far from what we need, but it’s on the rise.  VBP:  What new or different forces are emerging, if any, that will shape consumer health care decision-making in the next 10 to 15 years? Ness: I think we will see a push for even greater transparency in health care.  The National Partnership is working to bring more consumer advocacy groups to the table in order to ensure a strong and informed consumer voice for transparency.  In the past, most health care advocacy groups focused on access, not quality.  That is beginning to change.  Other forces moving the transparency agenda forward include employers, health plans, the Administration, and Congress.  Even the medical profession is looking at these issues differently.  The question today is not whether but how quality measurement and reporting will be done.   I think health information technology (HHIT) also will help move us toward more informed decision-making.  It will enable us to collect and report more information about health care quality and provider performance, and it will make such information more easily accessible to consumers.  The adoption of electronic health records (EHRs) and personal health records (PHRs) will also enhance consumer decision-making.  As discussed above, benefit trends will also drive consumer decision-making.  And, of course, the escalating costs of health care will affect consumers’ decisions about their health care.   VBP:  What are the major benefits or outcomes we can expect as a result of the expanding role of consumer decision-making related to choice of plans and providers, self-care and self-management, and shared medical decision-making? Ness: Certainly, shared decision-making between consumers and health care professionals holds the potential for huge benefits.  There is growing evidence that shared decision-making generally leads to consumers choosing more conservative, less invasive, and less costly services, often with better outcomes.  But for this to happen on a large scale we will need a much stronger evidence base, and there will need to be significant changes in the way clinicians practice.    One might also expect that consumers who participate in shared decision-making with their health care providers will be more likely to effectively manage their own health care.  More consumer decision-making based on comparative quality and cost information is also likely to lead to positive changes in provider performance with respect to both quality and cost.  However, we shouldn’t expect that consumer decision-making alone will re-shape the marketplace or drive down health care costs.  Even armed with the best information, consumers on their own cannot Value Based Purchasing  May 2007,  Volume 1 Issue 1 “tame” the marketplace any more than employers have been able to do with all their purchasing leverage.  More transparency and better consumer decision-making need to be accompanied by significant changes in the provider payment system.  VBP:  What potential downsides or cautions are there to the expanding role of consumers in these types of health care decisions? Ness: First of all, there is the risk of creating the wrong incentives for consumers.  A benefit design that pushes consumers to make decisions based on cost alone could result in consumers getting poor quality or inadequate care.    In addition to creating the right incentives, we will also need to change the consumer mindset to one that is more oriented to thinking about care in terms of appropriateness and value.  To do that, we need to debunk a number of myths and misconceptions such as “more care is always better” and “more expensive care is better quality care.”   A lot of education, and perhaps re-education, must be done to get people to the point of believing that it is possible to get better care while spending less.  Also, we need to promote understanding of the concepts of “appropriate care” and “evidence-based care.”   VBP:  How will the expanding role of consumer decision-making affect the future structure and delivery of health care? Ness: In combination with other strategies, consumer value-based decision-making can lead to positive changes in the way care is delivered.  As providers focus on improving quality and efficiency, they will need to reengineer the processes of care and hopefully move to a system that delivers better integrated and coordinated care with more emphasis on primary and preventive care.    It’s also important to realize that consumer behavior can help change the delivery system - whether or not the majority of consumers are actively on board and engaged in value-based decision-making.  We will never have everyone engaged, but I am optimistic than we can get enough people engaged to foster significant change.  VBP:  What are the major barriers to increased consumer decision-making in health care? Ness: There are many barriers we need to overcome.  I’ve already mentioned the lack of evidence regarding treatment effectiveness.  Sound evidence is essential to support shared decision making and to create incentives for consumers to choose the most appropriate and effective care.    We also have little evidence about the effectiveness of different benefit designs.    Value Based Purchasing  May 2007,  Volume 1 Issue 1 While availability of information on quality is growing, we lack good measures that are meaningful to most consumers.    Health literacy is a huge problem, and many consumers still lack access to the Web.  Many providers lack the skills needed to provide “culturally competent” care or to transcend problems of health literacy and language barriers.    And there are still many providers who will resist the move to greater transparency and the need to adopt fundamental changes in the way they practice.    Finally, our payment system doesn’t reward quality and efficiency.  In fact, in many ways it discourages the very improvements in quality and efficiency that we seek.  VBP:  What will be the impact of new technology on consumer decision-making? Ness: We need widespread adoption of HIT to provide the platform for the data collection and public reporting that would enable value-based decision-making by consumers.  As comparative cost and quality information becomes more available, user-friendly, and actionable, we can expect consumers to increasingly use this information to make choices about providers.      The availability of both EMRs and PHRs will also enable consumers to better manage their own care and to be more active players in both seeking and receiving care from their providers.  Also, we can expect continued growth in consumers’ use of the Web as a source for health information of all kinds.     VBP:  Which consumers are likely to benefit most from these new developments and which will benefit least?  What needs to be done to include consumers who otherwise might be left out? Ness: All consumers will benefit from these developments.  Certainly those who can access and understand this information easily will be the prime beneficiaries because they are most likely to use this information in their decision-making.  But all consumers will benefit from the changes that result from increased transparency and accountability.  There is plenty of evidence that making comparative quality and safety information publicly available drives improvements and changes in provider behavior regardless of consumer use.  And, as I already said, consumer behavior can help change the delivery system, even if only a segment of consumers engage in value-based decision-making.    VBP:  What critical steps need to happen to support effective consumer decision-making in the future? Value Based Purchasing  May 2007,  Volume 1 Issue 1 Ness: We must overcome the barriers I mentioned earlier -    • We need to expand the evidence base for treatment, and we must build an evidence base for benefit design to ensure that we create the right incentives.    • We must reform the payment system and align provider incentives in ways that encourage high quality and efficient care delivery.    • We need comprehensive adoption of HIT, including both EMRs and PHRs.    • We need greater transparency.  We need standardized measures of quality that are meaningful to consumers, and public reporting of those measures in ways that enable consumers to assess differences and make value-based decisions.    Finally, to make all this happen, we need to have all the stakeholders at the table, especially consumers.  We need their perspective, their buy-in, and their help in order to get to the kind of health care system we all want.  There is a growing number of consumer advocacy organizations beginning to focus on these quality, transparency, HIT and payment issues.  This will ensure that we shape a system that meets the needs of patients and consumers.  It will also help us reach, inform and enable consumers to become better healthcare decision-makers and more engaged patients.  

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VBP Interview with Debra Ness

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