Population Health Demands Transparency

"Physicians have been able to be blind to [cost] because it's never part of the conversation with patients," says Intermountain Healthcare System's CHIO. That will have to change if population health is going to succeed.

At the heart of population health efforts is the hunt for a way to give physicians the ability to improve patient outcomes at a lower cost. At this year's HealthLeaders Media Population Health Exchange, executives in charge of overseeing physicians, specialty practices, quality, IT, and transformation, said transparency within organizations is a hurdle that needs to be cleared to meet patient demands and to move their systems closer to population health's goal.

Some organizations, such as the American Gastroenterological Association (AGA), are pursuing ways to give patients more price transparency. Larry Kosinski, MD, chairman of the AGA's practice management and economics committee, and owner of Illinois Gastroenterology Group, says the auto industry's Monroney sticker, which is on the window of every new car detailing price, crash rating, and cost for options, provides a good template for one of the most common procedures GI doctors perform.

"Every car dealership has a Monroney sticker," he says. "We are in the process of creating one at the AGA for a colonoscopy because the consumer needs to know, 'What is a colonoscopy? What should be in a quality colonoscopy?' We have to think this way."

3 Out of 4 Internal Medicine Residents Clueless on Costs

Physicians need to start thinking this way because it's the new mindset of patients, especially those who are participating in high deductible plans. In previous years, when a $10 or $20 co-pay was all patients paid out-of-pocket, patients acquiesced to physicians ordering tests, procedures, etc. Now that more money is coming out of patients' pockets, they want to know how much services cost, says Sameer Badlani, MD, chief health information officer for Intermountain Healthcare System in Salt Lake City.

"For the first time in my life, I'm on a high deductible health plan," he says. "I look at things closely now. I never looked at my bill before, and that, in my mind, is the start of patient engagement."

Badlani says his experience as a high-deductible plan consumer gives him insight into new expectations for doctors. "Physicians have been able to be blind to [cost] because it's never part of the conversation with patients," he says. "As a physician I have the responsibility to answer [patients'] questions."

Intermountain is working on a transparency project that gives its physicians quality data, but Badlani would like to eventually create a dashboard that shows physicians how their decisions are affecting cost, which in turn, impacts their own reimbursement.

Patient Demand?
Even when physicians know where patients can find a better price for a follow-up service, it doesn't mean patients are ready to choose.

"It's remarkable," says Brian Yeaman, MD, chief medical informatics officer for Norman Physician Hospital Organization in Norman, Oklahoma. "In practice, I'll say, 'I need you to get an MRI, where do you want your MRI done?' They say, 'I don't care, wherever you want me to do it.' "

After Yeaman tells them price differences, patients still aren't ready to make a decision. "Patients still defer to the provider. As a family doctor, I see it nonstop."

The state of Massachusetts made price transparency for patients a top priority in 2014, requiring healthcare providers to give price information to inquiring patients within two business days. Prices varied for patients, depending on their insurance provided. But, so far, the law doesn't seem to have made patients or providers more aware of price, according to a report released Wednesday by The Pioneer Institute, a Boston-based public policy research organization.

To gauge how well healthcare providers were able to respond to patients' price requests, Pioneer called 32 providers (22 hospitals, 10 free-standing clinics), and asked for the price of an MRI for a left knee with no contrast.

"We chose an MRI because it is such a common procedure," states the report.

All but one hospital was able to provide the price for, but the length of time varied from 10 minutes to six days (average response time was two to four days), and most providers seemed caught off guard by the request.

Data Transparency for Physicians
Price transparency for patients is not well developed, yet, but the move toward transparency is necessary for population health, say healthcare leaders. That's because doctors, who are on the frontlines of care, need to be armed with quality data on themselves and post-acute providers to manage patients' health.

Some organizations share HCAHPS scores or patient experience measures with physicians. It's time to bring doctors into the conversation about other quality indicators, too, which, inevitably could include price. That kind of transparency is transformational, but it's also a tough culture change that requires looking beyond the walls of a hospital or clinic.

"Our medical groups are much more advanced," says Ken Lawonn, senior vice president and chief information officer at Sharp HealthCare, the San Diego–based integrated healthcare system with seven hospitals, two medical groups, and a health plan.

"But the hospitals are seen as the center of attention, and [they] don't want to give up reimbursement and patient volume. If we're going to get at real population health, we've got to get away from the silos. The key is how we align incentives."

Incentivizing physicians for the quality of care provided instead of the quantity of care provided is tricky, too. Some groups are increasing the amount of compensation tied to quality, but not many have gone the way of Cleveland Clinic, with its straight salary model.

The point is not lost on Badlani, who says that physicians are not likely to change their behavior without major changes.

"We talk about shifting from volume to value, but our physician contracts are fee-based," he says. "We may tell them, show them all the data, but the message we send every two weeks in their paycheck is 'You are appreciated based on the number of patients you see.' You can say we have some quality aspects to the contract, but to me, that's like putting lipstick on a pig. Until we turn our physician contracts into truly value-based contracts, little will change."

Another major change that needs to happen is physicians giving up some control over their patient panels, and allowing other mid-level providers to be part of the care team.

"Changing the work environment, and making sure every person is working at the top of his or her license is going to be key," says Assaad Sayah, MD, chief medical officer of Cambridge Health Alliance, a health system with three hospitals, 15 primary care practices, and operator of the Cambridge Public Health Department.

"When doctors are conducting the orchestra, and not playing every single instrument… that's when they'll be efficient and not pushed toward an RVU productivity model. They'll be pushed toward to the total care quality of the panel that they're managing."