Public Perspectives on Health Delivery System Reforms

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Looking across an array of inputs, including meetings, polls, and secondary review of existing poll data reveals remarkable consistency over time with respect to broad views about the health care system and health care in the United States.¹ Together with published scientific literature addressing public perceptions of and values regarding health care, this input provides some direction for policymakers considering health system reforms. The majority of the American public seem to agree with policy experts that there are serious problems with how health care is organized and delivered, and that fundamental changes may be needed to ensure access to affordable, high quality care.² 

In the broadest strokes, the health system reforms that policymakers are debating would build on a foundation of comprehensive coverage and emphasize health promotion, disease prevention, and shared decision making by providers and patients, all supported by sound evidence regarding clinical effectiveness and by health information technology. The public also has expressed clear support for improved coordination of care, better communication between patients and providers, less interference in the care process by third party administrators, and, in the abstract, moving toward a system that helps, rather than prevents people from getting the right care, at the right time, in the right place. But there is only limited evidence to support the view that people will react positively to any changes that result in, or might result in, their choices being constrained, even if limits would increase health care quality and effectiveness. Further, people with disabling conditions as well as those in generally poor health have greater concerns about access to providers and the specialized treatment they need than healthier people.³ Policymakers need to better engage the public on the need for reforms and the positive impact on quality of care and health outcomes that these reforms may lead to. 

Consistently, throughout the entire range of public opinion research on health care, Americans have expressed serious concerns about the health care system as a whole, but are generally happy with their own health care.⁴ Although Americans report barriers to care, such as problems with communication and coordination among providers, and annoyance with administrative inefficiencies, the majority—who have health insurance and have a regular doctor or place where they go for care—are mostly happy with what they have, and don’t want to lose it.^5,6 There are important differences between current proposals and the managed care models that generated consumer backlash in the 1990s. These include more credible and accountable systems for oversight and quality assessment of health plans and providers. There is also some evidence that the public may, given the increasing costs of health care and insecurity of insurance coverage, be less concerned about constraints on health care options than in the past.⁷ However, now, as a decade ago, reforming health care ultimately comes down to the issue of trust. 

Effective reform will require constraining both consumer and provider choices, that is, creating incentives and mechanisms that help people make better choices that will lead to more efficient and effective care delivery and better outcomes. Educating the public to the shortcomings of the current system and the potential for reform to improve health outcomes will be necessary in order to maintain the public trust and not allow interest groups to use scare tactics to derail reform.  When the public does not understand specific proposals—or lawmakers do not fully understand public reactions to these ideas—interest groups are able to leverage public opinion to derail reform.⁸ Developing a deeper understanding of consumers’ preferences and communicating about proposed reforms in a way that addresses their concerns will be essential to the success of health reform.

A recent HCFO report and issue brief by Jill Bernstein, Ph.D., address the issue of public perspectives on health delivery system reforms in greater detail.

The following are select grants from the HCFO portfolio that address issues related to health delivery system reforms: care coordination and health information technology. For other HCFO grants, see www.hcfo.org.  

Title: Accountable Care Teams for Disabled Medicaid Beneficiaries
Grantee Institution: University of Minnesota
Principal Investigator: David Knutson 
Grant Period: November 01, 2008 - July 31, 2009

The researchers will identify health care providers who share a common patient population (accountable care teams), using a technique known as “network methodology.” These teams could serve as a medical home for their patients. If successful, the process of identifying accountable groups of providers could also support value-based purchasing. The researchers will employ the network methodology to identify provider “clusters” – those who are densely interconnected through serving a common patient population, in this case disabled Medicaid patients in Minnesota. They will then (1) assess the “fit” of the clustering with observations about care organization in Minnesota, and (2) develop measures of cluster cohesiveness. The objective of the project is to introduce a new technology for identifying accountable groups of providers that can be the basis of medical homes/care teams and inform efforts to implement value-based purchasing of health care.

Title: The Costs and Benefits of Health Information Technology: Computerized Physician Order Entry
Grantee Institution: University of Minnesota
Principal Investigator: Jeffrey McCullough, Ph.D. 
Grant Period: September 01, 2008 - February 28, 2010

The researchers will measure the quality and cost effects of clinical information technology (IT), specifically computerized physician order entry (CPOE) systems. They will use data from 1997 to 2006 to measure the direct value of CPOE, as well as the value it creates in conjunction with complementary technological and organizational investments. The value of CPOE will be based on its causal effect on medical errors, financial costs of medical errors, financial value of CPOE-driven error reductions, and “charge capture,” which the researchers describe as more effective billing and the ability to extract higher payments from Medicare and other payers. The objective of this study is to provide new insight into how clinical IT creates both financial and clinical value, while enhancing the empirical rigor with which that value is measured.

Title: Promoting Readiness and Interest in Self Management
Grantee Institution: Visiting Nurse Service of New York
Principal Investigator: Penny H. Feldman, Ph.D./Linda M. Gerber, Ph.D. 
Grant Period: July 01, 2008 - September 30, 2009

The researchers will investigate how patient activation occurs and under what circumstances in a historically under-represented population – Black/African Americans – who suffer disproportionately high rates of chronic illness. Patient activation, or engaging patients in their care, can improve the quality of care and health outcomes for those living with chronic conditions. Specifically, the researchers will: 1) evaluate psycho-social and clinical/functional determinants that influence a change in patients’ activation levels over time; 2) examine patients’ perspectives on their involvement in their care; 3) investigate factors that may help or hinder home care nurses’ promotion of self management and patient engagement; and 4) provide recommendations to improve clinician education and patient interventions. The objective of the proposed project, funded under a special topic solicitation on consumer activation, is to promote patient-centered care by identifying and providing recommendations to overcome patient-related barriers to self-management and to cultivate facilitators of clinician involvement in promoting patient self care.

Title: Getting Tools Used: Lessons Learned from Successful Decision Support Tools Unrelated to Health Care 
Grantee Institution: Center for Advancing Health  
Principal Investigator: Jessie C. Gruman, Ph.D. 
Grant Period:  July 2008 - June 2009  

The researchers will develop case studies of four successful decision-support tools from the transportation, education, electronic, and nutrition industries in order to promote greater public demand and use of decision tools for health care. The case studies will focus on the development, marketing and dissemination of the representative tools and consider questions such as: 1) Who initiated development of the tool and why? 2) Who was the audience? 3) How was the benefit of the tool framed? 4) How did this tool become a household name? 5) What were the dissemination strategies? 6) How was it marketed? 7) How were the tool and the dissemination strategies modified over time? 8) What were the barriers to the tool’s acceptance? 9) What was the timeline leading to acceptance? 10) How has the tool influenced consumer choice over time? and 11) Why did similar attempts not succeed? The objective of this project, awarded under a special topic solicitation on consumer activation, is to help health care decision tool developers refine their approaches to development, dissemination, and promotion and to increase public use of these tools to make informed choices about health and health care.

Title: Can Disease Management Control Costs?
Grantee Institution: Mathematica Policy Research, Inc.
Principal Investigator: Deborah N. Peikes, Ph.D. 
Grant Period: March 01, 2008 - August 31, 2009

The researchers will test the ability of disease management (DM) and care coordination (CC) programs to control health care costs, examine which features make certain programs effective, for which target populations, and how they can be replicated. They will build on prior work for CMS' Medicare Coordinated Care Demonstration that estimated program impacts over the first four years of program operations, described the basic features of the 15 programs’ interventions, and linked program features to overall program effectiveness. Five interrelated studies would determine: 1) the effects of DM/CC on costs over a longer follow-up period and the types of beneficiaries for whom DM/CC is most effective; 2) the operational features of DM/CC programs that were able to reduce costs and how they can be replicated; 3) what features of the DM/CC programs did not work and why; 4) whether intensifying contacts at the time of hospital discharge contributes to reducing costs; and 5) whether DM/CC interventions are more effective at reducing costs if the doctor has a greater number of patients receiving the intervention. The objective of this study is to help decision makers determine whether to offer disease management and care coordination to Medicare beneficiaries, as well as chronically ill patients with commercial insurance and Medicaid, and will provide information about how best to implement this intervention.

Title: How Does Fragmentation of Care Contribute to the Costs of Care?
Grantee Institution: Harvard University School of Public Health
Principal Investigator: Eric C. Schneider, M.D. 
Grant Period: March 01, 2008 - August 31, 2009

The researchers will develop new measures of care fragmentation that can be used to assess fragmentation within episodes of care and evaluate the relationship between care fragmentation and the costs of care for Medicare beneficiaries. They hypothesize that a higher degree of fragmentation of care will be associated with higher episode-specific costs of care after controlling for type of clinical episode, severity of clinical episode, clinical comorbidities, and the sociodemographic characteristics of patients. To test this hypothesis, the researchers will modify existing measures of fragmentation and develop new measures based on their relevance for episodes of care, select an approach to measuring costs, and select the clinical episodes for which they will test for the association between fragmentation and costs. The objective of this study is to improve quality and reduce the growth of health care costs in the U.S. by assisting the Medicare program and other insurers to measure and monitor fragmentation and target improvements to episodes with higher fragmentation.

Title: Identifying Best Practices in the Coordination of Care
Grantee Institution: Center for Studying Health System Change
Principal Investigator: Ann S. O'Malley, M.D., M.P.H. 
Grant Period: October 01, 2007 - May 31, 2009

The researchers will examine how care is coordinated in ambulatory care settings. Specifically, they will identify and document “best practices” in physician offices that have developed care coordination processes and determine the financial implications of increased coordination. For example, the researchers will assess whether a periodic care coordination fee or itemized billing for coordination activities is more efficient. They will also examine a group of “average practices” to assess how they set priorities for coordination activities and what barriers they encounter. The objective of the proposed project is to better inform the replication of organized care coordination processes in medical practices.

Title: The Economics of Health Information Technology in Physician Organizations
Grantee Institution: University of California at San Francisco
Principal Investigator: Robert H. Miller, Ph.D. 
Grant Period: February 01, 1999 - October 31, 2001

How do managed care organizations and large physician groups implement and use health information technologies (HIT)? Investigators at the University of California, San Francisco will: 1) develop a conceptual and theoretical framework for understanding HIT use; 2) obtain and analyze information on HIT, especially clinical information; and 3) analyze effects of existing HIT developments on purchaser, regulator, and legislator policies for quality reporting requirements and payment models. They will also explore the effects of HIT on contractual and ownership relationships among managed care organizations. Methods will include interviews of managers in 30 physician groups and 6 HMOs, and managers in the groups’ parent firms, if applicable. Both capitated groups and groups which accept few capitated contracts will be included. They will also conduct interviews of HCFA, industry association staff/public managers in selected states, and NCQA staff about the relative importance of existing HIT as obstacles to strengthening performance reporting requirements and introducing risk-adjustment capitation rates. The objective of the project is to help policymakers, regulators, managers and researchers understand the economic logic of HIT use in managed care organizations and physician groups, and policies that could hasten the pace of HIT change. This study will complement another HCFO grant being investigated by researchers at the University of Minnesota on health information technologies.

Title: Information Technologies and the Use of Information in Managed Care
Grantee Institution: University of Minnesota
Principal Investigator: Jon B. Christianson, Ph.D. 
Grant Period: January 01, 1999 - June 30, 2001

How do health maintenance organizations (HMOs) implement and use health information technology (HIT)? Investigators at the University of Minnesota investigated: 1) What has been the role of HIT in shaping the development of the managed care industry over the past two decades? 2) How is HIT currently being used to organize and coordinate work within different model types of MCOs (group, staff, IPA, network, mixed model), and at different levels within individual MCOs? 3) What factors influence the structure of IT in HMOs? And 4) What public policy issues are emerging in relation to the organization and management of HIT in MCOs? The investigators used questions from the InterStudy survey database to examine these issues, as well as telephone surveys of 50 independent information technology vendors and 50 information technology managers within managed care organizations. The objective of the project was to inform policy makers about the role of HIT in managed care organizations, so they can better develop appropriate public policy towards HIT development in the managed care industry in the future

1 The findings presented here are based on reanalysis of data from the Citizens Health Care Working Group, available at http://govinfo.library.unt.edu/chc; data from other state and local initiatives designed to elicit community input about health care and health reform options, including meetings held by the Obama Transition Team in late 2008 (Review of Americans Speak on Health Reform, March 2009: www.healthreform.gov) and review of over 100 surveys, polls, and reports on quantitative and qualitative analyses of public views of health care, focusing on past 3 years.
2 In a Gallup survey conducted in November 2008, 14 percent of respondents agreed that the U.S. health care system is in a state of crisis, 59 percent that it has major problems. Saad, L. “Americans Rate National and Personal Healthcare Differently.” Gallup, Inc., December 4, 2008. Also see www.gallup.com/poll/112813/Americans-Rate-National-Personal-Healthcare-Differently.aspx?version=print. A Washington Post–ABC News poll conducted in early December 2008 found that 77 percent of respondents thought that President Obama should start right away to make major changes in the U.S health care system. “Washington Post–ABC News Poll,” The Washington Post, December 2008. Also see www.washingtonpost.com/wp-srv/politics/documents/postpoll_121508.html?sid=ST2008122001562&s_pos=list.
3 Iezzoni, L. et al. “Satisfaction With Quality and Access to Health Care Among People With Disabling Conditions,” International Journal for Quality in Health Care, Vol. 14, No. 5, October 2002, pp. 369-381.
4 See Saad, L. “Americans Rate National and Personal Healthcare Differently: Public Thinks U.S. Healthcare Has Problems, But Own Coverage is Fine,” on Gallup poll findings from 2002-2008 www.gallup.com/poll/112813/Americans-Rate-National-Personal-Healthcare-Differently.aspx?version=print  Also see Jacobs, L. “1994 All Over Again? Public Opinion and Health Care,” New England Journal of Medicine, Vol. 358, No. 18, May 1, 2008, pp. 1881-83; Employee Benefit Research Institute. EBRI Notes. Vol. 29, No. 10, October 2008; and Blendon, R. et al. “Understanding The American Public’s Health Priorities: A 2006 Perspective.” Health Affairs, Web Exclusive, October 17, 2006, W508-W515.
5 The 2007 Harris Interactive/Commonwealth International Health Policy Survey found that while a higher percent of Americans reported problems with some aspects of obtaining care, information about care, communicating with providers, etc. than did people in other nations (Canada, New Zealand, United Kingdom, Germany, and the Netherlands), Americans were nonetheless generally satisfied with their care across the dimensions addressed in the survey. For example, 79 percent of Americans in that survey reported they were confident or very confident that they would get quality and safe medical care if they became seriously ill. Forty-three percent of Americans said that their regular doctor/provider practice always helped them to coordinate the care they receive from other doctors and places, which was the highest percentage among all seven nations surveyed. Americans also reported high levels of confidence about being able to get the most effective drugs and best medical technology, ranking about midway among all seven nations on both measures. Harris Interactive/The Commonwealth Fund. “The 2007 Commonwealth Fund International Health Policy Survey: Data Sheeted Questionnaire.” July 6, 2007. Also see www.commonwealthfund.org/usr_doc/28662_DSQ_Final_070607.pdf?section=4056.
6 In reviewing the findings from a February, 2009 Kaiser Health Tracking Survey, Robert Blendon noted that one poll number that is more important than any other is the percent of people who think that they (or their families) will be better off or worse off if health reforms were enacted. In that particular survey, 38 percent said they thought they or their family would be better off, compared to 59 percent who said the country as a whole would be better off. Altman, D. “Pulling it Together: What Will Health Reform Do for Me” Kaiser Family Foundation, February 26, 2009. See www.kff.org/pullingittogether/022609_altman.cfm. 
7 This trend may be well underway. Data from the Community Tracking Survey show that among adults (age 18-64) with employer-sponsored health coverage, those saying they would be willing to accept a limited choice of physicians and hospitals to save money on out-of-pocket health costs increased from 51 to 59 percent from 2001 to 2003. Schur, C. et al. “Public Perceptions Of Cost Containment Strategies: Mixed Signals For Managed Care,” Health Affairs, Web Exclusive, November 10, 2004, W4-516-525; Tu, H. “More Americans Willing To Limit Physician-Hospital Choice For Lower Medical Costs,” Issue Brief, Center for Studying Health System Change, No. 94, March 2005. Similarly, EBRI’s 2003 Health Confidence Survey found that over half of respondents said that, if health care costs were to increase significantly, they would be willing to accept greater restrictions on their choice of hospitals (55 percent) and physicians (52 percent). Employee Benefit Research Institute. “2003 Health Confidence Survey: Summary of Findings,” Health Confidence Survey, September 2003. Also see www.ebri.org/pdf/surveys/hcs/2003/03hcssof.pdf.
8 Blendon, R. et al. “Understanding The American Public’s Health Priorities: A 2006 Perspective.” Health Affairs, Web Exclusive, October 17, 2006, W508-W515; Jacobs, L. “1994 All Over Again? Public Opinion and Health Care,” The New England Journal of Medicine, Vol. 358, No. 18, May 1, 2008, pp. 1881-83.