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Comparison shopping moves to medicine
(Oregonian (Portland, OR) (KRT) Via Thomson Dialog NewsEdge) Jan. 22--Employers and health plans want patients to act more like smart health care shoppers. But comparison shopping has been almost impossible.
That's starting to change.
Last summer, the state of Oregon started to post hospital quality comparisons on a Web site. Under pressure from lawmakers, a hospital industry group recently opened a publicly searchable database to compare Oregon hospital charges. Health insurers are developing detailed ratings for their members.
The comparisons reveal stark differences in performance. Average death rates for treating heart attack, hip fracture and open-heart surgery patients, for instance, are double the statewide average at several hospitals. Financial charges can vary by 100 percent or more for patients with similar medical problems.
"It's all been hidden from consumers until now," says Judith Hibbard, a University of Oregon professor who studies health care quality issues. "So there's really been no need for hospitals to compete on price or quality."
The newly revealed data are stirring hospitals to refocus their quality improvement efforts and adjust their charges.
For consumers, the impact is less clear. The information is limited -- and hard even for experts to interpret. Hospitals and doctors continue to closely guard the details of their prices, insisting that the information is business sensitive. The lag in consumer-friendly data could complicate employers' efforts to get workers to share the burden for their care.
"If you are going to be given choices, you're going to need the right information and the right incentives," says William McKinney, a vice president for Regence BlueCross BlueShield, which is racing to develop detailed quality and price comparisons for members.
Employers who are requiring workers to pay bigger shares of insurance premiums or higher deductibles also are giving them more choices of where and how they spend their health dollars. Some employers are supplying workers with a fixed dollar amount each year to cover health care costs. Workers who spend frugally can bank savings from year to year in a health savings account.
"The consumer, by and large, has been a bystander in health care," says Jim Walton, benefits manager for a group of 250 wood products and manufacturing companies and president of the Oregon Coalition of Health Care Purchasers. "We have come to a point with the cost of health care that that simply can't be accommodated any longer. Like it or not, consumers are going to be responsible for making more choices."
In response, employers, labor unions and health insurers are driving the demand for public reporting of quality and cost information. Many benefits managers and health plan executives think objective rankings and report cards will help consumers apply market forces to restrain health care costs. Informed consumers, they assert, will seek cost-effective caregivers, or at least avoid inefficient and low-quality ones.
But even with increased public reporting on the quality of medical caregivers, shopping for health care remains a daunting challenge. The array of services is vast and complex. Available information is limited to a fraction of services done in hospitals -- and based on crude measures, such as death rates. Important hospital comparisons such as complication rates and infection frequency are not yet available to the public.
"The state Web site is really just a start," says Dr. Brett Sheppard, a professor of surgery at Oregon Health & Science University who advised on the state report. "We obviously have to do a much better job providing meaningful information to patients."
The state Web site, produced by the Office for Oregon Health Policy and Research, makes it easy to compare hospital death rates for a few procedures and conditions, such as balloon angioplasty, heart bypass surgery, heart attack and stroke, for which there is some evidence that higher death rates may result from poorer care quality. The Web site also highlights hospitals' experience with procedures, such as open-heart surgery, in which more practiced centers tend to show better outcomes.
Reassuringly, the analysis shows most Oregon hospitals are performing well within a narrow range of quality, and some are doing even better. But the analysis also reveals that some have a significantly higher death rate for certain procedures. And, it raises a number of red flags that consumers should be aware of before choosing a hospital:
Many Oregon hospitals lack the level of experience that can help avoid complications in certain high-risk operations. Of the 31 hospitals performing carotid-artery-clearing surgery in 2004, only three performed more than 100 cases a year -- the level of experience that researchers have linked with better results. Those three were Providence St. Vincent Medical Center in Portland, Rogue Valley Medical Center in Medford and Sacred Heart Medical Center in Eugene. Only one hospital, St. Vincent, performed enough abdominal aortic aneurysm repairs to exceed the threshold for proficiency set by the federal Agency for Health Care Research and Quality.
Oregon hospitals have higher death rates than the national and Western states' averages for seven out of eight treatments examined in the state project. For heart bypass surgery and heart attack patients, the risk of dying at Oregon hospitals was a full percentage point higher than the rate across 12 Western states -- 11.4 percent for heart attack patients, compared with 10.3 percent, and 3.8 percent for heart bypass surgery, compared with 2.8 percent. The exception was pediatric heart surgery: Oregon's two centers, Legacy Emanuel Hospital and OHSU, performed at the U.S. average and above the rate across Western states.
When a hospital ranks high in one type of care, patients should not assume it rates well in other areas. OHSU, for instance, stood out as better than average in stroke care in the 2004 data, but OHSU patients who had surgical repair of weakened and bulging abdominal aortic arteries were more likely to die than at other hospitals performing the same procedure.
"Where you go does matter," says Hibbard, the University of Oregon researcher.
Surgeons and hospital officials emphasize the limits of available ratings. To compare hospitals, the state drew upon the only publicly reported data it could get: billing records. These records lack details about patients' underlying health. Comparisons based on such records can make a hospital look bad if it has treated a larger-than-average share of severely ill patients or those with multiple problems.
To offset this factor, Oregon officials weighted death rates using a statistical technique called risk adjustment. But officials acknowledge the method is far from perfect and differences in mortality may not reflect differences in quality.
Legacy Good Samaritan officials say the hospital's death rate for heart bypass surgery appears higher than average because the hospital performs a higher proportion of combined valve replacement and bypass operations.
"If you look at simple, uncomplicated bypass surgery, that difference goes away," says Dr. Keith Marton, chief medical officer for Legacy Health System.
OHSU asserts that its higher-than-average death rate for abdominal aortic aneurysm repair resulted from treating more dire cases than other hospitals, including a larger proportion of patients whose bulging aortas had already ruptured and patients transferred from smaller hospitals.
That said, OHSU officials did not question the risk-adjustment method when it came to the ratings for stroke care, in which OHSU stood out as better than average. In fact, the university posted a boast on the state Web site: "After adjusting for the severity of their overall medical condition, OHSU stroke patients had a significantly lower death rate."
So how meaningful are the numbers?
Tina Edlund, research manager for the state Office for Oregon Health Policy and Research, puts it this way: "You are not going to see a hospital that is much, much below average with this data and, when you go to the more detailed clinical data, is above average."
Glenn Rodriguez, a family physician and a quality manager for Providence Health System, says at this stage, the public reports are better at raising questions than providing answers. Rodriguez was among the outside advisers for the Oregon quality-rating project.
"This is always going to be just one piece of the information you should use to make decisions," he says. Other factors worth considering are the qualifications of the surgeon, the opinions of a trusted doctor, and what friends or family say about their experiences.
Karl Welke, a cardiothoracic surgeon and outcomes researcher at OHSU, says patients would do better to focus on hospitals' efforts to standardize care and make sure patients receive tests and treatments known to improve results.
The Leapfrog Hospital Quality and Safety Survey posts a few such ratings. But Leapfrog has surveyed only 11 Oregon hospitals, and its "process excellence" measures are limited to heart bypass, angioplasty procedures, abdominal aortic aneurysm repair and high-risk baby deliveries.
"We know there is variation in the quality of health care," Welke says. "But there is much more to an individual patient's situation than just the overall mortality at the hospital. No one single piece of information should determine where patients go for medical care."
With all its limitations, public reporting appears to be rousing Oregon hospitals to focus improvement efforts.
Officials at Sacred Heart Medical Center in Eugene were surprised to learn that their stroke patients were significantly more likely to die than those at most other hospitals in the state, including major centers such as OHSU and Providence St. Vincent that handle a large share of the most difficult cases. Sacred Heart learned of its outlier status two years ago after joining a stroke registry with other hospitals.
The hospital assembled a team of doctors, nurses and administrators to review stroke care and make recommendations for improvement. As a result, the hospital says, it has made a variety of changes, including speeding up the delivery of brain scans and the administration of clot-busting drugs.
Ray Englander, the neurologist who led the team, says the hospital would have taken the same steps without public reporting. And he says the group concluded that Sacred Heart's death rate did not result from poor care, but rather from its mix of severely ill patients. Yet, he says public reporting probably has focused the hospital more intently on improving stroke care.
"Clearly, it was a flag," he says. "It caught people's attention."
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