David Gergen, Editor at Large, US News and World Report, led an important panel discussion on transparency and the quality of health care. The panelists were Peter Lee, President and CEO, Pacific Business Group on Health and Mike Straube, CMS Chief Medical Officer and Director, Office of Clinical Standards & Quality.

The underlying question: what is the link between quality and cost, and will transparency about costs and quality lead to improvement in both? I’ll focus on the questions from David Gergen and from the audience; following are not direct quotes but paraphrasing of the questions and responses.

Gergen question #1: is quality being taken out of hands of physicians and taken over by people who don’t understand clinical practice?

Straube: Physicians were not used to being held accountable or being measured, so it takes a while to get used to being graded. Once they get past that, there’s a series of concerns:
- are measures valid, legitimate, pertinent to practice?
- Everyone thinks their patients are sickest, so risk adjustment is important
- Attribution of care – who’s responsible for a given outcome? We’re still struggling with this. More straightforward in primary care and specialty care.

Lee: Physicians are at the table more; physicians are now part of the playing field, and are more willing to accept measures. Straube, a physician, agreed.

Gergen: How much savings can measurement and improvement of quality represent? Some argue single-payer would save a lot. Where does quality fit into the equation?

- Peter Lee: quality leads to improved savings under any system; it’s the underpinning of capturing value; measuring performance right will do it. Even IT – we need to measure care to see what kind of a difference IT makes

- Straube agrees; it’s an issue that crosses politicial parties, and applies regardless of system we end up with. Potential savings are enormous; e.g., Jack Wennberg’s work: almost 10-foild variation in care for Medicare beneficiaries; in some places, $1500/yr for Medicare beneficiaries, some around $9000 – has to do with care received, not regional cost of living. You can also pick measures based on potential cost savings.

Emily’s comment: Not necessarily. I agree with Staube’s comment on Wennberg’s work, but nobody has yet uttered the word “overuse.” Lee’s response may imply that quality takes care of overuse, but the current environment of quality measurement unfortunately does not address efficiency and overuse explicitly, and payment reform is a crucial part of this equation. But stand by…

Gergen: What about legislating Medicare’s power to negotiate drug prices? Staube won’t comment.. Lee shifts the conversation back to transparency. Regarding insurers’ drug formularies, he says, consumers now see that generic drugs are a financial choice that makes sense, not something foisted on them – that’s what transparency means. Millions of Americans are now making choices about their health care, though, based on poor information, by Googling, etc.

Gergen: how will we know if we’re successful in terms of dealing with costs? Lee: Healthcare cost increases at national consumer price index or below will represent success, but we need to address the problem of reimbursement based on volume, and reward efficiency instead. Staube:: low-cost providers end up providing better care. the quality metric should be focus and costs will come down. [Emily: see above: I don’t think you can generalize.]

Audience question: For his bypass surgery, Bill Clinton picked a hospital with poor quality scores. Was he a poor consumer? Peter Lee: Not necessarily, because he could have picked based on the surgical team. And within a hospital, there is a range of performance. But you could say by some metrics that he was a “bad consumer.” What will be most useful for consumers will be a composite of pieces of information on which to base choices.

Audience question: Prevention vs. provision of acute care downstream (e.g., diabetes prevx vs amputation). Staube: patient safety is important, and CMS is are working with their QIOs on preventive services. Under original Medicare, there were no preventive services; Medicare will be at forefront of prevention. Peter Lee: We’re taking baby steps: what do we pay for? We pay more for acute interventions than for time spent to avoid care in the future. We don’t reward preventive care. CABG/stents vs. counseling patients – where’s the incentive?

Emily: Perverse incentives are the elephant in the room. How will Medicare address this?

In response to a question about who else, besides care providers, should be responsible for transparency, Peter Lee answered: We need to hold employers (health care purchasers) accountable for transparency, too. What’s your benefit design? Is it encouraging prevention? On the health plan side – we have a ways to go. Regarding whether transparency should be voluntary, it should be understand that transparency is part of price of admission.