In what is said to be an Australian-first, WA’s biggest health insurer will ask hospital patients to rate their clinical care including whether they are happy with the outcome.
By Cathy O’Leary
Surveys of hospital patients are hardly new, with people often quizzed about their stay and whether they liked the food and felt looked after.
But in what is thought to be the first move of its kind in Australia, HBF is set to launch a detailed data collection system which will see patients asked about their clinical experience – and importantly if the outcome was what they expected.
This will see patients give feedback about their doctor including rating their satisfaction with their treatment or surgery – details of which will be fed back to hospitals and doctors themselves.
It is based on an international model which has been used in some jurisdictions for several years. It has two parts – PREMS or patient reported experience measures – and PROMS or patient reported outcome measures.
According to HBF, the concept has been used by some health funds and hospitals in Australia but often in a limited or in-house capacity that does not allow any meaningful comparison or analysis of trends.
In coming months, the insurer will start to target private hospital admissions as well as those admitted to public hospitals as private patients among its one million WA members and expects to send out up to 800,000 surveys each year.
HBF Group Executive Insurance and Health Services, Dr Daniel Heredia, said the concept had been around for some time, but not adopted in any significant way in Australia.
“We are a bit behind here, but it’s not straight forward and it’s a big piece of work, and you have to commit to it because it takes an extended period of time before there are enough data points to use it meaningfully,” he told Medical Forum.
Rate your call “on steroids”
“The concept is not dissimilar to how, when you access a service, you might get a ‘please rate the call’ or your experience – so that is the essence of it, but on steroids.
“Even with experience surveys, they have traditionally asked things like ‘were you happy’ and ‘how was your hospital stay’, but this goes much more into the clinical care. So we’re asking things like ‘when you were in pain, was this addressed’ and ‘were you able to access appropriate information about the procedure’ rather than was the wifi fast enough.
“It’s the things that are relevant to clinical care and that’s why when you look at some of the statistics, if you have a 1% improvement in your PREMs or experience, there’s a lower rate of readmission.
“This is not about the wifi or the food – it’s about the elements of the experience that actually lead to improvements in clinical care.”
The PREMS/PROMS model comes under the umbrella of value-based care, and HBF says it will ultimately help to pinpoint low-value care – a concept established by Harvard Business School Professors Michael Porter and Elizabeth Teisberg many years ago.
It led to the development 12 years ago of the International Consortium for Health Outcomes Measurement, which now includes more than 40 datasets of patient outcomes measuring 60% of diseases and conditions, including atrial fibrillation and diabetes.
HBF argues that patients are the best judges of the impact of their illness and treatments, but currently there are limited ways to capture their feedback across the whole cycle of their care.
The backdrop for the new program is the escalating healthcare spend, which is not necessarily leading to improvements in clinical outcomes, with some studies suggesting that 30% of health expenditure is waste, duplication or of low value, and 10% of it results in harm or adverse events.
“It’s with the outcomes side of things that things get interesting because it’s very evidence-based and structured,” Dr Heredia said.
“There are 45 different data sets already made by this international consortium, which is a not-for -profit, dealing with the most common medical conditions – things like prostate cancer surgery, heart failure and osteoarthritis.
“There is a standardised set of questions that get asked in various frequencies, so it’s not necessarily one-off questionnaires, and depending on the disease, you might get three separate surveys that come out over a period of 12 months.
“You’re really starting to track longitudinally – for that individual for that specific condition – what was their outcomes after two weeks, three months, 12 months.
“If they had a joint replacement, after 12 months are they able to sit or stand properly, are they able to jog or run, so it’s very disease-specific and there is a significant evidence base behind these surveys, and they’re standardised and being used internationally.”
Dr Heredia said HBF was the only major health fund in Australia that he was aware of that would be running both PREMS and PROMS on this scale. Medibank ran PREMS across its clinicians, but not PROMS, and other health funds had dabbled in a very select way, perhaps with one disease.
“We will be the first major fund to run it across every one of our patient admissions in this State – so it’s significant numbers – between 500,000 and 800,000 surveys going out every year,” Dr Heredia said.
Drilling down to doctors
“Because those numbers are so big, we will be uniquely placed that within six, 12, 18 months we will start to have significant amounts of data that we can share back, initially with the hospitals, and over time with the doctors.
“We can also ultimately drill down to what was the difference depending on the operator – that’s how powerful the data is once you get the numbers there, but that takes a long time.
“The intent then is to share that directly with the surgeons. It’s not about us giving it to the membership, we want to share that information with the doctors and the hospitals to say ‘look this is how you’re performing against the broader peer group and do with that as you will.’
“But experience internationally shows that most people once they actually get the data, they’re motivated to do something with it.”
He accepted there could be pushback from some doctors or health care operators, but said the campaign was not about trying to reduce benefit payments, stopping patients having the care they need, or pitting patients against doctors.
“We should never be afraid of data, transparency and quality improvement. There is increasing acceptance, and it will come down to how we use this data, and we’re very clear it will be used to support improvements in care, and you can’t achieve that by just throwing data out there in the public domain.
“It’s more about giving it back to providers and supporting them, and we would love to partner with them, if they’re interested, as to why there is a variation, and what they can do as an individual or hospital to improve that.
“Some people will say ‘it’s none of your business, you should just pay the bills’, and there will anxiety about what we’ll do and what’s the end goal, but the intent is about quality improvement and not ways to reduce costs.”
But Dr Heredia said that if the outcome ended up being that certain procedures proved to be not as beneficial from a patient outcome point of view, that expenditure could be redirected to new treatments or used to reduce premiums.
The bottom line was to improve outcomes for patients and the performance of health care organisations.
While taking part in the surveys would be voluntary for patients, Dr Heredia said it was important to get high participation.
“Our system will know whenever our member has a procedure or is admitted to hospital. It will then look at their demographics such as age, where they live, and decide, based on historical experience, whether that patient is more likely to respond if they get an SMS or an email,” he said.
“They will be contacted saying you’ve just completed your admission, and we really want to hear from you, and that’s how they will receive their survey.
“We need them to respond, and, positively, the experience with some smaller health funds is that 40-50% of members respond, and that shows people really want to take part.
“They will be prewarned that we’ll be collecting data down the track, but we’ll need to educate them about this process.”
Feedback to ‘outlier’ doctors
Over time, information would be shared with doctors. The insurer might also identify specific doctors who were high volume or significantly deviating.
“We would like to work with them and show them the data, because if they are an outlier we want to understand why – and there might be a good reason why they are,” Dr Heredia said.
“Increasingly, with most colleges and CPD, there are requirements for doctors to review their practice and the outcomes, so hopefully this will help doctors. We can collect data for doctors, and they can do the reflective part.”
Dr Heredia said there was a finite pool of resources and the annual growth rate in terms of health care costs was far-outstripping the ability of anyone to support it. This was a pressing issue for all funders – Federal and State governments as well as insurers.
“Clinicians are often operating in isolation, particularly in the private system, and that makes it hard to know how they are compared with other people. And there is so much information out there, it makes it hard to stay on top of what’s the evidence-based practice and, most importantly, it’s about making sure the care provided is tailored to suit the person in front of you.
“That’s where the outcomes come in. it’s not about saying everyone who has osteoarthritis of the knee needs to have a joint replacement, it’s about saying what is important to this person, what is the outcome they want and how we best give those outcomes.
“I think this will also have a flow-on effect to the public system because many doctors work in public and private, doing the same procedure. It would be amazing for the public system to come on board, where everyone is doing the same standardised procedures.”
So far, doctors’ groups and health care operators have been reluctant to be drawn on the merits or otherwise of the HBF initiative, which is due to rolled out in coming months. Some have informally told Medical Forum that the devil will be in the detail and how the data is used.
Cautious support
St John of God Health Care Group CEO Bryan Pyne said his organisation supported HBF’s commitment to improving patient outcomes through its value-based care initiative, using patient-reported experience and outcome measures.
“As an organisation, we have a long-standing practice of capturing patient experiences and using this data along with patient co-design principles to drive service optimisation,” he said. “We welcome any initiative that seeks to further improve the quality of care and patient experiences.”
But Mr Pyne said it was crucial that patient feedback was contextualised within the complexity of healthcare delivery.
“We appreciate the opportunity for continued engagement with our healthcare provider peers and all health funders to ensure that the data collected is used constructively and supports meaningful improvements.
“Our shared goal is to improve patient outcomes while maintaining the trust and collaborative relationships between patients, clinicians, health professionals, providers and funders.”