Evaluating Demand-Side Approaches

Demand-side approaches to improving quality of care can be considered under the broad heading of "demand management." Demand management has been defined as "the support of individuals so that they may make rational health and medical decisions based on a consideration of benefits and risks." Viewed in this way, traditional health promotion and disease prevention can be regarded as quality of care-related demand management. Much of the attention received by demand management has been directed at controlling utilization and cost of health care. Yet, there is intuitive appeal to the concept of modifying consumer behavior to improve quality of care. There is also some research evidence to suggest such an approach can be effective.

It has long been apparent that providing preventive services is an important element of quality health care. The U.S. Preventive Services Task Force, a panel of medical and health experts appointed by HHS, has published guidelines that have set the standard for quality in preventive care since 1989. Since that time, the NCQA has incorporated measures of delivery of selected preventive services into its HEDIS measures of MCO performance. Clearly, employers can improve the quality of care received by their employees by increasing employee demand for these preventive services.

Research also suggests that consumer-directed decision support, in the form of interactive video, can be effective in improving the appropriateness of medical treatment. This approach, referred to as shared decision-making programs, has produced dramatic changes in patient preferences for treatment of benign prostatic hypertrophy (BPH) or benign enlargement of the prostate gland. Patients with BPH participating in early shared decision-making programs showed a 44 percent to 60 percent reduction in surgery rates, opting more frequently for "watchful waiting" as an alternative. These results suggest the tremendous potential for targeted and well-designed demand management programs to improve quality. For more information on shared decision-making programs contact the Foundation for Informed Medical Decision-Making, Hanover, NH, atwww.healthdialog.com.

Another approach attempting to modify consumer care-seeking behavior has been the dissemination of information about provider quality. This approach has been used by the Minnesota Health Data Institute, the Cleveland Health Quality Choice program, the Foundation for Accountability (FAACT), the Pennsylvania Health Care Cost Containment Council, and others. Schneider and Epstein studied the impact of this approach, as implemented by the Pennsylvania Health Care Cost Containment Council in its Consumer Guide to Coronary Artery Bypass Graft (CABG) surgery. The Guide provided CABG mortality ratings of all cardiac surgeons and hospitals in the state. A telephone survey of patients who had undergone CABG in one of four hospitals included in the Guide revealed that only 12 percent of patients were aware of the Guide, and fewer than 1 percent knew the correct rating of their surgeon or hospital and reported that it had a moderate or major impact on their selection of provider. The authors concluded: "Efforts to aid patient decision-making with performance reports are unlikely to succeed without a tailored and intensive program for dissemination and patient education."

Despite the proliferation of physician report cards, there are few studies indicating that they influence consumer behavior. In a survey of employees in firms participating in the Minneapolis-based Buyers Health Care Action Group, health care consumers reported they were using employer-provided information on satisfaction and service-quality for physicians. A more recent survey of individuals with employer-sponsored health benefits reported that patients remain largely passive consumers of physician services.

More general approaches to demand management have produced suggestive, though less well-documented results. One such approach is telephonic nurse counseling. These services offer telephone access to nurses to discuss health issues in general and answer clinical questions in particular. Vendors of these services purport to be effective in reducing costs and improving appropriateness of health care, and they appear to have convinced a growing number of employers and health plans.

Telephonic nurse case management is also being targeted to patients with specific medical conditions, such as congestive heart failure, diabetes, and asthma. A variety of organizations offer this type of service, including pharmacy benefit management firms, MCOs, hospitals, and others. This approach appears to hold promise for improving compliance with state-of-the-art treatment through improved self-care and patient-provider communication.

The explosive growth of the Internet and its widespread use in the arena of health, suggests that it may be a medium that can contribute to health care quality improvement. Yet, its growth and use have raised a number of new quality-related issues. One study of Internet-derived information on clinical questions found that:

• Eighty-nine percent of retrieved pages were not applicable to the question that prompted the search.
• Fewer than 1 percent of pages consisted of original research or systematic reviews.
• Sixty-nine percent of pages did not indicate an author.
• Only 1 percent of pages provided information on financial or other conflicts of interest.
• Fewer than 18 percent of pages gave the date they were posted or most recently updated.

While the Internet represents a tool with great promise for health care quality improvement, consumers, purchasers and providers should employ the same rigor in evaluating its application as we do for other quality improvement interventions.

The U.S. Department of Health and Human Services, Agency for Health Care Research and Quality has useful resources for consumer decision-making about health care quality. These resources and internet links can be found at www.ahcpr.gov. Another source—NCQA—has developed a suite of tools for employers to assist employees in accessing information on quality of care and using the information to make more informed patient choices. HealthChoices^TM offers an Internet portal, data on quality ratings, custom report cards, and other employee communication tools. These tools can be found at the NCQA web site at www.ncqa.org.

Demand management represents a wide variety of concepts and products with potential application to quality improvement. The most cost-effective of these are likely to be focused on well-defined, measurable target behaviors, and to include education and skill-building, monitoring, and reinforcement of target behaviors. Effective integration of such demand-management programs with supply-management programs will likely bring about the greatest impact on quality improvement.