INTRODUCTION

For advice about sources of health care, Americans have traditionally relied on family or friends and on physicians. Today, most people still depend mainly on recommendations from their immediate circle of acquaintances for assistance in reaching decisions about health care providers (204,255,369,599,719) and consult with physicians for referrals to other physicians and hospitals. As changes in the medical marketplace and medical technology have increased consumers' choices and the financial importance of these choices, an issue that has come to the fore is the need for lay people to have information about the quality of care delivered by physicians or hospitals. Some observers would deny the need for such information on the grounds that the average individual lacks the ability either to make health care decisions in general or to assess the quality of physicians' and hospitals' care in particular. Consumer advocates and others who believe that better information is needed, however, do not phrase the question in terms of people's ability to judge; they simply point out that people are becoming more involved in decisions about their own health care and in making choices among providers (296).

If people are to make informed choices among providers on the basis of quality, they either must have understandable, accurate information about provider performance at hand or must be able to acquire such information easily. Until recently, information on the quality of care provided by hospitals, physicians, and other providers was not available to the public or, for that matter, to health professionals. Although quality-of-care information is increasingly being generated for public use by government agencies, consumer organizations, the popular press, and health care organizations, much of the information is unevaluated, not systematically produced and disseminated, expensive to acquire, or difficult for lay people to interpret.

The focus of this chapter is on a future strategy for effectively disseminating evaluated information to the public on the quality of physicians' and hospitals' care. As background, the discussion considers the audience for information on the quality of care and the present situation with respect to the availability of information for individual consumers.

rangements between employers, unions, and health care providers (256). At least one health benefit consultant has used indicators of quality in negotiations for establishing a hospital preferred provider organization (PPO) (322).

Many unions have historically been active users of health care information when negotiating health benefits for their members. The recent trend among employers to limit employee choices to certain health care providers by limiting employees'

choice of health care plans has accentuated union interest in information on quality of care. Unions, as well as employers, have little information on the quality of care provided by health maintenance organizations (HMOs), PPOs, and other types of managed care plans to which many of their members are limited (556). Validated information on the quality of medical providers in the fee-for-service sector is also scarce.

Some physicians and hospitals are ambivalent about the publication of quality-of-care information as currently constructed (41,427). Clearly, however, accurate information on the quality of hospitals and physicians could be used by physicians to select hospitals at which they will seek staff appointment; to select suitable hospitals for the admission and treatment for patients with specific medical problems, and to select hospitals or practitioners to whom to refer patients. Physicians, particularly primary care physicians, could also use information on quality to help patients choose hospitals and other practitioners. The complex nature of quality-of-care information often requires that physicians assist patients in interpreting the information's meaning.

Hospitals could use physician-specific qualityof-care information to select physicians for staff appointments and to grant admitting privileges to physicians. Hospitals could use hospital-specific and physician-specific quality-of-care information to monitor their own performance and to initiate and augment quality assurance activities and risk-management programs. Quality assurance and risk management are particularly important for hospitals in areas where providers are scarce and individuals have little choice.

Individuals and their families need quality-ofcare information in order to make informed choices of physicians and hospitals. Individuals' choices are often limited. Employees' are often constrained in their choice of hospitals and physicians by the limited range of health plan options to which their employers and unions have agreed. If the only plan offered is an HMO, the employees are limited to hospitals and physicians that

participate in that HMO; because of financial considerations, they would be hesitant to choose providers outside of the HMO. Medicaid recipients in some States, including California, are limited to those providers participating in Medicaid. Furthermore, millions of Americans live in areas where only one hospital or one physician trained in a certain procedure is geographically accessible. Their choice of provider is limited by geographic location. Finally, an estimated 35 to 40 million Americans are without health insurance coverage and cannot pay for care (635). These individuals are often limited in their choice of hospitals to public hospitals (72), which provide a disproportionate amount of uncompensated care (606).

Although some Americans defer decisions about choice of hospitals to their physicians, the majority of them make decisions about hospitals either alone or in conjunction with a physician. A summary of recent research found that onethird of Americans select hospitals themselves; one-third decide together with their physician; and one-third have the physician choose the hospital for them (320). Most of the decisions about which physician will provide their health care are made by individuals and their families (314). The primary health care decisionmakers within families tend to be females: women choose physicians and hospitals that family members will use as much as two-thirds of the time (320,496).

Thus, individuals' decisions are very important in the actual selection of a specific physician or hospital. Although providers and organizational purchasers of health care also have informational needs, this chapter adopts the perspective of the individual consumer in discussing both the present situation and the elements of an effective strategy for disseminating information on quality. In reading the discussion that follows, however, one should keep in mind the fact that most individual consumers' choices occur in an environment that is partly restricted by physician referral and limitations imposed by employers, third-party payers, geographic location, and lack of health insurance.

Individual Consumers' Concerns About and Knowledge of Aspects of the Quality of Care

More than 80 percent of people in the United States have repeatedly reported that they are satisfied with the care they receive from hospitals and physicians (391,392). People's satisfaction may vary with their knowledge and rating of differences in quality. A national consumer survey found that most respondents (79.3 percent) knew that hospitals differ in their quality of care (314). Respondents with higher incomes and more education were more knowledgeable than others. Another survey reported that 69 percent of respondents deemed the quality of the health care they were receiving to be excellent or pretty good (391). People nationally expressed more dissatisfaction with the quality of care in emergency rooms and with the availability of health care on weekends and at night than with the quality of hospital care generally (390).

In rating physicians, Americans place a high value on a physician's knowledge and technical competence, but they also place a high value on the interpersonal aspects of the quality of care,1 including the communication of information (see table 2-1). When asked the importance of certain characteristics for physicians, 96 percent of the respondents in a national survey stated that it was very important for physicians to be able to answer questions honestly and completely (see ta

1See ch. 3 for a discussion of the definition of the quality of medical care and its different aspects.

ble 2-1) (392). At least three of the other characteristics rated very important by at least 92 percent of respondents pertained to clear explanations of medical problems. Having a physician spend sufficient time to diagnose and prescribe not only was rated highly, but its absence was cited as a cause of dissatisfaction by a majority of people who changed physicians. Available research on the validity of patients' assessments discussed in chapter 11 of this report suggests that people do have the ability to judge the interpersonal aspects of

care.

Whether lay people have the knowledge they need to evaluate the technical competence of a provider is not entirely clear. The discussion in chapter 11 concludes that research on the validity of patients' assessments of the technical aspects of medical care is sparse and difficult to interpret. Furthermore, some research results can be questioned because experts disagree on criteria for evaluating the technical aspects of quality. In a 10-item questionnaire administered to 4,976 nonelderly persons to measure their knowledge both in choosing medical care providers (e.g., specialist v. primary care physician) and in making decisions at the time services were used (e.g., whether to have an operation), Newhouse, et al., included board certification as a valid indicator of good quality (464); as discussed in chapter 10 of this report, however, definitive evidence on the validity of board certification of the technical quality of care is lacking. Thus, depending on how one interpreted them, certain responses to the questionnaire could signify either knowledge or a difference of opinion as to the validity of the indicator as a measure of quality. Other findings of the Newhouse, et al., study suggest that consumers are knowledgeable about some matters and uninformed about others.

Bunker and Brown's study of physicians' use of medical services gives indirect evidence on lay people's knowledge of quality of care (107). Surgical rates for physicians and their wives were found to be as high or higher than surgical rates for other groups of professionals (107). The