Considering the Confused Healthcare Consumer: Why Less Is More When It Comes to Cost and Quality Data

Oct. 4, 2016
What effect does the presentation of healthcare cost and quality data have on consumers? Jessica Greene, Ph.D. and her colleagues have found that simplicity of data presentation is key—with major implications for healthcare IT leaders

What effect does the presentation of healthcare data have on healthcare consumers? The question is far from an abstract one. Indeed, as CIOs and other healthcare IT leaders prepare with their colleagues to report and publish quality and cost data for a variety of purposes, including value-based purchasing programs, accountable care organization (ACO) and bundled-payment contracting (whether through the Medicare program or through private health insurers), for population health purposes, and any number of other purposes, it will be extremely important for healthcare IT and other healthcare leaders to understand the ways in which data being shared with healthcare consumers is perceived, understood, and used.

A recent study published in the April issue of Health Affairs underscores some of the major challenges in this area. The article, written by Jessica Greene, Ph.D., Judith H. Hibbard, Ph.D., and Rebecca M. Sacks, is entitled “Summarized Costs, Placement Of Quality Stars, And Other Online Displays Can Help Consumers Select High-Value Health Plans.”

Jessica Greene, Ph.D.

As the article’s abstract explains, “Starting in 2017, all state and federal health insurance exchanges will present quality data on health plans in addition to cost information. We analyzed variations in the current design of information on state exchanges to identify presentation approaches that encourage consumers to take quality as well as cost into account when selecting a health plan. Using an online sample of 1,025 adults,” the authors note, “we randomly assigned participants to view the same comparative information on health plans, displayed in different ways. We found that consumers were much more likely to select a high-value plan when cost information was summarized instead of detailed, when quality stars were displayed adjacent to cost information, when consumers understood that quality stars signified the quality of medical care, and when high-value plans were highlighted with a check mark or blue ribbon. These approaches, which were equally effective for participants with higher and lower numeracy”—the ability of individual consumers to understand mathematical and financial data and information presented to them—“can inform the development of future displays of plan information in the exchanges.”

As the authors note in the main text of the article, “We sought to learn from the variation in current presentation approaches in state exchanges to identify the approaches that encourage consumers to consider quality as well as cost when selecting a health plan. This study also advances the literature, which is currently limited and conflicting, on whether or not it is effective to highlight high-value plans and how to refer to them effectively.”

Further, the authors note, “We used two online randomized experiments to test the extent to which the amount of cost information, the labeling and placement of quality stars, and the highlighting of high-value plans influenced consumers to choose high-quality affordable plans. We further examined the extent to which numeracy, literacy, and knowledge of health plan terminology influenced marking high-value health plan choices, and whether there were particular comparative display approaches that supported consumers with relatively low numeracy skills.”

Essentially, what the researchers found was that health plan selection was “highly dependent” on presentation. In other words, precisely what information was conveyed, how it was presented and shared, and how it was framed, was extremely important in consumers’ selections of health plans from a menu of options.

Clearly, there are very strong implications here for the leaders of patient care organizations, as their organizations become more involved in value-based purchasing, accountable care, bundled-payment contracting, and other programs, and especially as healthcare consumers are increasingly pressured by their employers to select high-deductible health plans.

In the context of that landscape, lead author Jessica Greene, Ph.D., a professor and associate dean for research at the George Washington University School of Nursing in Washington, D.C., spoke recently with HCI Editor-in-Chief Mark Hagland regarding the findings of this study, and the implications of those findings, for healthcare IT leaders. Below are excerpts from that interview.

Fundamentally, it appears clear that how information is presented to healthcare consumers has an enormous influence on the choices they make, correct?

Yes, it really makes a huge difference in how data is presented and information is articulated. In addition, my colleagues and I have done similar studies on data from hospitals and medical practices. And the variables are different, but we found the same story, that presentation makes a tremendous impact on how consumers understand the information, make sense of it, and make choices around it.

Please walk me through Experiments 1 and 2, and what you learned from them.

Well, to begin with, we have 14 state marketplaces out there offering private health plans under the provisions of the Affordable Care Act], and six are currently explaining quality, and next benefit year, it will be all 14. And among these six, there’s a tremendous amount of variation, but no research on the relative value of presentation, and our study was the first. The first experiment had to do with how much cost was being reported alongside quality, where the quality stars were relative to the cost. And they were placed in different places, or labeled in different ways. So this was about trying to understand how much these differences mattered. Experiment 1 found that the placement of the stars really mattered; and the summarizing of the cost information.

So when you pace the quality information alongside the cost information, we found that participants were 15 percent more likely to select the high-value health plan, when the quality information was next to the cost information, rather than above it. And it was almost that large of a difference when the cost information was summarized rather than detailed. There was a 14-percent difference, they were 14-percent more likely to select a high-value health plan when they got summary rather than five detailed data points.

Was it at all surprising to you that consumers wanted less rather than more information?

No, we find again and again that “less is more” when it comes to consumers. And every approach to presenting information is a nudge in one direction or another. So if you’re putting out five cost measures, you’re telling people that cost is more important than quality. But when you’re presenting the same amount of information on cost and quality, you’re sending the message that they’re of equal value. But when you present too much information and overwhelm consumers, they will go to the lowest-cost choices.

And it’s hard to take the time to make informed choices as healthcare consumers. To take one example from day-to-day life, if one goes to one’s grocery store, one often encounters more than 100 breakfast cereal choices in the cereal aisle. And who has the time or energy to read 100 cereal labels?


So while the theory is that more information is always better, essentially in practice, that isn’t true, correct?

That’s right. The theory around these health insurance exchanges is that we need to be presenting comparative information to consumers so that they can move the market and vote with their feet. But what we know is that that theory doesn’t always hold up, because making informed choices is hard, and providing more information can be overwhelming. And in this case, we have terminology that is complicated, and in addition, quite complex numeracy skills are required to compute what their costs will be, including out-of-pocket costs, deductibles, etc. So there is a lot of literature finding that more information doesn’t improve consumers’ ability to make choices, all the way from making choices about cereals to making choices about health plans.

And consumer empowerment is a process, right? Over time, more consumers will become better-informed and will seek more information, but not at flip of a switch, right?

That’s right, and we found in this study that even those consumers with high numeracy skills were helped by simpler presentation. Providing less cost information and presenting quality information alongside the cost information, helped equally those who were high-numeracy-literate and those who were low-numeracy-literate.

I think it’s interesting that both groups were helped by the simplicity of presentation.

It is interesting, isn’t it? The high-numerate were more likely to pick a high-value plan than the low-numerate. But even the high-numerate did considerably better with simpler displays. So making things simpler and clearer seems to provide a great deal of help.

What should our audience think about all this, as they prepare to present more data from the provider side, for consumers?

I think everyone needs to get out of their bubble a little bit, and try on that consumer perspective; test the displays with consumers. Give it to their family members who are not in this world, to see how people make sense of this information? Can they make sense of it? When you present all the information at once, it overwhelms people, and undercuts the purpose of helping people to make informed choices.

And with seniors, most will want to choose quickly and efficiently. While some seniors will want to delve deeply, most will probably only want summary-level data and information, correct?

Yes, I agree. Hopefully, they’ll have family members who can help them. Because these quality measures do matter, but we have to help them make sense of the information, and if we overwhelm them, we’re not helping to inform them.