A Different Lens: Evaluating Quality of Care From the Consumer Perspective

Ellen Harrison

Quality of care means different things to different people depending on their perspective. As a result, defining and delivering quality can be elusive. The Institute of Medicine defines quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” A simpler definition might be doing the right thing—at the correct time and in a proper manner—for the right person, and getting the best possible health outcomes.

Ellen Harrison

Ellen Harrison

Managed care organizations are charged with delivering on this promise of quality care and measuring the results through various standards, including NCQA HEDIS measures and Medicare Star ratings. For the most part, these measures are objective and quantifiable.

But the consumer’s point of view can be wildly different from that of a health care executive because it is based on an individual experience. For example, a long wait to see a doctor could drastically affect the quality of someone’s health care experience.

For managed care organizations, member perceptions of quality are measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the Health Outcomes Survey (HOS) for Medicare Advantage plans. These can certainly provide insight into the consumer perspective, but some information gets lost. Based on sampling methodology, the survey results are aggregated so specific individual member data are not available. And it’s not always apparent which subpopulations are faring well (or poorly).

Despite these limitations, health plans utilize CAHPS and HOS results as a starting point to improve the consumer’s experience and perspective on the quality of care delivered through their plan.

Here are five steps to take that incorporate the consumer point of view when formulating your action plan for improving quality and the patient experience:

  1. Begin with the aggregated trends gleaned from the CAHPS and HOS survey results. Dig deeper by performing off-cycle surveys of the full member population to gather detailed data about experience and perception. Interactive voice response or web-based surveys are faster, less expensive, and have higher response rates than mail surveys.
  2. Supplement these off-cycle surveys with additional information. Collect data around members’ social and economic barriers, health literacy, and other social determinants of health.
  3. Develop targeted interventions for at-risk members such as those who are at risk of developing diabetes or hypertension. Intervene at the individual member level whenever possible. Once you’ve identified those members, provide immediate support through your care management or services teams.
  4. Follow member communication preferences when possible; if a customer prefers email or text, email or text her. Also, encourage members to take achievable actions to improve their health and to stick with treatments. A recent review of 37 randomized controlled trials found that providing patients with targeted education materials led to greater overall satisfaction with care.
  5. Develop a continuous improvement cycle of access, analyze, act, measure, and repeat year-over-year. Focus your finite resources on a limited number of interventions to drive positive member care experiences at first and then expand to additional interventions over time. It’s difficult to immediately improve member perceptions of quality and experience, so it requires a long-term commitment.

CMS continues to push on measuring and reporting information from the consumer perspective for Medicare Advantage and Part D contracts. Others will follow, and we can expect more emphasis on member-reported outcomes and experience measures across all lines of business. So the time to focus on the consumer and, more specifically, improving member perceptions of care quality and experience, is now.

Ellen Harrison is vice president for market strategy and consulting for HMS, an Irving, Texas, health technology and consulting company.


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