Medicare and Market Demand for Quality

Harvard Medical School, Boston MA

Investigators

Linked publications, trials & patents

Abstract

REVISED PROJECT SUMMARY/ABSTRACT Project 5 will leverage the quality judgments of market participants (physicians and patients) to study the underlying market for quality within Medicare. A key objective of the Medicare program is to ensure that beneficiaries receive high-quality care. Yet there is wide variation in quality and evidence of diminished health outcomes for many patients due to deficient care. Medicare has pursued pay-for-performance and public reporting initiatives to improve quality, but these strategies have had limited impact, raising the need for new policy approaches. In theory, market forces should incentivize quality improvement by rewarding high-quality providers with more patients and high-quality organizations with physician labor. In practice, demand for provider quality may be weakened by market failures, including limited information and barriers to switching. This project will deepen understanding of the market for quality by assessing the quality perceptions of market participants and the barriers to acting on this information. Although we will also draw from standard quality metrics, the project’s primary focus is a novel compilation of quality judgments made by physicians and patients. We will capture the medical profession’s perceptions of physician quality using residency evaluations, board exam scores, and physicians’ choice of providers for their own care (as physicians are among the best-informed consumers of health care). We will capture physicians’ judgments of organization quality using employee surveys and their revealed preferences as patients. And we will assess patient perspectives using survey data and revealed preferences. Given the challenges of quality measurement, the judgments of the most informed actors in the system are likely to reveal important and understudied information. Furthermore, these perceptions may drive care, referral, and employment decisions more strongly than standard measures used for public reporting, enhancing detection of market responses to perceived quality variation. In Aim 1, we will compare judgments of physician quality made by the profession with conventional metrics, and describe the allocation of physician quality across geography, organizations and populations. This aim will quantify differences within and across areas or organizations in access to high-quality physicians, depending on patients’ rural/urban residence, income, and chronic disease burden. In Aim 2, we will investigate whether patients discern dimensions of physician quality that are also valued by the profession, and whether patients can act on their preferences to obtain care from physicians with higher patient- or profession-perceived quality. Using quasi-experimental variation in Medicare Advantage (MA) enrollment, we will test how narrower MA provider networks affect patient access to high-quality physicians. In Aim 3, we study how organizations’ management quality shapes choices of where physicians work and where patients seek care, thereby gauging the rewards for quality improvement at the organizational level. Together, the analyses in this project will suggest new avenues for fostering access to high-quality care for Medicare beneficiaries.