The Kaiser Family Foundation/Agency for Health Care Research and Quality

Summary

# National Survey on 

**Americans as Health Care Consumers:**

An Update on The Role of Quality Information

December 2000

[Methodology:]{.underline}

The results of the Kaiser Family Foundation/Agency for Healthcare
Research and Quality *National Survey on Americans as Health Care
Consumers: An Update on the Role of Quality Information* are based on a
telephone survey conducted between July 31 and October 9, 2000, among a
randomly selected nationally representative sample of 2,014 adults 18
years or older. Representatives from both organizations worked together
to develop the survey questionnaire and to analyze the results.
Fieldwork was conducted by Princeton Survey Research Associates for the
Kaiser Family Foundation. The margin of sampling error is +/-2
percentage points. For results based on subsets of respondents the
margin of error is higher. Note that in addition to sampling error there
are other possible sources of measurement error.

Trends from 1996 are from the Kaiser Family Foundation/Agency for
Healthcare Research and Quality *Americans as Health Care Consumers:
TheRole of Quality Information* national survey conducted from July
26-September 5, 1996 with 2,006 adults. Fieldwork for this survey was
also conducted by Princeton Survey Research Associates. The margin of
error for that survey is +/-3 percentage points.

*The Henry J. Kaiser Family Foundation, based in Menlo Park, California,
is a nonprofit, independent national health care philanthropy and is not
associated with Kaiser Permanente or Kaiser Industries.*

*The Agency for Healthcare Research and Quality is the lead Federal
agency charged with supporting research designed to improve the quality
of health*

*care, reduce its cost, address patient safety and medical errors, and
broaden access to essential services.*

OVERVIEW:

This summarizes results from the Kaiser Family Foundation and the Agency
for Health Care Research and Quality survey conducted to learn more
about the role of quality information in consumer's healthcare
decision-making, and to assess changes over time by making comparisons
to a similar survey conducted in 1996.

As in 1996, Americans are more likely to say that quality of care is
their biggest concern in choosing a health plan, over low cost, a wide
range of benefits, and having a wide choice of doctors. People are more
likely than they were in 1996 to say that there are big differences in
the quality of health care among specialists, hospitals, and health
plans. Furthermore, the public is still more likely to choose doctors
and hospitals that they are familiar with, over those that are more
highly rated, although this gap has narrowed over time. And, as in 1996,
people are more likely to say they rely on recommendations of friends,
family, and health professionals they know than on standardized quality
indicators.

Only about one in ten Americans have used information that compares
quality among health plans, hospitals or doctors to help them make their
health care choice. This may be expected when considering that few
people have seen any comparative quality information (about a quarter
say they have about health plans, 15% about hospitals, and about one in
ten about doctors). Even among those who have seen quality information,
many say that they did not need to make a decision at the time they saw
the information or that the information wasn't specific to their
personal health care issue or concern. Furthermore, about 4 in ten
Americans with employer sponsored health plan coverage say they have no
choice in health plans at all, making comparative quality information
about plans less relevant.

Despite the fact that few people have used comparative quality
information for their decision-making, most Americans believe that
information about medical errors, providers' past experiences, and
patients' experiences in getting care would tell them a lot about the
quality of doctors, hospitals, and health plans. These measures may
resonate so well with people given that they are more concerned about
mistakes happening when they receive health care services than when they
fly on an airplane.

Most Americans get their health insurance through their employer and
many large employers have been interested in making quality information
available to their employees. However, six in 10 people say they don't
trust their employer to provide them with information about the quality
of the health plans available to them because employer's main concern is
too save money on their health benefits.

Doctors and pharmacists are considered highly trustworthy sources of
information about prescription drugs, but less than one in ten Americans
trust information that comes from health websites on the Internet or
through advertisements.

Americans see a role for government in terms of promoting, monitoring,
or providing information about the quality of health care. Furthermore,
the public believes in their right to know. Almost three-quarters say
the government should require health care providers to report all
serious medical errors to make sure this information is publicly
available, and reject concerns about protecting the privacy of patients
and medical staff as reasons to withhold this data.

**HIGHLIGHTS:**

# I. Health Care Quality

1.  *Americans say that quality of care is their biggest concern in
    choosing a health plan.* The public is about equally likely now as
    they were in 1996 to say that quality of care is their biggest
    concern in choosing a health plan, over low cost, a wide range of
    benefits, and having a wide choice of doctors. (Chart 1)

> Biggest Concern in Choosing a Health Plan

  --------------------------------------------- ------------ ------------
                                                2000         1996

                                                             

  Quality of care                               44%          42%

  Low cost                                      18           17

  Wide range of benefits                        17           14

  Wide choice of doctors                        15           17
  --------------------------------------------- ------------ ------------

2.  *Americans are more likely now than in 1996 to say there are big
    differences in the quality of local health plans, hospitals, and
    specialists.* More than half the public says there are big
    differences in the quality of care among local health plans, an
    increase from 1996 (55% vs. 47%). Nearly half the public says there
    are big differences between local hospitals, an increase from 1996
    (47% vs. 38%). Forty-two percent say that there are big differences
    in local specialists, an increase from 28% in 1996. Forty-five
    percent of Americans say there are big differences in the quality of
    care at local nursing homes (no comparison data for 1996). (Chart 2)

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1.  ***Americans are about equally likely as they were in 1996 to say
    there are big differences in quality among local family doctors.***
    Forty percent of people say there are big differences in the quality
    of care between local family doctors and general practitioners,
    similar to results from 1996 (37%). (Chart 2)

# II. Defining "Quality" {#ii.-defining-quality .unnumbered}

2.  ***When asked in an open-ended question to name the most important
    factor in determining the quality of health care patients receive,
    people are most likely to mention doctors' qualifications as key to
    determining the quality of care patients receive.*** People
    mentioned the qualifications of doctors (22%), followed by ability
    to choose your own doctor (7%), the patient/provider relationship
    (7%), insurance coverage of care and procedures (6%),
    affordability/cost (5%), and availability of appointments (5%).
    (Chart 3)

3.  ***When given a list of different types of information, the public
    is more likely to choose medical errors, information about
    providers' experiences, and information about patients' experiences
    getting needed medical care than most other quality indicators as
    informative to their choice of doctor, hospital, or health plan.***

-   A majority of Americans say they can tell "a lot" about quality from
    information about medical errors and providers' past experiences.
    For example, helpful information includes comparing the number of
    medical errors made by health plans' doctors and hospitals (71%),
    the number of malpractice suits a doctor has filed against him or
    her (70%), reports of medical errors at hospitals (69%), a health
    plans' percentage of doctors who have had a complaint filed against
    them or lost malpractice lawsuits (67%), how much experience the
    hospital has in performing a particular test or procedure (66%), and
    the number of times a doctor has done a specific medical procedure
    (65%), and whether a doctor is board certified and has had
    additional training and testing in their specialty area (63%).

    -   Patient experiences getting needed care were also frequently
        cited as quality indicators, including whether the plan has
        programs to help people with chronic illnesses (67%), how easy
        it is for plan members to see specialists (66%), how quickly
        patients in a health plan can see a doctor when they need an
        appointment (64%), the percentage of plan members who get
        preventive care for things like high blood pressure (63%),
        whether the plan will help you find the care you need (61%), how
        easy it is for plan members to get lab tests they need (60%),
        how easy it is for plan members to get lab tests they need
        (60%), the range of health benefits available beyond basic
        medical coverage (60%), patient survey results on how well the
        doctor communicates (57%), how many patients die after having
        surgery at the hospital (57%), patient surveys about how well
        the health plan's doctors communicate (57%) or about the quality
        of care in that plan (55%), the number of patients at a hospital
        who do not get standard recommended treatments (51%), and how
        patients who are surveyed rate the quality of care at a hospital
        (50%). (Charts 4 -- 7)

    1.  Other information that fewer people considered useful indicators
        of quality among *doctors* include whether a doctor has
        admission privileges to a particular local hospital (37%),
        whether the doctor was highly rated by a local newspaper or
        magazine (26%), or whether a doctor charges more than other
        doctors (19%).

    2.  Other information that fewer people considered useful indicators
        of quality for *hospitals* include whether the hospital has been
        accredited (47%), whether the hospital is a teaching hospital
        (44%), and whether the hospital was highly rated by a newspaper
        or magazine (29%).

    3.  For *health plans*, fewer people thought the following
        indicators useful turnover rates of doctors in a health plan
        (52%) whether the plan has been accredited (38%) and what health
        improvement programs the plan offers or pays for (34%).

# *Measures related to medical errors and potential harm may resonate with the public because they are more concerned about errors or mistakes happening when receiving health care, particularly at a hospital or doctor's office, than when they fly on airlines or eat food from the supermarket.* The public is more likely to say that they are very concerned about serious errors or mistakes happening when they receive care at a hospital (47%), or when they receive health care in general (47%), or doctor's office (40%) than when they fill a prescription at a pharmacy (34%), fly on U.S. commercial airliners (32%), eat foods purchased at the supermarket (30%). Six percent of the public report that they have experienced a medical error in the past year. (Chart 8)

# III. What Influences Decisions {#iii.-what-influences-decisions .unnumbered}

-   *The majority of people say they feel confident that they are
    getting enough information to make the right choices about their
    health care.* The majority of the public says they felt confident
    that they had enough information to make the right choices the last
    time they decided on a treatment option (81%), doctor (79%), new
    prescription drug (79%), hospital (73%), or health plan (67%).
    (Chart 9)

4.  ***As in 1996, if they had to choose a new hospital, doctor, or
    health plan, people are more likely to rely on the recommendations
    of people they know than on standardized quality indicators.***
    Around 6 in 10 Americans would rely "a lot" on friends and family
    members or on their regular doctors to make choices. Less than half
    Americans say they would rely on indicators such as patient surveys,
    consumer groups, and newspapers and magazines. (Charts 10 -- 12)

    -   In choosing a new doctor, people are more likely to rely a lot
        on friends and family members (65%) and their regular doctors or
        other individual doctors (64%) than patient surveys (41%), their
        employers (26%), groups of doctors like state medical societies
        (24%), government agencies (14%), consumer groups (16%), and
        ratings in newspapers or magazines (7%).

    -   In choosing a new hospital, people are more likely to rely a lot
        on their regular doctors or other individual doctors (64%) and
        friends and family members (63%) than patient surveys (41%),
        groups of doctors like state medical societies (28%), their
        employers (25%), consumer groups (18%), government
        agencies(15%), and ratings in newspapers or magazines (12%).

    -   In choosing a new health plan, people are more likely to rely a
        lot on their regular doctors or other individual doctors (60%)
        and friends and family members (60%) than patient surveys (39%),
        their employers (29%), groups of doctors like state medical
        societies (25%), consumer groups (16%), government
        agencies(13%), and ratings in newspapers or magazines (8%).

5.  ***Similarly, people seeking quality information are more likely to
    ask for recommendations from people than know instead of contacting
    official groups or looking at printed information.*** The majority
    of people say that if they wanted to find information comparing the
    quality of different doctors, hospitals, or health plans, they would
    be "very likely" to ask for recommendations from friends, family
    members, or co-workers (70%) or from a doctor, nurse, or other
    health professional they know (65%). (Chart 13)

-   Fewer people choose sources of quality information such as
    contacting someone at or referring to information from their health
    plan (37%), going online to get quality information (28%), calling a
    toll-free number to hear recorded information (18%), and referring
    to a section of a newspaper or magazine that lists quality
    information (17%).

6.  ***Familiarity plays a more important role than expert ratings in
    the selection of doctors and hospitals.*** More people say that they
    would choose a surgeon they had seen before but who was not well
    rated (50%) than a surgeon they had not seen before who was rated
    higher (38%). Similarly, people are more likely to choose a hospital
    that is familiar (62%) over one that is rated higher (32%). (Chart
    14)

7.  ***However, the gap between those choosing familiar doctors and
    hospitals over those that are higher rated by independent experts
    has narrowed since 1996.*** In 1996, people were even more likely
    than they are in 2000 to choose the surgeon they had seen before
    over the higher-rated surgeon (76% in 1996 vs. 50% in 2000), and to
    choose the hospital that is familiar over a more highly rated
    hospital (72% in 1996 vs. 62% in 2000). (Note that some of the drop
    in choosing a familiar surgeon may be due to a slight wording change
    in the question that was made between the 1996 and 2000 surveys).
    (Chart 14)

8.  ***In thinking about information about prescription drugs, the
    public trusts doctors and pharmacists, but are considerably less
    likely to trust information that appears in advertisements or on
    health websites.*** Seventy-six percent of the public says they
    trust their doctor "a lot" to provide accurate information about
    prescription drugs and 70% say they trust their pharmacist. About
    half trust printed information in prescription drug packages and 37%
    trust government agencies like the FDA. Few have "a lot" of trust in
    health websites (9%) or advertisements for prescription medicines
    (6%). (Chart 25)

    **The Role of Friends, Family, and Employers**

-   ***People are equally likely now as in 1996 to say that the opinions
    of friends and family members are a good source of information about
    health plans.*** The majority of people (67%) say that the opinions
    of friends and family are a good source of information about health
    plans. We found similar results in 1996, when 69% said this. In 2000
    and 1996, 27% of the public said that friends and family do not have
    enough knowledge and experience to provide good information about
    health plans. (Chart 15)

-   ***In choosing a health plan, the public says recommendations of
    friends and family and the recommendations of experts are about
    equally likely to play an important role in their choice of health
    plans.*** The public is about equally likely to choose a health plan
    recommended by friends as a health plan rated highly by experts (47%
    vs. 45%). This has shifted since 1996, when people were more likely
    to choose a health plan recommended by friends and family (52%) over
    one recommended by experts (43%). (Chart 15)

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-   ***Eleven percent of Americans have seen quality information that
    was given out at work.***

-   ***Around one-fourth of Americans say they would rely "a lot" on
    information from their employers when choosing a new doctor,
    hospital, or health plan.*** This ranks lower than reliance on
    friends and family, doctor recommendations, and patient surveys, but
    higher than government agencies, consumer groups, and newspapers or
    magazines. (Charts 10 -- 12)

-   ***However, 6 in 10 people say that employers are not a good source
    of information about quality.*** Sixty-one percent of the public now
    says they do not trust employers because their main concern is
    saving the company money, while 29% say that employers are a good
    source of information about health plan quality because employers
    examine plans closely when deciding which ones to offer. (Chart 16)

    **IV. Exposure to and Use of Quality Information**

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-   ***Few Americans have actually used quality information to make
    their health care choices.*** Four percent of Americans have used
    quality information in selecting a doctor, 4% in selecting a
    hospital, 9% in choosing a health plan, and 12% have used any
    quality information in making decisions in the last year. In 1996,
    4% of Americans said they had used quality information about
    doctors, 6% had used quality information about hospitals, 12% had
    used information about health plans, and 15% had used any quality
    information in making decisions. (Chart 17)

9.  ***It may not be surprising that so few people have used this type
    of information given that less than 3 in 10 Americans have seen
    quality information in the last year.*** Twenty-seven percent of
    Americans have seen ANY information comparing the quality of
    different doctors, hospitals, or health plans. Twenty-three percent
    of Americans say they have seen information comparing the quality
    among health plans, 15% say they have seen information comparing
    quality among hospitals, and 9% say they have seen information
    comparing quality among doctors. (Chart 18)

-   ***Furthermore, many Americans do not have a choice of health
    plan.*** Fifty-five percent of Americans with employer-based health
    coverage have a choice of health plans, but 41% say their employer
    offers only one plan. (Chart 19)

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-   ***The majority of people who saw quality information said they did
    not use it, but often this was because they did not need to make a
    decision at the time or the information was not specific to their
    health concerns.*** The majority of people who had seen quality
    information but did not use it said that this was because they did
    not need to make a decision at that time about their doctor (67%),
    hospital (71%), or health plan (65%) or that the information was not
    specific to their personal health conditions of concerns (59% for
    doctors, 48% for hospitals, and 43% for health plans). (Chart 20)

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-   Other commonly listed reasons for not using the quality information
    they had seen about doctors, hospitals, and health plans: factors
    other than quality, such as location or cost, were more important
    (44%, 40%, and 39%), the information didn't cover the specific
    doctor, hospital or health plan they needed to know about (43%, 35%,
    and 37%), and the information was confusing or difficult to
    understand (22%, 15%, and 25%).

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-   ***As in 1996, more than 8 in 10 of people who saw quality
    information said they thought the quality information they saw would
    be useful.*** Eighty-seven percent of people who saw information on
    health plans said it would be useful to someone making decisions
    about health plans, 86% of people who saw quality information on
    doctors thought it would be useful, and 85% of people who saw
    information comparing hospitals thought it would be useful. This is
    about the same as in 1996 (87%, 86%, and 83%). (Chart 21)

-   ***People were most likely to have seen quality information in a
    newspaper or magazine or to have gotten it in the mail.*** Seventeen
    percent of Americans say that they saw quality information in a
    newspaper or magazine, 15% saw quality information that came through
    the mail, 11% saw information that was given out at work, and 7% saw
    that they saw quality information online.

## The Internet

-   ***One of the biggest changes in the country since 1996 has been the
    increasingly widespread adoption and use of the Internet. However,
    few people are currently tuning to the web to find quality
    information and few have a lot of trust in information provided over
    health websites.*** Only 7% of people have actually seen quality
    information over the Internet. However, when asked where they would
    turn, 28% of Americans say they would go online to get quality
    information, although far more would ask for recommendations of
    friends, family, and co-workers (70%) or from a health professional
    they know (65%). Just 9% say they have "a lot" of trust in health
    websites to provide accurate information about prescription, but an
    additional 31% say they trust this source "somewhat." (Chart 24)

**VI. The Role of Government in Information about Quality**

-   *Sixty-three percent of the public says the government should be
    involved in promoting, monitoring, or providing information about
    quality of health care.* People were most likely to say that the
    government should work directly with providers to improve quality
    (28%), 21% said that the government should go further and penalize
    providers that fail to meet standards, and 12% said that the
    government should just make sure information is available. Thirty
    percent of Americans say the government should not be involved in
    this at all. (Chart 22)

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-   ***Nearly three-quarters of the public favors mandatory reporting
    and public availability of medical error information.***
    Seventy-three percent of the public says the government should
    require health care providers to report all serious medical errors
    to make sure this information is publicly available, while 21% say
    that reporting of medical errors should be done a voluntary basis to
    ensure privacy for patients and medical staff. (Chart 23)

# VII. Special Groups

-   **Seniors.** Seniors' willingness to use recommendations of friends
    and family as a resource for quality information appears mixed.
    Seniors are more likely than Americans under age 65 to say they
    would choose a health plan recommended highly by friends over a plan
    recommended highly by experts. However, they are less likely than
    younger Americans to say they would be "very likely" to ask friends,
    family members, and co-workers for recommendations when comparing
    the quality of health care or to ask friends and family members for
    specific recommendations of doctors, hospitals, or health plans.
    Seniors are more likely than younger Americans to say they felt
    confident that they had enough information to make the right choices
    the last time they had to choose a doctor, hospital, or health plan,
    and less likely to say there are big differences in quality among
    family doctors, specialists, hospitals, nursing homes), and health
    plans. (Chart 26)

  ------------------------------------------------ --------- ------------
                                                   Seniors   Under Age 65

                                                             

  Would choose a health plan recommended highly by 51%       44%
  friends                                                    

  Would choose a health plan recommended highly by 37        49
  experts                                                    

                                                             

  Say friends or family members would have "a lot"           
  of influence on choice of                                  

  doctors                                          57        67

  hospitals                                        48        66

  health plans                                     46        63

                                                             

  Say they felt "very confident" that they had               
  enough information to make the right choices the           
  last time they had to choose a                             

  doctor                                           62        46

  hospital                                         55        45

  health plan                                      44        34

                                                             

  Say there are "big differences" in the quality             
  of care among                                              

  family doctors                                   30        42

  specialists                                      34        43

  hospitals                                        34        50

  nursing homes                                    37        47

  health plans                                     47        57
  ------------------------------------------------ --------- ------------

-   ***People with a Chronic Disease or Disability.*** People with a
    chronic disease or disability are more concerned than people without
    a disease or disability about errors or mistakes happening when
    receiving health care in general, care at a doctor's office, or
    prescription medicines. Furthermore, they are more likely than
    people without a chronic condition to say they have experienced a
    medical error in the past year. Perhaps related to this heightened
    concern, people with a chronic disease or disability are more likely
    than people without these conditions to say they would seek quality
    information in a variety of places such as ordering a printed
    booklet or contacting a state agency for quality information. (Chart
    27)

+----------------------------------+-----------------+-----------------+
|                                  | People with a   | People Without  |
|                                  | Chronic Disease | a Chronic       |
|                                  | or Disability   | Disease or      |
|                                  |                 | Disability      |
+----------------------------------+-----------------+-----------------+
| "Very concerned" about errors or |                 |                 |
| mistakes happening when          |                 |                 |
+----------------------------------+-----------------+-----------------+
| receiving health care in general | 57%             | 45%             |
+----------------------------------+-----------------+-----------------+
| receiving care at a doctor's     | 47              | 38              |
| office                           |                 |                 |
+----------------------------------+-----------------+-----------------+
| filling prescription medicines   | 43              | 33              |
+----------------------------------+-----------------+-----------------+
|                                  |                 |                 |
+----------------------------------+-----------------+-----------------+
| Experienced a medical error in   | 14              | 5               |
| the last year                    |                 |                 |
+----------------------------------+-----------------+-----------------+
|                                  |                 |                 |
+----------------------------------+-----------------+-----------------+
| "Very likely" to seek quality    |                 |                 |
| information, for example by      |                 |                 |
+----------------------------------+-----------------+-----------------+
| ordering a printed booklet       | 27              | 19              |
+----------------------------------+-----------------+-----------------+
| contacting a state agency for    | 30              | 18              |
| quality                          |                 |                 |
|                                  |                 |                 |
| information                      |                 |                 |
+----------------------------------+-----------------+-----------------+

-   ***People Who Have Had Difficulty Communicating with a Provider.***
    People who say they or other family members have ever had difficulty
    communicating with a provider because of language or cultural
    difficulties are less likely than people who have not had these
    difficulties to say they felt confident that they had all the
    information they needed the last time they chose a doctor, hospital,
    or treatment option. They are also more likely than people who have
    not had communication difficulties to say that there are big
    differences in quality among family doctors, specialists, and
    hospitals and to say they experienced a medical error within in the
    last year. (Chart 28)

  --------------------------------- --------------------- ---------------
                                    People Who Have Had   People Who Have
                                    Difficulty            Not Had
                                    Communicating with a  Difficulty
                                    Provider              

  Felt "very confident" that they                         
  had enough information to make                          
  the right choices the last time                         
  they chose a                                            

  doctor                            38%                   51%

  hospital                          36                    48

  new treatment option              34                    44

                                                          

  Say there are "big differences"                         
  in quality among                                        

  family doctors                    49                    39

  specialists                       53                    40

  hospitals                         57                    45

                                                          

  Experienced a medical error in    13                    5
  the last year                                           
  --------------------------------- --------------------- ---------------

-   ***Racial and Ethnic Minorities.*** Blacks are more likely than
    Whites to have concerns about errors or mistakes in health care,
    with Hispanics' concern falling between these groups. Blacks and
    Hispanics are more likely than Whites to say they think the
    government should be involved in promoting, monitoring, or providing
    information about the quality of health care. However, in terms of
    the reporting of medical errors, Blacks and Hispanics are more
    concerned about privacy than Whites. Blacks and Hispanics are more
    likely than Whites to say that reporting should be done on a
    voluntary basis to ensure the personal privacy of patients and staff
    involved. (Chart 29)

  ------------------------------------ ----------- ------------ ----------
                                       Blacks      Hispanics    Whites

  "Very concerned" about errors or                              
  mistakes happening when                                       

  receiving health care in general     71%         45%          43%

  receiving care at a hospital         62          57           44

                                                                

  Say the government should be         79          69           60
  involved in promoting, monitoring,                            
  or providing information about                                
  quality of care                                               

                                                                

  Reporting of medical errors should   32          29           19
  be done on a voluntary basis to                               
  ensure the privacy of patients and                            
  staff involved                                                
  ------------------------------------ ----------- ------------ ----------