Rachel Grob

Treating, Fast and Slow: Americans’ Understanding of and Responses to Low-Value Care

Policy Points: Effectively addressing low-value care calls for engaging the public, including the one-third of Americans who currently cannot envision benefits from avoiding low-value care. Public awareness of and response to low-value care can be enhanced through revised media messaging. These efforts are more effective if they emphasize health risks rather than the financial costs associated with unnecessary tests and treatments. Long-term robust public support for addressing low-value care may require shifting the focus from particular tests and treatments to emphasize, instead, the potential for better communication and more personalized attention if clinicians spend more time talking and less time testing. Context As much as 30% of US health care spending may be unnecessary. The Choosing Wisely campaign, now active in a dozen countries, addresses this problem in part through public education campaigns. This article explores Americans’ understanding of low-value care in 2015, assesses the impact of media messaging, and tests alternative message framing. Methods We use a mixed-methods design incorporating (1) 8 focus groups exploring Americans’ understanding of and language for low-value care, (2) 48 intensive interviews with patients on their interactions with physicians regarding questions of cost and value, (3) a national survey of 920 respondents examining their awareness of low-value care, and (4) a survey experiment with 785 participants, testing the impact of media messages on attitudes about low-value care, treatment choices, and selection of a primary care clinician. Findings One-third of Americans have difficulty envisioning benefits from avoiding low-value care, a figure that increases to half for less educated and minority respondents. Most Americans who anticipate benefits hope that less testing and treatment will be replaced by more interactive and personalized care. Even without media priming, many Americans would avoid common forms of low-value care like unnecessary antibiotics or excess imaging for lower back pain, but few favor clinicians who avoid these practices. Although the publics awareness and actions are increased and disparities are reduced by media messaging, conventional messages also exacerbate the blame placed on providers. Avoiding low-value care is enhanced, blaming providers is reduced, and disparities are further diminished if messages put more emphasis on the health risks of these tests and treatments. Conclusions The publics awareness of low-value care is incomplete, with substantial disparities related to race, ethnicity, and socioeconomic status. Media messaging can help fill these gaps but, in the short run, would be enhanced by fine-tuning how low-value care is characterized. In the longer run, building robust public support for reducing low-value care may require refocusing attention away from specific tests and treatments and toward the relational benefits for patients if clinicians spent less time on testing and more time on personalized care.

Family Stories: Narrative Genetics and Conceptions of Heritability in Pregnant Women

As our understanding of genetics has grown, and its importance has increased in clinical care, pregnancy and the fetus are often seen through a genetic lens. Clinicians who care for pregnant women are charged with explaining genetic risk and overseeing prenatal screening. For the clinician, genetics represents clearly defined application of a particular kind of scientific knowledge. Further, heritability in clinical terms is understood as purely genetic. Pregnant women themselves, however, may not give these genetic explanations the same primacy or meaning. In order to better understand the way pregnant women actually understand and explain heritability, we completed in-depth interviews with 26 pregnant women, listening as they gave weight and substance to the various factors they describe as influencing the personhood of their unborn children. Two-thirds of our respondents were Hispanic or African American. Most were recruited through programs that serve low-income women. The interviews were coded and analyzed by using categories that emerged directly from the narratives captured in the interviews and that revealed the broad, cross-cutting, overlapping parameters of womens deeply-held beliefs about heritability. These stories represent narratives of heritability that are profoundly familial and cultural. They incorporate belief in the authoritative knowledge of medicine-including any genetic information-into a complex and usually multicultural context, woven together by ancestry, household, and community.

CAHPS and Comments: How Closed-Ended Survey Questions and Narrative Accounts Interact in the Assessment of Patient Experience

Objectives: To investigate whether content from patient narratives explains variation in patients’ primary care provider (PCP) ratings beyond information from the closed-ended questions of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey and whether the relative placement of closed- and open-ended survey questions affects either the content of narratives or the CAHPS composite scores. Methods: Members of a standing Internet panel (N = 332) were randomly assigned to complete a CAHPS survey that was either preceded or followed by a set of open-ended questions about how well their PCP meets their expectations and how they relate to their PCP. Results: Narrative content from healthier patients explained only an additional 2% beyond the variation in provider ratings explained by CAHPS composite measures. Among sicker patients, narrative content explained an additional 10% of the variation. The relative placement of closed- and open-ended questions had little impact on narratives or CAHPS scores. Conclusion: Incorporating a protocol for eliciting narratives into a patient experience survey results in minimal distortion of patient feedback. Narratives from sicker patients help explain variation in provider ratings.

Educating, Enrolling, And Engaging: The State Of Marketplace Consumer Assistance Under The Affordable Care Act

Programs created under the Affordable Care Act to connect consumers to health care coverage represent an unprecedented public-sector investment. State-level implementation of these programs has varied greatly, making it possible to learn from differences in strategy and performance. In this article we assess the current state of Marketplace enrollment assistance, synthesizing evidence from published evaluations (largely derived from grey literature) and analyses of data from nationwide surveys of assisters. Synthesis of this evidence suggests that assister programs play a vital role supporting consumers in the new Marketplaces, particularly when assisters maintain extended ongoing relationships with consumers; assisters come from and are situated within communities they serve; local programs are well coordinated; and postenrollment issues can be addressed. Stable funding commitments, year-round employment, and enriched training were identified as crucial long-run strategies for building a more professional assister workforce and stronger infrastructure.

Playing With Ideas: Evaluating the Impact of the Ultimate Block Party, a Collective Experiential Intervention to Enrich Perceptions of Play

Parental attitudes shape play opportunities afforded to children in home, community, and school settings. This study presents evaluation of an intervention designed to enrich parents conception of play and its relationship with socially valued skills and capacities. On the basis of data from 291 racially and ethnically diverse parents/caregivers of young children (median age between 3 and 6) attending an event in NYC, we find the intervention helped parents conceptualize play in complex ways and altered perceptions of its impact on childrens current-but not future-lives. Multivariate analyses reveal the causal pathway for these changes as exposure to multiple play sites, rather than time at the event-a finding with direct implications for exposing parents to developmental science in community settings.

A Rigorous Approach to Large-Scale Elicitation and Analysis of Patient Narratives

Patient narratives have emerged as promising vehicles for making health care more responsive by helping clinicians to better understand their patients’ expectations, perceptions, or concerns and encouraging consumers to engage with information about quality. A growing number of websites incorporate patients’ comments. But existing comments have fragmentary content, fail to represent less vocal patients, and can be manipulated to “manage” providers’ reputations. In this article, we offer the first empirical test of the proposition that patient narratives can be elicited rigorously and reliably using a five-question protocol that can be incorporated into large-scale patient experience surveys. We tested whether elicited narratives about outpatient care are complete (report all facets of patient experience), balanced (convey an accurate mix of positive and negative events), meaningful (have a coherent storyline), and representative (draw fulsome narratives from all relevant subsets of patients). The tested protocol is strong on balance and representativeness, more mixed on completeness and meaningfulness.

The SelectMD 2.0 Provider Choice Experiment: Methodological Overview

This document has not been formally edited. RANDs publications do not necessarily reflect the opinions of its research clients and sponsors. is a registered trademark. ii Preface This document provides a detailed methodological overview of the SelectMD 2.0 provider choice experiment. This study uses an experimental design to test different methods of incorporating patient comments along with Consumer Assessment of Healthcare Providers and Services (CAHPS) survey results, Healthcare Effectiveness Data and Information Set (HEDIS)-like measures of effective clinical treatments, and indicators of patient safety in web-based physician quality reports. In addition, the study allowed for exploration of the role of patient navigators in affecting provider choice. The study aims to help the Agency for Healthcare Research and Quality (AHRQ) better understand how people choose a doctor as their regular source of medical care and advice. The SelectMD 2.0 provider choice experiment and the preparation of this report were supported by two cooperative agreements from AHRQ (2U18HS016980 and 1U18HS016978) to RAND and Yale University, respectively. This study was reviewed and approved by the RAND Human Subjects Protection Committee, RANDs Institutional Review Board (IRB) to review research involving human subjects. Acknowledgments We would like to thank the following people who helped the SelectMD 2.0 experiment come to fruition: for providing on-site supervision of the patient navigators x Caren Ginsberg and Chris Crofton, our project officers at ARHQ, for their support of this study x Lacey Rose Barre for her work developing the coding scheme for open-ended responses on the survey questions and other research assistance x Lane Hanson and Chaz Felix for their work coding open-ended survey responses x Bennie Osafo-Darko at Westat for her support of our teams research. The SelectMD 2.0 study used an experimental design to test different methods of incorporating patient comments about providers along with CAHPS survey results, HEDIS-like measures of effective clinical treatments, and indicators of patient safety in web-based physician quality reports. In addition, the study allowed for exploration of the role of patient navigators in affecting provider choice. The SelectMD 2.0 experiment was designed to achieve the following goals, each elaborated in more detail below: 1. Provide further insight into how to incorporate patient comments into health care quality reporting sites. 2. Test the effects of the provision of roll-up measures on decisionmaking. 3. Test the effects of patient navigators on decisionmaking. Provide further insight into how to incorporate patient comments into health care …

Choosing Doctors Wisely: Can Assisted Choice Enhance Patients’ Selection of Clinicians?:

We conducted a simulated clinician-choice experiment, comparing choices and decision-making processes of participants (N = 688) randomized among four experimental arms: a conventional website reporting only quantitative performance information, a website reporting both qualitative (patient comments) and quantitative information, the second website augmented by a decision aid (labeling of patient comments), and the decision-aided website further augmented by the presence of a trained navigator. Introducing patient comments enhanced engagement with the quality information but led to a decline in decision quality, particularly the consistency of choices with consumers’ stated preferences. Labeling comments helped erase the decline in decision quality, although the highest percentage of preference-congruent choices was seen in the navigator arm. Engagement with the quality information and satisfaction with choices available were likewise highest in the navigator arm. Findings held for high- and low-skilled decision makers. Thus, navigator assistance may be a promising strategy for equitably promoting higher quality choices in information-rich contexts.

“Oh, the Places You'll Go” by Bringing Developmental Science Into the World!

Urie Bronfenbrenner and Ernest Boyer argued for leaving the laboratory to conduct rigorous developmental research in the real world where children are found-in the places they go. Contributions to this special issue meet Bronfenbrenner and Boyers call while at the same time recognizing the continued importance of laboratory research. These articles range from a review of research on the arts to a language intervention in Senegal to large-scale dissemination and intervention projects designed to communicate the best developmental science to families, public agencies, and schools. Together these articles illustrate how we can study development in the world and enrich our work on the factors that promote development. Taking this path presents us with a set of additional hurdles to be addressed, such as how to communicate with the public and how to scale up our interventions in the face of diversity along many dimensions.