April 4, 2018

What Yelp Tells Us About How Consumers Shop for Care

by Chas Roades

THE GIST

As consumers bear more of the cost of care, and have more choices of where to receive it, they are increasingly relying on ratings sites like Yelp—and revealing a wider set of decision criteria than before

THE FACTS

  • A recent Brookings study revealed that patients prefer using online review sites like Yelp over government-sponsored quality-data sites like Hospital Compare when choosing where to receive care
  • The authors found that non-clinical information from commercial ratings sites was at least as important as clinical information from governmental sources (and even more important to female patients)
  • Consumer preference for commercial ratings sites raises concerns among some providers, who view them as unreliable sources of information on quality of care

OUR ANALYSIS

1. Consumer choice in healthcare is relatively new—and increasingly urgent

Not that long ago, figuring out where to get care was pretty straightforward. You’d go to your family doctor for primary care, and if you needed a specialist you’d go wherever your doctor sent you. For hospital care, you’d be admitted wherever your doctor had privileges. For emergency care, you’d go to the nearest ER. Need lab work or an x-ray? A slip of paper from the front desk at your doctor’s office would tell you where to go. If you had insurance, almost everything was “in-network” and covered. Maybe you were in one of those pesky HMOs, but that just made your choices simpler: the gatekeeper would make your decisions for you. A generation of Americans grew up making few real choices about their care and thinking that everything could be had for the price of a copay.

What a different world we live in now. Each level of care delivery has splintered into myriad options—primary care is now delivered in retail clinics, worksite clinics, urgent care centers, concierge practices, community health centers, (troublingly) emergency departments, and even on our smartphones. Surgeries are performed in strip malls, where you can also find MRIs (open or closed—you pick), dialysis centers, and sleep labs. For emergency care, you might find yourself somewhere that looks nothing like a hospital—no ambulances, no beds, maybe no more than a doctor or two. And your family doctor? If you even have one, she might make eye contact a couple of times during your ten-minute visit, just after she double-checks your name on her computer so she remembers who you are. We’ve gone from a world of limited, guided choice to one of perplexing, overwhelming choice, in the space of just a decade.

At the same time, the stakes have gotten much higher for consumers. Average deductibles, coinsurance, and out-of-pocket maximums have risen to the point that most Americans who have private insurance are essentially self-insured unless something catastrophic happens. The financial consequences of seeking care have become frightening for many people. How are patients navigating this new, fraught landscape of healthcare?

We’re doing what we’ve been taught from childhood to do in every other facet of our lives—we’re shopping

Unsurprisingly, we’re doing what we’ve been taught from childhood to do in every other facet of our lives—we’re shopping. We’ve become consumers. And as we do with any meaningful, expensive purchase, we’re looking for any available, reliable information to help us make our care choices. To meet the growing demand for help in choosing a provider, a panoply of online “ratings” sites have sprung up: Healthgrades, Vitals, DoctorScorecard, RateMDs, and others. And consumer-review companies from outside healthcare—notably Yelp—have quickly jumped into the business of providing consumers information about the care providers they’re evaluating. Surveys indicate that consumers are hungry for this kind of information.

2. Information to guide consumer choice is flawed and incomplete

But the usefulness of these services is limited by lack of transparency into all but the most basic aspects of care. In various ways, these sites package basic safety and quality information, credentialing and disciplinary data, reputational rankings, and consumer-written reviews into simplistic “star ratings” of providers.

Notably absent from most ratings services is any visibility into the price consumers will pay for care, thanks to the secrecy shrouding most third-party payer contracts with providers. Imagine buying a washing machine this way—all you can find out is that the Whirlpool machine won’t set fire to your laundry room, and clothes will emerge from it wet and smelling somewhat clean…and only later can you find out what it costs. “Four stars!”

It’s understandable that providers are wary of being “shopped for” under these conditions. Not only does the lack of transparency limit what information is available to consumers, but the ratings information available is often confusing and conflicting. It’s not clear that “quality” as described by the ratings sites has any correlation to “quality” as defined by clinicians or regulatory agencies. And perversely, giving consumers the ability to share anecdotes about their care on review sites may actually lower the quality of care that physicians deliver. Little wonder that, as we increasingly try to apply our shopping skills in healthcare, we’re met by physicians who aren’t at all excited to have us “shopping”. More than 30,000 signatures have been gathered thus far in a physician-led initiative to remove provider reviews from Yelp altogether.

Clearly, we have a long way to go before we’re at a point where consumers are able to rely on ratings sites to make fully-informed choices about care. But that doesn’t matter. Consumers aren’t waiting—they can’t afford to. Any information is better than no information, and even without perfect data on quality and price on Yelp, consumers are still using it to guide their choices. And as they do, we’re learning something interesting about what they care about.

3. Consumers are looking for information about value—not just “quality”

A growing body of research indicates that non-clinical aspects of care—parking, billing, navigation—are at least as important to consumers in driving their care decisions as clinical data on the quality of care. Negative online anecdotes about service quality seemingly weigh as heavily in consumers’ minds as government-provided information about clinical outcomes.  And in a rude awakening for many of the nation’s leading clinical powerhouses, many traditionally top-tier healthcare institutions fare poorly when consumers review their own care.

Have a look at the Yelp reviews for your local hospital. Here are some that show up for mine:

“After hours of watching and hearing the staff be rude and inconsiderate I wanted to crawl out of there.”

“Parking was horrible. The machines were down so it was cash only. The lines were wrapped around multi-levels of the parking lot.”

“One visit will likely require you to shell out a huge chunk of your deductible even for something simple.”

And on and on. Yes, there are “grateful patient” stories and plaudits for the hospital’s life-saving care, but you have to search for them amid the cacophony of comments about poor service, long wait times, and incoherent billing. Notably, this is a top-tier hospital in a dominant regional health system, consistently cited as one of the best in the region. And—here’s the kicker—this hospital earns a five-star ranking on Medicare’s Hospital Compare website.

Clinical quality isn’t the only thing that matters to consumers. Convenience, and efficiency, and kindness, and many other features matter too

What we’re learning in this new era of choice is that clinical quality isn’t the only thing that matters to consumers. In a world of limited options and little exposure to cost, patients were mostly willing to take what was on offer—sure, it might have been inconvenient and unpleasant, but it was literally “just what the doctor ordered.” But if I’m spending my own money, and a lot of it, what I’m getting had better be good. And what factors into “good” is a whole lot more than just clinical quality—it’s all the other benefits and features of the care experience.

Providers are right to push back on ratings systems and evaluation methodologies that underweight or obscure legitimately important aspects of what they do—clinical quality should always be at the center. But value—true consumer value—is not simply “quality minus cost.” (Or quality divided by cost…there seems to be a disagreement among academics about whether subtraction or division is more appropriate here.) Value is benefits minus costs. Clinical quality is one very important benefit consumers receive from care, but so are convenience, and efficiency, and kindness, and many other features of the care experience.

As transparency increases and consumers grow more accustomed to shopping for care the way they shop for everything else in their lives, providers will need to embrace this more expansive definition of value—and compete on their ability to deliver it.

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