2007 Quality Driven Consumer Tr Final
- 1. ReseaRch PaPeR The QuesT for The QualiTy-Driven Consumer SEPTEMBER 2007 LINDA MACCRACKEN, MBA GARY PICKENS, PHD LEAH RAY, MBA KAVEH SAFAVI, MD, JD
- 3. Defining The QualiTy- Driven Consumer As price transparency and excellence in healthcare quality continue to gain momentum and grow in magnitude, the hospital and physician selection process increases in complexity.1 For many consumers, location and a friend or family member’s recommendation no longer shape healthcare decisions as much as high-quality physicians and the best treatment options. At the same time, healthcare change concepts, such as value- and results-based competition,2 raise the question of how much consumer preference truly matters. Consumers are demanding comprehensive, quality-driven information on providers, and healthcare organizations are listening and responding. Hospitals are proactively communicating areas of excellence and differentiation in their advertising and communication vehicles,3 and they extensively promote third- party awards, top rankings, and improved or better-than-average outcomes. Government organizations such as Hospital Compare (www.hospitalcompare.hhs.gov) are providing quality information on thousands of individual hospitals as well as comparisons against state and federal benchmarks. Numerous other organizations, such as The Leapfrog Group (www.leapfroggroup.org) and the Agency for Healthcare Research and Quality (www.ahrq.gov), provide vast amounts of information on quality to any interested consumer. As the demystification of healthcare quality continues and processes become increasingly transparent, healthcare organizations are increasingly interested in defining the target groups most focused on quality. The need for hospitals to differentiate themselves in the marketplace has never been so compelling. Many are responding by engaging in an image makeover4 targeting the engaged consumer5 who actively evaluates healthcare providers. Consumer research, linked to market segment characteristics, identifies the attributes of the quality-driven consumer who is most likely to search for quality information and switch hospitals accordingly. The term “quality-driven consumer” is an evolution of the term “quality-conscious consumer,” coined in 2004 by Solucient, which was acquired by the Healthcare & Science business of Thomson Reuters in 2006. Both terms represent consumers who would seek quality ratings information about providers and change their loyalty if their hospital received an unfavorable rating. With the quality-driven consumer, the focus is the action taken based on quality information. New research included in this paper reveals key insights into who quality-driven consumers are, how they search for health information, and what kinds of services they use. Quest for the Quality-Driven Consumer 3
- 4. Key Findings • For 58% of the adult population, good physicians and the best treatment options drive opinions on quality healthcare. Conversely, only 7% of adults are far less likely to indicate good hospitals as the top factor in quality healthcare. • One in five customers is a quality-driven consumer who is likely to research information on doctors and hospitals and likely to change loyalty if their preferred hospital received an unfavorable rating. • If shown a low quality rating for their hospital, 57% of adults would change hospitals; 24% of adults would change private physicians if shown low quality ratings. • One in five quality-driven adults is more likely than other adults to be invested in planned and preventive care — using physician referrals, wellness/fitness programs, and health education events. • Quality-driven consumers choose physicians, hospitals, and specialty care based on different priorities than all adults. Further, specialization is highly influential to quality-driven consumers, whereas it is of no importance to other adults. • Willingness to pay more for highly rated providers and trusting quality organizations and quality rating Web sites are unique to the quality-driven consumer compared with all other adults. • High income and education levels are key attributes of quality-driven consumers. Quality-driven consumers are more prevalent in the Sun Belt than the metropolitan areas of the coasts or Midwest. • In terms of healthcare advertising, response rates for quality-driven consumers are uniformly higher than all other adults. Quality-driven consumers are more interested in all types of healthcare information. • Most adults strongly prefer the Internet as a source of healthcare information. For quality-driven consumers, the Internet is by far the most preferred source, comprising a twice-as-high ranking (over 55%) to the second most preferred source, a private physician (approximately 25%). The QUesT To disTingUish and PinPoinT QUaliTy-driven ConsUmers Although Thomson Reuters data suggest that the healthcare consumerism movement has stabilized, understanding quality-driven consumers is a powerful tool for healthcare marketers with significant implications for targeting this unique consumer segment. The quest to distinguish and pinpoint quality-driven consumers begins with an exploration of five business questions: • Quality focus: What defines the quality-driven consumer? • Utilizing services: Which healthcare services do they use? • exhibiting behaviors: Which healthcare behaviors do they exhibit? • segmenting and targeting: What are they like? • Tailoring communications: How can they be reached? 4 Quest for the Quality-Driven Consumer
- 5. QUaliTy FoCUs: WhaT deFines The QUaliTy-driven ConsUmer? Approximately one out of five adults is a quality-driven consumer — likely to research information on doctors and hospitals and likely to change their loyalty if their preferred hospital received a low rating. For the last five years, quality-driven consumers have consistently comprised approximately 20% of the adult population. Interestingly, however, the largest segment, representing 38% of all adults, is unlikely to research healthcare information but is likely to change providers. Further research is needed on this unique 1 out of 5 U.S. Adults are Quality group of individuals. One possible implication is that it is too difficult for these consumers to research hospital quality information. (See Figure 1.) Conscious about Healthcare FiguRe 1: ONe OuT OF FiVe u.s aDuLTs WiLL sWiTch hOsPiTaLs Because OF LOW RaTiNgs Quality-Driven Unlikely to Research, Likely to Research, Unlikely to Change Likely to Change 34% 19% Likely to Research, Quality-Driven Consumer is: Unlikely to Change • Likely to research ratings information 9% on hospitals or doctors • Likely to change hospitals if preferred hospital received a low rating Unlikely to Research, Quality-driven consumers use Likely to Change the same amount of services as all 38% other adults. Source: HealthView® Plus 2006 When all consumers are asked to define high-quality healthcare, good physicians and the best treatment options are the top two factors, comprising 58% of responses. Interestingly, good hospitals are significantly lower at 7%. These findings suggest that the perception of what makes a good or great hospital is still open to interpretation. For marketers, this information translates into an examination of how these impressions are conveyed to Consumer Definition of Quality Health Care consumers and how the marketing opportunity can be best shaped to the target market segments. (See Figure 2.). “Most Important Factor in Defining Quality Health Care (Choose One)” FiguRe 2: MOsT iMPORTaNT FacTOR iN DeFiNiNg QuaLiTy heaLThcaRe (chOOse ONe) Clinical Trials 1% Healthier Patients 3% No Waiting 6% Advanced Technology 6% Good Physicians Good Hospitals 37% 7% Good Service 9% Treated With Respect 10% Best Treatment Options 21% Source: HealthView® Plus 2006 Quest for the Quality-Driven Consumer 5
- 6. UTilizing serviCes: WhiCh healThCare serviCes do QUaliTy-driven ConsUmers Use? The healthcare utilization patterns of quality-driven consumers are quite comparable to those of the general population. Consumers were asked about the following healthcare services: screenings, health education programs and referrals, therapies and procedures, healthcare facilities, and use of healthcare professionals. The concentrations of screenings, therapies, and procedures and the use of numerous types of healthcare facilities and healthcare professionals were similar, with quality-driven consumers slightly higher across all areas. In terms of health education, quality-driven consumers are more likely than other adults to use physician referrals, fitness/wellness programs, and health education events. This information may provide valuable insights to marketers onServices do they Use? reach quality-driven consumers. (See Figure 3.) Utilization: What the best channels to use to Healthcare 3: use OF eDucaTiONaL to General Population FiguRe Facilities: Use of Services Similar seRVices sLighTLy higheR ThaN geNeRaL POPuLaTiON 12.0% 10.0% 8.0% % of Consumers Quality-Driven Adults: Yes 6.0% All Other Adults: No 4.0% 2.0% 0.0% Health Care Info./Phys. Referral Fitness/Wellness Program Health Education Event Birthing Class Quitting Smoking Program Source: HealthView Plus 2005-2006 exhibiTing behaviors: WhiCh healThCare behaviors do QUaliTy-driven ConsUmers exhibiT? Despite the compelling similarities between quality-driven consumers and the general population in terms of healthcare utilization, quality-driven consumers behave in unique ways. The following factors were considered: physician selection and drivers in switching, hospital selection and drivers, willingness to pay more based on doctor or hospital ratings, and confidence in hospital or doctor ratings sources. Regarding physician selection, quality-driven consumers place more emphasis on physician credentials and background than other adults. More than 20% of quality-driven consumers look at physician credentials versus 10% of all other adults. Like all other adults, quality-driven consumers largely rely on family referrals to primary care physicians, and primary care physician referrals to specialists. Quality-driven consumers place a higher emphasis on advanced technology and research than other adults. Conversely, physician recommendation, previous experience, and location are more important to all other adults. Both groups continue to select hospitals primarily on reputation. (See Figure 4.) Opinion: What are Key Attitudes? FiguRe 4: QuaLiTy-DRiVeN cONsuMeRs PLace MORe eMPhasis ON hOsPiTaL TechNOLOgy aND ReseaRch Hospital Selection Drivers: Reputation and Information Dominate 40.0% 35.0% 30.0% 25.0% % of Adults Quality-Driven Adults 20.0% All Other Adults 15.0% 10.0% 5.0% 0.0% Strong Reputation Physican Most Technologically Previous Research Location Friend/Relative Overall Recommendation Advanced Experience Recommendation Source: HealthView Plus 2005-2006 6 Quest for the Quality-Driven Consumer
- 7. For hospital specialty care, quality-driven consumers are more interested in state-of-the-art facilities, advanced technology, comprehensive care, and medical staff. Location is more important to all other adults. These findings logically follow the previous findings that quality-driven consumers place more emphasis on advanced technology, research, and physician credentials and background. (See Opinion: What are Key Attitudes? Figure 5.) Specialty Hospital Selection Drivers: High Tech mostPReFeReNces FiguRe 5: hOsPiTaL sPeciaLTy caRe Important 70.0% 60.0% 50.0% 40.0% % of Adults Quality-Driven Adults All Other Adults 30.0% 20.0% 10.0% 0.0% rt y re re n f e ls g e g -A log Ca are Ca MD tio taf nc ria ou p ati on hin nc sin he no nt eC ve ral ca lS rie lT Gr ac ara rti f-t ch tie siv nti fer Lo ica Ex pe ica ort orm Te pe Ad ve -o Te Pa en ve Re ed lin pp Inf Ap ate ed reh Pr e M mi ly C Su et St nc mp Fa ern va Co Int Ad Source: HealthView Plus 2005-2006 Quality-driven consumers also select hospitals by specialty. Specialization is highly influential to quality-driven consumers, while it’s of no importance to the majority of other adults. More than 60% of quality-driven consumers indicated that hospital specialty is highly influential on their choice of hospitals, while more than 70% of all other adults said Opinion: What are Key influence on their choice of hospitals. (See Figure 6.) that hospital specialty has no Attitudes? Hospital Selection Drivers: Specialization Highly Influential FiguRe 6: QuaLiTy-DRiVeN cONsuMeRs seLecT hOsPiTaLs By sPeciaLTy 80% 70% 60% 50% % of Adults Quality-Driven Adults 40% All Other Adults 30% 20% 10% 0% No Influence Moderate Influence High Influence Source: HealthView Plus 2005-2006 Quest for the Quality-Driven Consumer 7
- 8. Quality-driven consumers express a greater willingness to pay more for highly rated providers than do all other adults. Sixty-three percent of quality-driven consumers and 47% of all other adults are willing to pay more for highly rated providers.are Key Attitudes? Opinion: What (See Figure 7.) How much more would you be willing to pay to use a higher rated doctor or hospital? FiguRe 7: QuaLiTy-DRiVeN cONsuMeRs WiLLiNg TO Pay MORe Quality-Driven Adults All Other Adults > 50% More > 50% more 2% 6% 25%-50% More 25%-50% More 3% 6% 10%-25% More 16% Nothing 37% 10%-25% More Nothing 26% 53% < 10% more 26% < 10% more 25% Source: HealthView Plus 2005-2006 In addition, quality-driven consumers trust quality organizations and quality rating Web sites much more than all other adults. All other adults have a slightly higher level of trust Opinion: What are Key Attitudes? in health plans than quality-driven consumers. (See Figure 8.) Hospital Rating Information: Higher trust in third parties FiguRe 8: higheR LeVeL OF TRusT iN QuaLiTy ORgaNizaTiONs 40.0% 35.0% 30.0% 25.0% % of Adults Quality-Driven Adults All Other Adults 20.0% 15.0% 10.0% 5.0% 0.0% Quality Organization Quality Rating Web Site Hospital Health Plan Source: HealthView Plus 2005-2006 Furthermore, all consumers are more likely to change hospitals than physicians for poor ratings. If shown a low quality rating for their own physician, only 24% of consumers would switch doctors, whereas 57% of all consumers would change providers if their hospital received a below-average quality rating. segmenTing and TargeTing: WhaT are QUaliTy-driven ConsUmers liKe? Generally speaking, quality-driven consumers are high-income, highly educated households that seek healthcare and ratings information over the Internet. The ability to identify and target quality-driven consumers depends on the appropriate use of a segmentation system that accounts for the key drivers of consumers’ healthcare decisions. High income, Baby Boomer, and Generation X (ages 25-34) dominate quality-driven consumers. Quality-driven consumer households vary by household characteristics and appear to be disproportionately present in high-income adults and Generation X, regardless of income. As the segments change in terms of age, from older to younger households, income becomes less important. 8 Quest for the Quality-Driven Consumer
- 9. Lower-income families have a low prevalence of quality-driven behavior. Quality-driven consumers are notably less prevalent in lower-income adults over age 35 and single female households with children, regardless of income. On a per capita basis, quality-driven consumers are more prevalent in the Sun Belt region of the South and Southwest than the metropolitan areas of the coasts or Midwest, consistent with recent population shifts. (See Figure 9.) FiguRe 9: QuaLiTy-DRiVeN cONsuMeR POPuLaTiON DOMiNaTes suN BeLT Quality-Driven Consumer Penetration Quintile 1 — Highest Penetration Quintile 2 Quintile 3 Quintile 4 Quintile 5 — Lowest Penetration Top Quintile Penetration > 22.5% Bottom Quintile Penetration < 13.6% Source: HealthView® Plus 2005-2006 Collegiate and post-collegiate education is a key attribute of quality-driven consumers. Twenty-five percent of quality-driven consumers have a college degree or higher, and 28% of quality-driven consumers have household incomes of $85,000 or more per year. Quality-driven consumers are also predominant in the African-American segment with an income lower than $55,000. (See Figure 10.) Education is a Key a Key aTTRiBuTe OF QuaLiTy-DRiVeN cONsuMeRs FiguRe 10: eDucaTiON is Attribute of Quality Conscious Consumers All Adults: 19.4% Quality-Driven Adults All Other Adults Education: Education: < College Degree College Degree or More 16.3% 25.1% Income Education: Education: Income: < $55K: < Post-Grad Post-Grad >= $55K 14.8% 23.3% 28.8% Race: Race: White, Asian, Income: White, Native American Native American < $85K 13.8% 18.9% 22.8% Race: Race: Income: African American, African American, Other >= $85K Asian, Other 26.7% 28.4% 18.1% Source: HealthView Plus 2005-2006 Quest for the Quality-Driven Consumer 9
- 10. QUaliTy-driven ConsUmers: mosT-PeneTraTed hoUsehold segmenTs In addition to age, income, and household composition data, the HouseholdView™ segmentation system of HealthView Plus® is based upon similarities in healthcare attitudes, behaviors, and utilization patterns. It is absolutely critical that a healthcare-specific segmentation system be applied. Regardless of which segments are most prevalent, it is essential to understand how these segments are clinically relevant, financially appropriate, and behaviorally responsive. (See Figure 11.) FiguRe 11: MOsT-PeNeTRaTeD hOusehOLD segMeNTs: aNTiQueRs aND high sOcieTy chaRacTeRisTics OF MOsT PeNeTRaTeD hOusehOLD segMeNTs householdview U.s. Population- Quality-Conscious market size head of household household segment 2006 Consumer household Composition income Penetration age Antiquers 19,743,000 25.4% 5,014,000 55-64 Married w & w/o Kids Upper High Society 15,637,000 26.1% 4,081,000 45-54 Married Upper Time to Travel 8,173,000 28.3% 2,313,000 65-74 Married w & w/o Kids Upper Settling Down 7,579,000 23.9% 1,810,000 25-34 Married Upper Middle, Upper Great Expectations 7,096,000 24.9% 1,770,000 25-34 Married w/ Kids Upper Spa Goers 4,797,000 27.3% 1,310,000 55-64 Single Female w/ & Upper w/o Kids Enjoy Your Time 4,557,000 23.9% 1,087,000 25-34 Married Lower, Lower Middle Made Her Way 3,931,000 25.0% 984,000 35-54 Single Female Upper On Her Own 3,347,000 24.0% 804,000 35-54 Single Female Upper Middle Quality-Driven Consumer Profile: Antiquers • Between the ages of 55 and 64 • Married, with or without children • High income • Service utilization: Somewhat high for chronic and preventive services while average for outpatient and alternative care services • High propensity to research healthcare, research ratings, and use the Internet for healthcare research • Do not view cost as a main driver when making healthcare decisions and are less likely to view hospitals in their area as the same • Media responsiveness: Average for traditional media (TV, radio, and print), direct mail, and non- traditional media (Internet, physician office, friends and family) Quality-Driven Consumer Profile: High Society • Between the ages of 45 and 54 • Married • High income • Service utilization: Somewhat high for preventive services while average for chronic, outpatient, and alternative care services • Very likely to research healthcare, research ratings, and use the Internet for healthcare research • Do not view cost as a main driver when making healthcare decisions and are less likely to view hospitals in their area as the same • Media responsiveness: Higher than average in terms of traditional media and direct mail responsiveness, while average for non-traditional media 10 Quest for the Quality-Driven Consumer
- 11. QUaliTy-driven ConsUmers: leasT PeneTraTed hoUsehold segmenTs Although the least penetrated household segments are far less likely to change providers because of quality information, understanding this group is often useful for healthcare marketers. There may be significant marketing and education opportunities for these least penetrated segments to discover the power and value of provider quality information. (See Figure 12.) FiguRe 12: LeasT PeNeTRaTeD hOusehOLD segMeNTs: cOuPON cLiPPeRs aND MaKiNg DO chaRacTeRisTics OF LeasT PeNeTRaTeD hOusehOLD segMeNTs householdview U.s. Population- Quality-Conscious market size head of household Composition household segment 2006 Consumer household income Penetration age Carpool Moms 9,605,000 12.5% 1,198,000 18-34 Single Female w/ Kids All No Frills 3,751,000 11.8% 441,000 45-54 Married w/ Kids Lower Earlybird Specials 4,029,000 10.3% 414,000 75+ Married Lower Coupon Clippers 4,694,000 8.8% 412,000 35-44 Married w/ Kids Lower Making Do 3,995,000 8.7% 347,000 55-64 Married/Married w/ Kids Lower Profile: Coupon Clippers • Between the ages of 35 and 44 • Married with children • Modest income • Service utilization: Less likely to use preventive care services, average use of alternative services, and higher-than-average use of chronic and outpatient services • Strongly view cost as a main driver when making healthcare decisions and are somewhat highly likely to view hospitals in their area as the same • Less likely to use the Internet for healthcare research and average propensity to research healthcare and ratings • Media responsiveness: More responsive to nontraditional media, and average in responsiveness to traditional media and direct mail Profile: Making Do • Between the ages of 55 and 64 • Married, with or without children • Modest income • Service utilization: Very likely to use chronic care services, somewhat highly likely to use outpatient services, average utilization of preventive services, and less likely to use alternative services • Less likely to use the Internet for healthcare research and have an average propensity to research healthcare and ratings • Significantly more likely to view cost as a main driver when making healthcare decisions and are somewhat highly likely to view hospitals in their area as the same • Media responsiveness: Significantly high level of responsiveness to nontraditional media, traditional media, and direct mail Quest for the Quality-Driven Consumer 11
- 12. Tailoring CommUniCaTions: hoW Can QUaliTy-driven ConsUmers be reaChed? Quality-driven consumers strongly prefer the Internet as a source of healthcare information, with 55% ranking it number one. The second most preferred source, a private physician, was selected by approximately 25%. Quality-driven consumers also have a uniformly higher response to all sources of Communication: How to Reach Them advertising. (See Figure 13.) Type of Information: Internet is dominant preferred medium FiguRe 13: QuaLiTy-DRiVeN cONsuMeRs PReFeR The iNTeRNeT 60.0% 50.0% 40.0% % of Adults Quality-Driven Adults 30.0% All Other Adults 20.0% 10.0% 0.0% Internet Your Doctor Your Info Mailed Med Paper/Mag Your Other Library Report Employer Telephone Pharmacist To You Journal Hospital Healthcare Book Cards Info Line Provider Source: HealthView Plus 2005-2006 Quality-driven consumers are more interested than all other adults in all types of healthcare information. Most report that the focus of the information sought is an understanding of conditions and drugs, not provider information. Quality-driven consumers trust quality organizations and quality ratings Web sites more than other adults, with more than 30% of quality-driven consumers having a lot of trust in quality organizations, compared with 20% of all other adults. Both groups trust hospitals only slightly more than health plans. (See Figure 14.) Quality Conscious Consumers Trust Quality Organizations More Than Other Adults FiguRe 14: MORe TRusT iN QuaLiTy ORgaNizaTiONs aND RaTiNgs WeB siTes “From what sources would you have a lot of trust in hospital or doctor ratings?” 60.0% 50.0% 40.0% % of Adults Quality-Driven Adults All Other Adults 30.0% 20.0% 10.0% 0.0% Doctor Quality Organization Quality Rating Hospital Health Plan Web Site Source: HealthView Plus 2005-2006 12 Quest for the Quality-Driven Consumer
- 13. reaChing QUaliTy-driven ConsUmers One out of five adults is a quality-driven consumer who is interested in searching for hospital quality ratings and motivated by these ratings to switch hospitals. Additionally, one out of two consumers is interested in hospital quality ratings, but not yet motivated to switch because of these ratings. With the increasing focus on transparency and sharing quality ratings, the four out of five consumers who aren’t currently searching for ratings information may become more interested in quality ratings. In the quest to find the quality-driven consumer, how should healthcare organizations target them? The quest has revealed that the quality-driven consumer is a target group in which: • Quality ratings matter • Hospital technology and physician credentials make a difference • Service specialization is important • Population is concentrated in the Sun Belt • Quality rating organizations and Web sites are preferentially trusted, followed by physicians Healthcare organizations have an additional opportunity to provide quality information through physicians and quality-rating agencies. One hallmark of success is the engagement of physicians in developing how quality-rating postings and explanations are deployed.6 With detailed, refined customer insights, segmentation, and targeting activities, providers and payers have a greater likelihood of an intimate customer experience that leads to acquiring new customers and retaining existing ones. Quest for the Quality-Driven Consumer 13
- 16. aboUT healThvieW PlUs® aBOuT ThOMsON ReuTeRs The Healthcare business of Data for this analysis were gathered from the Thomson Reuters HealthView Plus® national healthcare Thomson Reuters produces consumer research tool and represent the collective responses of nearly 20,000 households annually. insights, information, benchmarks and analysis that enable This research tool helps hospitals understand the attitudes, behaviors and decision-making patterns of organizations to manage costs, healthcare consumers in their local markets. Covering such topics as health status, chronic conditions, improve performance, and enhance utilization, hospital and physician selection, use of information resources, and media and lifestyle the quality of healthcare. Thomson Reuters is the world’s leading behavior, HealthView Plus provides the information hospitals need to support development of highly source of intelligent information targeted consumer marketing strategies and tactics. for businesses and professionals. We combine industry expertise Footnotes with innovative technology to Data for this analysis were gathered from the Thomson Reuters HealthView Plus® national healthcare consumer research tool, deliver critical information to and represent the collective responses of nearly 20,000 households annually. This research tool helps hospitals understand the leading decision makers in the financial, legal, tax and accounting, attitudes, behaviors and decisionmaking patterns of healthcare consumers in their local markets. scientific, healthcare and media markets, powered by the world’s 1 Berenson, et al. “Specialty Service Lines: Salvos in the New Medical Arms Race,” Health Affairs, vol. 25, 2006. most trusted news organization. With headquarters in New York and 2 Porter, Michael and Tiesberg, Elizabeth. Redefining Healthcare, Harvard Business School Press, 2006. major operations in London and Eagan, Minn., Thomson Reuters 3 Francis, Theo. “How to Size Up Your Hospital,” The Wall Street Journal, July 10, 2007. employs more than 50,000 people in 93 countries. Thomson Reuters 4 Johnson, Rick. “Image Makeover,” HealthLeaders, March 14, 2007. shares are listed on the New York Stock Exchange (NYSE: TRI); Toronto Stock Exchange (TSX: 5 “Meet the Engaged Consumer: Informed and Involved,” Healthcare Strategy Alert. Forum for Healthcare Strategists, January/ TRI); London Stock Exchange (LSE: February, 2004. TRIL); and Nasdaq (NASDAQ: TRIN). 6 “Rolling Out an Online Quality Report,” Spectrum, Society for Healthcare Strategy and Market Development, January/February, 2006. healthcare.thomsonreuters.com Thomson Reuters 777 E. Eisenhower Parkway Ann Arbor, MI 48108 USA Phone +1 800 366 7526 ©2009 Thomson Reuters. All rights reserved. PRO-6706 05/09 MC