Does Public Reporting Really Lead to Better Care and Consumer Choice?
What is it?
Public reporting is an approach to address quality and cost in the health care system by providing consumers, payers, and health care providers, such as doctors and hospitals, with information regarding the performance of these providers and insurance plans. It can include such tools as “report cards” on hospital performance, including the information found on Medicare’s Hospital Compare website. Public reports can make available the comparison of costs, quality (such as rates of hospital acquired infections), and how satisfied patients are with service.
Public reports more and more are being developed and used by a range of players, including federal, state, and local governments; hospitals and other health care institutions; professional associations; health insurance plans; employers; and consumers. The enactment of the Affordable Care Act of 2010 created a new context for these initiatives by creating a national policy for quality improvement, including through public reporting.
Federal activities: Two federal agencies within the HHS share primary responsibility for these activities: AHRQ and CMS. AHRQ supports research and works with public and private stakeholders to develop quality measures, report aggregate national- and state-level data, and conduct research on the science of public reporting. It does not, however, report measures at the provider level.
CMS collects data on performance measures from providers participating in the Medicare, Medicaid, and Children’s Health Insurance Program. CMS posts comparative provider specific information about hospitals, doctors, nursing homes, home health agencies, and kidney dialysis facilities at www.healthcare.gov. The most information reported at the national level is for general hospitals (www.hospitalcompare. hhs.gov). Since 2005 this site has reported on quality measures focusing on heart attack/failure pneumonia, and surgical care for all acute care hospitals. This website also includes measures developed from patient surveys in such areas as communication with doctors and nurses, responsiveness of hospital staff, pain management, cleanliness and quietness, and instructions about medications and discharge.
New requirements under health reform: With the inception of The Affordable Care Act (ACA), HHS Secretary Sebelius was directed to establish a national tactic for quality improvement that includes public reporting of performance information through health care quality websites. CMS and AHRQ are required under the law to organize multistakeholder groups and develop performance measures tailored to the needs of “hospitals and other institutional health care providers, physicians and other clinicians, patients, consumers, researchers, policy makers, states, and other stakeholders.” The Secretary must issue quality improvement reporting requirements for employer group health plans, including self-insured and individual plans, as well as for qualifying plans in health insurance exchanges. Health plans will need to report on their quality improvement activities regarding coverage benefits and provider reimbursement structures that: improve health outcomes, prevent hospital readmissions, improve patient safety and reduce medical errors, and implement wellness and health promotion activities.
Although the concept of public reporting has wide support, its implementation has not always been met with approval—and there is at best mixed evidence about the degree to which it has sparked changes within health care or been used widely by consumers.
The optimists: Advocates of public reporting believe that it helps consumers make informed decisions when choosing among providers and health plans, and guides purchasers when selecting insurance plans. Reporting can also assist primary care providers choose specialists for patient referrals. Providers and health plans, in turn, are motivated to improve their performance to protect their reputations and the demand for their services. Lastly, publicly reported information may also be useful to policy makers when assessing system performance and value.
Causes for concern: Skeptics of public reporting have a number of concerns, including the accuracy and dependability of the information within the reports. The costs related with collection, analysis, and distribution of data can be high, especially for providers who do not fully use EHRs. There is also potential for unintended consequences that could result from providers “fixing” report card scores, for example, by refusing to treat patients with serious conditions that might negatively impact their ratings. There is a risk of misinterpretation by consumers who may not understand the terms used or whether high or low rates reflect good performance.
Both supporters and critics acknowledge the need to address many issues with public reporting. These include choice of performance measures, data collection and system capabilities, formatting and content of reports, education and outreach to promote use of the information, and evaluation and continuous refinement to make sure the original reporting objectives are being achieved. Providers are especially concerned that public reports fairly and accurately reflect their performance, and not things that are beyond their control, such as the risk profile of a patient population. Payers are challenged to stay abreast of the latest quality measures being used by all industry stakeholder groups, including individual states, NCQA, NQF, Medicare, Medicaid, and CHIP. Both payers and providers must evaluate and implement clinical and quality analytic IT applications and management processes that enable them to collect quality data, analyze it, and make effective decisions.
Consumers and information: One of the main concerns associated with public reporting is increasing its use by consumers and improving reports’ usefulness in helping them make informed decisions among health care providers. In general, consumers’ use of public reporting is low.
A 2008 poll from the Henry J. Kaiser Family Foundation found that 30 percent of Americans said they saw information comparing the quality of different insurance plans, hospitals, or doctors, but only 14 percent reported having used such information.
The unsurprising conclusion was that consumers were more likely to be confused than informed. Much remains to be done to make public reports accessible, understandable, and relevant.
Policy makers have an opportunity to change the landscape of public reporting by taking advantage of advances in measurement, data collection, and health IT to deliver a more consumer-centered, and meaningful report card. Overcoming the constraint of limited public funding, and achieving the acceptance of providers, is critical to realizing future success.
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