Public Reporting

 

Public report cards use market forces to boost quality. Prospective patients or payers may view the report cards and select clinicians accordingly. Report cards take advantage of the social incentive for clinicians to look good in front of their peers and patients. Steinbrook (84) argues that if report cards are accurate and meaningful, they will be effective. Ornstein (254) suggests that all physicians must report data in order for public reporting to be successful. Majeed (154) even suggests that if quality markers between countries can be agreed upon, countries could compare data. Tu (317) provides a study of public report cards showing minimal to modest effect on quality after publicly reporting hospital level data. Natale et al. (453) showed that along with public reporting, the idea of benchmarking also produced mixed perceptions among medical directors of pediatric ICUs in regards to its ability to bring about higher quality health care and develop accurate comparisons between hospitals or hospital systems.

Although public reporting of clinician data is currently happening on a large scale (i.e. Minnesota’s Community Measurement Project: http://www.mnhealthscores.org/) much of the physician-driven literature reflects opposition to public report cards. Authors (143, 199, 207) suggest that few patients or physicians even use public report cards, while Dolan (222) shows that ratings thus far have been more frequently used by insurers than anybody else. Fogoros (224) believes report cards create incentives for physicians to avoid high-risk patients and game the system. Satin (236) cautions against moving towards individual clinician-level public reporting until we are able to accurately risk adjust and agree upon the most appropriate measures. Rhoads (310) states sub-specialties are slow to reporting data. Finally, a poll conducted by the AAFP (146) found that while most internists support P4P, many did not support public report cards, citing too many potential adverse effects.

 

Public Reporting Literature

 

(27) Terry K. Physician Report Cards: Help, ho-hum or horror? Medical Economics, July 21, 2006.

Link: http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.j...

Summary:

  • Questions validity of report card rankings.
  • Report cards vary state by state.
  • Identifies burdens of report cards including:
  • Physician selection against non-compliant patients
  • Undue influence of payers on physicians.
  • Data reporting can be burdensome.

Significance to Literature:

Although becoming popular, physician report cards have drawbacks.

 

(35) Glendinning D. AMA leads project to develop quality measures by year’s end. American Medical News. March 13, 2006.

Link: http://www.ama-assn.org/amednews/2006/03/13/gvl10313.htm

Summary:

  • AMA promised that physicians are ready for voluntary quality reporting to CMS.
  • Many specialties are not happy with this.
  • Many physician groups hope government will not mandate quality reporting.

Significance to Literature:

Outlines House-Senate working agreement signed in December 2005 by AMA board chair committing AMA to develop 140 quality of care measures by end of 2006 enabling voluntary reporting by physicians in 2007.

 

(84) Steinbrook R. Public Report Cards—Cardiac Surgery and Beyond. NEJM. 2006: 355(18) 1847-1849.

PMID: 17079758

Summary:

  • Status of report cards in the United States and United Kingdom in 2006.
  • CABG report cards have led to a dramatic increase in performance.
  • Author believes report cards can be successful if done well.

Significance to Literature:

Supports public report cards provided they are accurate, meaningful, and current.

 

Key Article

(143) Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine. 2008: 148(2) 111-123.

PMID: 18195336

Summary:

  • 45 articles were reviewed that evaluate the impact of public reported performance data on quality improvement at the individual provider, practice, and hospital levels.
  • Most patients will not change providers based on quality rankings, but first–time patients are more likely to choose a provider based on rankings. Many consumers do not look at performance ratings.
  • Authors suggest consumers are less interested in quality data than previously thought.
  • Evidence suggests that publicly releasing performance data stimulates hospital level quality improvement.
  • Evidence of public reporting on providers and practices is indeterminate.

Significance to Literature:

Landmark data on effect of public reporting on quality improvement.

 

(144) Hibbard JH. What Can We Say about the Impact of Public Reporting? Inconsistent Execution Yields Variable Results. Annals of Internal Medicine. Editorial. 2008: 148(2) 160-161.

PMID: 18195340

Summary:

  • Editorial is a response to Fung et al. original contribution. (143)
  • Outlines 3 pathways whereby public reporting may stimulate change in performance.
  • Most positive pathway is the “reputation pathway,” which induces hospitals to change in order to maintain a good reputation.
  • Information from reports must be easy for the public to interpret.

Significance to Literature:

Authors suggest that “we should improve the execution of public reporting and only then reevaluate the effect of public reporting on quality.

 

(146) Internists Weigh in on P4P, Public Reporting. AAFP News Now. April 4, 2007.

Link: http://www.aafp.org/online/en/home/publications/news/news-now/profession...

Summary:

  • 556 physicians responded to a survey about pay-for-performance.
  • Physicians expressed concern about quality assessments, firing patients, and unintended consequences.
  • Also, general internists support financial incentives, but oppose public reporting.

Significance to Literature:

Despite concerns, physicians may support P4P, but oppose public reporting.

 

(154) Majeed A, Lester H, Bindman A. Improving the quality of care with performance indicators. British Medical Journal, Analysis. 2007: 335 916-918.

PMID: 17974688

Summary:

  • Gives reasoning behind P4P, and why measuring performance is important.
  • Although public reporting does not seem to play a role in how patients choose their general practice physician, public reporting does encourage providers to improve quality.
  • Author recommends that internationally accepted data standards and coding would allow for large amounts of data, and comparisons of quality across countries.

Significance to Literature:

Outlines the use of P4P for quality comparisons from the individual clinician to the international level.

 

(199) Marshall MN. Shekelle PG. Leatherman S, Brook RH. The Public Release of Performance Data: What Do We Expect to Gain? A Review of the Evidence. JAMA. 2000: 283(14) 1866-1874.

PMID: 10770149

Summary:

  • Attempts to evaluate the impact of report cards on consumers, hospitals, and physicians.
  • Only 1 of 7 studies on United States public reporting systems has suggested that public disclosure had an effect on consumer decision making, pointing out CABG mortality reports in New York State as having a significant effect.
  • Hospitals in competitive markets were much more likely to implement change due to public reporting than any other group.
  • Article also discusses the impact of public reporting on quality of care and costs.
  • The adverse effects of public disclosure have received minimal attention.

Significance to Literature:

The use of public reports amongst consumers in the foreseeable future is unlikely to stimulate quality improvement. However, hospitals may be more likely to use it to promote change.

 

(207) Werner RM, Asch DA. The Unintended Consequences of Publicly Reporting Quality Information. JAMA. 2005: 293(10) 1239-1244

PMID: 15755946

Summary:

  • Article examines the role of publicly reporting information on health care quality.
  • Evidence suggests that few patients and few physicians use publicly reported data.
  • Public report cards might improve health care quality in three ways:
  • Providers change their practice to improve quality.
  • Limiting providers practice so they no longer provide care for areas of low scoring.
  • Low quality physicians exit market.
  • Report cards may lead to unnecessary interventions, discounting clinician judgment, and discounting patient preference.

Significance to Literature:

Is it worth revisiting whether public report cards are worth continuing?
 

(219) Interlandi J. Making the Grade. Newsweek. June 18, 2008.

Link: http://www.newsweek.com/id/132496

Summary:

  • Highlights the conflict of interest for insurers in public report cards.
  • Doctors complain about being penalized for patients who refuse to follow treatments.
  • Doctors would like a better sense of what the insurers are grading the physicians on.

Significance to Literature:

A mainstream press article about physician report cards, public reporting, and physician tiering.

 

(222) Dolan PL. Patients rarely use online ratings to pick physicians. American Medical News. June 23/30, 2008.

Link: http://www.ama-assn.org/amednews/2008/06/23/bil10623.htm

Summary:

  • A survey released in June reported that only 1% of patients change their hospital choice or health plan based on internet ratings. Only 2% changed their physician based on ratings.
  • However, more people are looking at physician ranking than three years ago.
  • Scores seem to mean more to insurers than patients.

Significance to Literature:

Physician ratings are used more frequently by insurers than patients.

 

(224) Fogoros RN. A Bad Report? The Problem With Physician Report Cards, And A Proposed Solution. MDNG. 2008: 10(4) 20-21.

Link: http://www.hcplive.com/journals/mdng-neurology/2008/apr2008/ne_bad_report

Summary:

  • Author suggests satirically that clinics could designate one physician, “the designated driver,” to handle all of the high-risk patients, so the other physicians can score better on report cards.
  • “Physicians best risk avoidance option is to refuse ‘care’”

Significance to Literature:

Report cards create incentives for doctors to avoid high-risk patients and game the system.

 

(236) A Conversation With David Satin M.D. Metro Doctors. September/October 2008.

Link: http://www.ehcca.com/presentations/hcii1/1_06.pdf

Summary:

  • Family physician/ethicist answers questions about P4P.
  • Recommends against any metrics of ethical clinician behavior.
  • Recommends against public reporting of individual clinician performance rather than aggregate practice performance.
  • Defends the concept of risk-adjusted efficiency measures that truly measure cost/outcome.

Significance to Literature:

Clinician/ethicist examines controversial issues surrounding P4P in 2008.

 

(254) Ornstein C. L.A. County Hospitals Opt Out of ‘Report Card.’ Los Angeles Times. June 17, 2006.

Link: http://articles.latimes.com/2006/jun/17/local/me-health17

Summary:

  • Four Los Angeles county hospitals opted out of state quality report card rankings citing costs of data collection as the primary reason for abstaining.

Significance to Literature:

The effectiveness of P4P and report cards relies on collecting data from all participants.

 

(310) Rhoads KF, Konety BM, Dudley RA. Performance Measurement, Public Reporting, and Pay-for-Performance. Urologic Clinic of North America. 2009: 36 37-48.

PMID: 19038634

Summary:

  • Outline of public reporting activities in California.
  • Second half of article focuses on public reporting in Urology, because P4P is limited in most surgical specialties.
  • Input from practicing Urologists, either to AMA or Urologic associations is crucial in guideline development.

Significance to Literature:

Surgical subspecialties are limited thus far in their advances in public reporting and P4P.

  

(317) Tu JV, et al. Effectiveness of Public Report Cards for Improving the Quality of Cardiac Care. The EFFECT Study: A Randomized Trial. JAMA. 2009: 302(21) 2330-2337.

PMID: 19923205

Summary:

  • Randomized trial of the effect of public report cards in Ontario, Canada. Authors compared process-of-care measures in AMI and CHF in an early feedback hospital group and a delayed feedback hospital group.
  • There was significant improvement in 1/12 AMI measures and 1/6 CHF measures in the early feedback group vs. the delayed feedback group.
  • Hospitals in the early feedback group were however more likely to initiate starting at least 1 quality improvement initiative. (73.2% vs. 46.7% in AMI, and 61.0% vs. 50% in CHF)
  • There was however general improvement in following most process measures in both groups, suggesting a cumulate synergistic impact.
  • Study also found a lower 30-day AMI mortality rate in the early feedback group after the report card intervention.

Significance to Literature:

Randomized public report card study showing minimal to modest impact on quality by public report cards.
 

(453) Natale JE, Joseph JG, Honomichl RD, Bazanni LG, Kagawa KJ, Marcin JP. Benchmarking, public reporting, and pay-for-performance: A mixed-methods survey of California pediatric intensive care unit medical directors. Pediatr Crit Care Med. 2011;12(6):e225-e232. doi:10.1097/PCC.0b013e3181fe2e26.

PMID: 21057357

Summary:

  • Cross-sectional survey of 16 pediatric ICU medical directors in the state of California that sought to assess attitudes regarding the need for, validity of, and potential impacts of benchmarking, public reporting, and P4P on critical care
  • Quantitative Results:
    • 73% of respondents agreed or strongly agreed that benchmarking improves patient outcomes
    • Majority of respondents disagreed or strongly disagreed that benchmarking leads to avoidance of higher-risk patients (75%), that it leads to avoidance of higher-risk procedures (75%), or that it undermines physician autonomy (67%)
  • Qualitative Results – Five major themes:
    • Value of comparative data for internal benchmarking
    • Concerns over perceived burdens of data collection
    • Concerns about inaccurate data collection and reporting
    • Concerns that benchmarking data do not contribute to quality improvement
    • Suggested approaches to data analysis and outcome measures

Significance to Literature

Pediatric ICU medical directors believe that benchmarking, public reporting, and P4P can improve patient outcomes, but further work is needed on the development of risk-adjustment methods and outcome measures in order to improve comparability between hospitals and hospital systems.