Public reporting and pay-for-performance programs in perioperative medicine
ABSTRACT
Public reporting and pay-for-performance reimbursement are two strategies designed to stimulate hospital quality improvement. Information about the quality of hospital care (including surgical volumes and staffing, process-based measures, and mortality and other outcomes) is compiled on various Web sites, giving the public means to compare providers. While public reporting has been shown to foster quality-improvement activities by hospitals, its effects on clinical outcomes are less certain. Likewise, consumers’ awareness and use of publicly available hospital and provider quality data have been low but appear to be increasing.
KEY POINTS
- Public reporting programs have expanded in recent years, driven by national policy imperatives to improve safety, increased demands for transparency, patient “consumerism,” and the growth of information technology.
- Hospital-based pay-for-performance programs have had only a minor impact on quality so far, possibly because financial incentives have been small and much of the programs’ potential benefit may be preempted by existing public reporting efforts.
- These programs have considerable potential to accelerate improvement in quality but are limited by a need for more-nuanced process measures and better risk-adjustment methods.
- These programs may lead to unintended consequences such as misuse or overuse of measured services, “cherry-picking” of low-risk patients, or misclassification of providers.
- Continued growth of the Internet and social-networking sites will likely enhance and change the way patients use and share information about the quality of health care.
DISCUSSION
Question from the audience: I’m concerned about what seems to be a unilateral effort to improve quality. There are many components of health care delivery beyond those you’ve described, including the efforts of patients, insurers, employers, and the government. The reality is that patients don’t plan for illness, insurance companies often deny care, more and more employers are providing less coverage or no coverage, and Medicare is on the road to insolvency. Is the battle for quality winnable when all these other components of delivery are failing?
Dr. Lindenauer: You make good points. But from the standpoint of professionalism, I think we have a compelling duty to constantly strive to improve the quality of care in our hospitals and practices. I have presented strategies for potentially accelerating improvements that providers are trying to make anyway. Public reporting and financial incentives are likely to be with us for a while, and their use is likely to grow. But as you said, they address only part of the problem confronting American health care.
Question from the audience: For the savvy health care consumer, is there one particular Web site for hospital or provider comparisons that you would especially recommend? Do you actually recommend using such Web sites to patients before they undergo certain procedures?
Dr. Lindenauer: I think the Hospital Compare site from the Department of Health and Human Services is the key Web site. The California Hospital Assessment and Reporting Taskforce (CHART) has a good site, and the Commonwealth Fund’s WhyNotTheBest.org is an interesting newcomer.
However, even the most ardent advocates for public reporting wouldn’t say the information available today is sufficient for making decisions. There’s still an important role for getting recommendations from other doctors who are familiar with local hospitals and providers.
I’m optimistic that the changes that are coming to these Web sites will provide a better user experience and make it harder to ignore the results of public reporting. Today we can say, “Hospital A is better at discharge instructions or smoking cessation counseling.” But we all can appreciate how weak those kinds of measures are because their implementation is subject to local interpretations. Once risk-adjusted outcomes and more-meaningful process measures are available, I’d be surprised if more patients weren’t willing to base their decisions on published comparisons.
