Public Reporting Put to the Test
Public reporting initiatives have multiplied and expanded at the local, state and national levels to include virtually all acute care facilities, as well as many ambulatory clinics. Stakeholders have had time to develop quality measure sets and work out the logistics of reporting. Meanwhile, the proliferation of EHRs resulting from federal incentives for adoption has made public reporting more viable than a decade ago. These initiatives encourage participation in quality improvement activities, but they still need to prove they are influencing actual improvements in quality.
Public reporting initiatives are past the "proof-of-concept" phase, according to Robert Wachter, MD, chief of medical service and hospital medicine at the University of California San Francisco (UCSF) Medical Center. Since the Joint Commission launched the first national public reporting initiative in 1997, the trend toward transparency has only quickened. "This is the way the world is going; the idea that data would be sequestered is gone," he says.
Mandating public reporting would have been unimaginable 20 years ago, when the healthcare system lagged even further than it does today behind other industries in the use of technology. "There was no way you could create a marketplace around quality that depends on robust measurement when you had to pick up a physical chart and plow through it to abstract it," Wachter says. "Until we had a computerized scaffolding to do this, the sheer volume of work involved made it impractical."
Efforts to increase health IT adoption through legislation like the HITECH Act and to improve interoperability through bodies like the Certification Commission for Health Information Technology have expanded the possibilities for public reporting. Past programs have mostly been voluntary, but public reporting will be required as ongoing health reform initiatives aim to significantly change healthcare delivery.
The Centers for Medicare & Medicaid Services' (CMS) Physician Quality Reporting System (PQRS) has been voluntary since it was established in 2006 and providers currently receive financial rewards simply for participating. These rewards have been necessary just to incentivize reporting and make providers aware of evidence-based quality measures.
"Anytime there's a financial impetus in a certain direction, you'll see the curve bend in that direction," says Navy Cmdr. Kevin Jackson, OD, MPH, deputy commander for education, training and research at Fort Belvoir Community Hospital in Virginia.
CMS will soon trade its carrot for a stick. The Patient Protection and Affordable Care Act makes PQRS participation mandatory beginning in 2015, and CMS will start issuing lower Medicare payments to providers failing to report, in addition to paying more or less based on quality measures met.
Some research suggests that CMS' approach to providers with PQRS is appropriate. Making organizational changes to healthcare delivery systems requires significant investment from providers. Public reporting initiatives that reward incremental progress can encourage providers to make these changes manageable, one step at a time, according to Maureen A. Smith, MD, PhD, MPH, an associate professor at University of Wisconsin School of Medicine and Public Health in Madison.
A study of clinics associated with physician groups in the Wisconsin Collaborative for Healthcare Quality revealed that the group's public reporting initiative encouraged quality improvement activities. The study, published in the March issue of Health Affairs, focused on efforts to improve diabetes care between 2003 and 2008. Only 6 percent of the clinics studied failed to implement a diabetes care quality improvement intervention by 2005, with most clinics implementing a single intervention in the early years of care delivery redesign and more comprehensive, multi-pronged interventions in later years.
"This suggests that many organizations start out with baby steps," says Smith, the study's lead author. "Public reporting is a way to engage physicians in quality improvement, and it seems appropriate to recognize these efforts even though organizations may not achieve all performance targets in the first year or two."
While this research shows that public reporting initiatives can encourage providers to change the care they deliver to meet quality measures, the science of public reporting hasn't kept up with public reporting initiatives. Meeting existing quality measures may not necessarily result in improved quality from the patient's perspective. "There's a separate issue of whether or not quality measures for diabetes care capture outcomes that are most important to patients," Smith says.
Public reporting initiatives may have moved past the proof-of-concept phase, but there are still numerous concerns with their current configuration.
"Quality measures as they currently exist are spotty," Wachter says. "Some are reasonable reflections of the quality of care that we deliver, but some are wrong and others have unintended consequences."
Public reporting might unfairly indicate poor care by some providers and hospitals because quality measures inadequately adjust for the severity of patients' conditions, so those treating the sickest of the sick could be negatively impacted by mortality metrics, for instance. Individual providers also are more heavily affected than hospitals since there's less statistical variation in the number of patients they see. Additionally, quality measures assess adherence to evidence-based treatments, not whether accurate diagnoses are being made.
Time will tell whether participation in public reporting programs drives quality improvements, Jackson says. "As we get more data on providers complying with evidence-based practices, hopefully we'll be able to measure a resultant improvement, specifically in chronic disease treatment."
Technological limitations also pose a barrier to public reporting participation. EHRs don't have the capability to capture data electronically and transmit it with the ease that providers would like. Many healthcare organizations, including Wachter's own UCSF Medical Center, now are attempting to reverse engineer their EHRs to enable functionalities that would allow automatic capture and transmission of data required for public reporting. "The real bang for the buck here will be automation," Jackson says.
Despite the need to continue refining quality measures and reporting procedures, health reform efforts, especially adjustments to payment structures, will rely heavily on measurements of healthcare quality and cost. No one is denying that public reporting programs are here to stay.
"It's disruptive and challenging, but it's absolutely the right direction," Wachter says.
Moving Beyond Proof of Concept
Public reporting initiatives are past the "proof-of-concept" phase, according to Robert Wachter, MD, chief of medical service and hospital medicine at the University of California San Francisco (UCSF) Medical Center. Since the Joint Commission launched the first national public reporting initiative in 1997, the trend toward transparency has only quickened. "This is the way the world is going; the idea that data would be sequestered is gone," he says. Mandating public reporting would have been unimaginable 20 years ago, when the healthcare system lagged even further than it does today behind other industries in the use of technology. "There was no way you could create a marketplace around quality that depends on robust measurement when you had to pick up a physical chart and plow through it to abstract it," Wachter says. "Until we had a computerized scaffolding to do this, the sheer volume of work involved made it impractical."
Efforts to increase health IT adoption through legislation like the HITECH Act and to improve interoperability through bodies like the Certification Commission for Health Information Technology have expanded the possibilities for public reporting. Past programs have mostly been voluntary, but public reporting will be required as ongoing health reform initiatives aim to significantly change healthcare delivery.
The Centers for Medicare & Medicaid Services' (CMS) Physician Quality Reporting System (PQRS) has been voluntary since it was established in 2006 and providers currently receive financial rewards simply for participating. These rewards have been necessary just to incentivize reporting and make providers aware of evidence-based quality measures.
"Anytime there's a financial impetus in a certain direction, you'll see the curve bend in that direction," says Navy Cmdr. Kevin Jackson, OD, MPH, deputy commander for education, training and research at Fort Belvoir Community Hospital in Virginia.
CMS will soon trade its carrot for a stick. The Patient Protection and Affordable Care Act makes PQRS participation mandatory beginning in 2015, and CMS will start issuing lower Medicare payments to providers failing to report, in addition to paying more or less based on quality measures met.
'One step at a time'
Some research suggests that CMS' approach to providers with PQRS is appropriate. Making organizational changes to healthcare delivery systems requires significant investment from providers. Public reporting initiatives that reward incremental progress can encourage providers to make these changes manageable, one step at a time, according to Maureen A. Smith, MD, PhD, MPH, an associate professor at University of Wisconsin School of Medicine and Public Health in Madison. A study of clinics associated with physician groups in the Wisconsin Collaborative for Healthcare Quality revealed that the group's public reporting initiative encouraged quality improvement activities. The study, published in the March issue of Health Affairs, focused on efforts to improve diabetes care between 2003 and 2008. Only 6 percent of the clinics studied failed to implement a diabetes care quality improvement intervention by 2005, with most clinics implementing a single intervention in the early years of care delivery redesign and more comprehensive, multi-pronged interventions in later years.
"This suggests that many organizations start out with baby steps," says Smith, the study's lead author. "Public reporting is a way to engage physicians in quality improvement, and it seems appropriate to recognize these efforts even though organizations may not achieve all performance targets in the first year or two."
While this research shows that public reporting initiatives can encourage providers to change the care they deliver to meet quality measures, the science of public reporting hasn't kept up with public reporting initiatives. Meeting existing quality measures may not necessarily result in improved quality from the patient's perspective. "There's a separate issue of whether or not quality measures for diabetes care capture outcomes that are most important to patients," Smith says.
Public reporting problems
Public reporting initiatives may have moved past the proof-of-concept phase, but there are still numerous concerns with their current configuration. "Quality measures as they currently exist are spotty," Wachter says. "Some are reasonable reflections of the quality of care that we deliver, but some are wrong and others have unintended consequences."
Public reporting might unfairly indicate poor care by some providers and hospitals because quality measures inadequately adjust for the severity of patients' conditions, so those treating the sickest of the sick could be negatively impacted by mortality metrics, for instance. Individual providers also are more heavily affected than hospitals since there's less statistical variation in the number of patients they see. Additionally, quality measures assess adherence to evidence-based treatments, not whether accurate diagnoses are being made.
Time will tell whether participation in public reporting programs drives quality improvements, Jackson says. "As we get more data on providers complying with evidence-based practices, hopefully we'll be able to measure a resultant improvement, specifically in chronic disease treatment."
Technological limitations also pose a barrier to public reporting participation. EHRs don't have the capability to capture data electronically and transmit it with the ease that providers would like. Many healthcare organizations, including Wachter's own UCSF Medical Center, now are attempting to reverse engineer their EHRs to enable functionalities that would allow automatic capture and transmission of data required for public reporting. "The real bang for the buck here will be automation," Jackson says.
Despite the need to continue refining quality measures and reporting procedures, health reform efforts, especially adjustments to payment structures, will rely heavily on measurements of healthcare quality and cost. No one is denying that public reporting programs are here to stay.
"It's disruptive and challenging, but it's absolutely the right direction," Wachter says.