Report cards for hospitals

There has been increasing interest in public reporting of hospital and individual physician performance. Currently, most of these public reports have been utilized by payers and referring physicians, but they will ultimately be tied to reimbursement and payment schedules with the goal of improving overall quality of care. However, providers have expressed opposition and reluctance to participate as these performance metrics begin to expand across all aspects of medicine. A recent article attempted to identify specific concerns regarding public reporting and possible solutions that will improve acceptance among surgeons.

Information was gathered via surveys and interviews to gain insight on the perception of public reporting from 185 board-certified surgeons from all sub-specialties at Northwestern University and its affiliated hospitals. Overall, most participants were in favor of aggregate hospital reporting, but were not as supportive of individual reporting. Concerns centered on patients’ difficulty interpreting data, surgeons refusing high-risk patients, and the lack of validated quality outcome metrics.

Other concerns included shifting high-risk patients to safety-net hospitals, inadequate risk adjustment, concern for appropriate procedures and outcome metrics, and medical-legal ramifications. Despite these concerns, 75% and 73% of surgeons surveyed believed that neither aggregate nor individual reports, respectively, would change their practice. This indicates that there would be little if any impetus for improvement in the delivery of care. A majority of surgeons (57%) believed that reporting aggregate hospital outcomes would improve clinical outcomes, in contrast to 64% who believed that reporting individual surgeon’s outcomes would not improve care (p<0.01).

Commentary

Quality metrics carry unintended consequences: Surgeons may attempt to protect and improve their outcomes numbers instead of actually improving quality by turning patients away whose cases are deemed as too risky.

High-risk patients may be funneled into safety-net hospitals. As a result, these facilities will see increasing numbers in high-risk procedures and high-risk patients, potentially worsening their aggregate outcomes. This could lead to further decreases in reimbursements for safety-net hospitals and could result in closure of facilities or service lines. Inevitably, access to care for vulnerable populations might worsen.

Policy makers should instead focus on methodological and implementation issues central to both hospital-level and individual-level public reporting. Consideration for practitioners’ perceptions of reporting as well as the workload capacity of each hospital or facility would alleviate reluctant attitudes towards participation. Changes to a comprehensive risk adjustment or stratification process should be considered as well as an internal review process. This would improve the quality of data reported and create a sense of accountability for those responsible for maintaining metrics.

Sherman, KL et al. Medical Care. 2013; 51 (12): 1069 – 1075.

by

Ellana Stinson, MD