Quality

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Does Public Reporting Affect Patient Behavior?

May 7, 2012 in Nursing Home, Nursing Homes, Quality | No comments

A number of studies have already examined this question.

  • Baker et al. (2003) examined the effectiveness of a public reporting effort in hospitals in Ohio, finding little relationship between a hospital’s report card ranking and changes in its market share.
  • Cutler et al. (2004) examined the effects of reporting quality information about cardiac surgery on hospital volume, finding that being identified as a high-mortality hospital was associated with a decline in the number of cardiac surgery patients at that hospital in the period following the designation.
  • Dafny and Dranove (2008) examine the influence of Medicare HMO report cards…showing that highly ranked plans were gaining market share prior to the report cards’ release but that the report cards led to further gains in market share for high-scoring plans.
  • Chernew et al. (2008) use a Bayesian learning model to estimate enrollees’ general assessment of plan quality prior to the release of report cards and the changes in these assessments over time. They find that the addition of publicly reported plan information has a small incremental effect.

A more recent study by Werner et al. (2012) examines whether Medicare’s Nursing Home Compare website affects consumer decisions. Nursing Home Compare evaluates nursing homes using a variety of factors including: 1) whether they passed inspections, 2) structural measures such as staffing ratios, 3) quality measures reported on MDS assessments.

The authors find “a very small (though statistically significant) demand response to public reporting.”  Skilled nursing facility (SNF) market share experienced a 0.1% increase in market share in cases where the facility increased its reported quality of treating patient pain from the 25th percentile SNF to the 75th percentile SNF.

Werner et al. note that this small economic response implies that SNFs are unlikely to invest in quality improvement since improving quality will not increase market share and improve profits.

One shortcoming of the study is that it only focuses on SNFs.  Since Medicare uses SNFs for shorter term post-acute care, the study cannot identify changing consumer responses for long-term nursing stays.  Because the time the patient spends in long-term nursing homes is typically much longer than SNFs and because patients typically have more time to review their long-term nursing home options than would be the case when they enter SNFs, it is more likely that a consumer response would be observed in the long-term nursing home setting.

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Medicare Spending per Beneficiary

April 30, 2012 in Hospitals, Medicaid/Medicare, Medicare, My Papers, P4P, Quality | 1 comment

Medicare’s Hospital Compare website evaluates hospital quality.  One of the most recent measures to be added to Hospital Compare is a measure of efficiency.  The measure calculates a price-standardized, case-mix adjusted measure of spending during period before, during and after a hospital admission. The Healthcare Economist (Jason Shafrin) and a team at Acumen (including Tom MaCurdy, Sajid Zaidi, Elen Shrestha, and David Pham) worked closely with CMS to develop this measure.  Additional information on this measure is available here or see the results for San Francisco General Hospital here.

“The Spending per Hospital Patient with Medicare measure shows whether Medicare spends more, less, or about the same per Medicare patient treated in a specific hospital, compared to how much Medicare spends per patient nationally. This measure includes any Medicare Part A and Part B payments made for services provided to a patient during the 3 days prior to the hospital stay, during the stay, and during the 30 days after discharge from the hospital.

This result is a ratio calculated by dividing the amount Medicare spends per patient for an episode of care initiated at this hospital by the median (or middle) amount Medicare spent per patient nationally.

A result of 1 means that Medicare spends ABOUT THE SAME amount per patient for an episode of care initiated at this hospital as it does per hospital patient nationally.

A result that is more than 1 means that Medicare spends MORE per patient for an episode of care initiated at this hospital than it does per hospital patient nationally.

A result that is less than 1 means that Medicare spends LESS per patient for an episode of care initiated at this hospital than it does per hospital patient nationally.

Lower numbers are better.“

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Why are there no doctor reviews on the web?

March 19, 2012 in Quality | No comments

The N.Y. Times has an interesting article citing a number of reasons why there are no good websites with doctors reviews on the web.  There are some ratings websites (HealthGrades, RateMDs, Angie’s List, Yelp), but the listings are often sparse, with few contributors and little of substance.)

For one, physicians don’t like them.

“Several years ago, a physician reputation management service called Medical Justice developed a sort of liability vaccine. Doctors would ask patients to sign an agreement promising not to post about the doctor online; in exchange, patients would get additional privacy protections.

…when I shared my feelings with the company, I was informed that the agreements had outlived their usefulness. What neither its vice president of marketing, Shane Stadler, nor its founder and chief executive, Jeffrey Segal, told me, however, was that the company had retired the agreements in the wake of a lawsuit related to them and a complaint filed with the Federal Trade Commission.”

The American Medical Association (AMA), unsurprisingly, stands behind the doctors.  A statement from AMA president, Dr. Peter W. Carmel stated,

“Anonymous online opinions of physicians should be taken with grain of salt and should not be a patient’s sole source of information when looking for a new physician.”

Dr. Carmel followed up by saying:

“To advise people anonymously through an open site when this is an important decision for people’s lives, I don’t think it’s proper.  The evidence that’s given on many of these consumer sites is undocumented, unverified and anonymous. It may well have nothing to do with actual patient treatment.”

Another reason there are so few reviews are that people do not want to offend their doctor.  They are worried that if their physician reads a poor review from a patient, they may provide inferior care to the patient.  Further, “if they live in a small town or are only one or two degrees of social separation from physicians or their family members, they may not want to create any awkwardness.”

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Patient Centered Medical Home: Is your doctor ready?

January 17, 2012 in Medical Home, Quality, Supply of Medical Services | 1 comment

The answer is probably not.  The NCQA defines 149 factors which would make a practice a successful medical home.  These include physician access during and after office hours, electronic access to patients information, availability of clinical data and use of that data for population management, identification of high risk patients, ability to refer patients to available community resources, care coordinate, and quality measure tracking.

As recent Health Economics articles finds that almost half of physician practices fail to meet the NCQA’s medical home standards.  Specifically,

“Forty-six percent…of all practices lack sufficient medical home infrastructure. While 72.3 percent…of multi-specialty groups would achieve recognition, only 49.8 percent…of solo/partnership practices meet NCQA standards. Although better prepared than specialists, 40 percent of primary care practices would not qualify as a medical home under present criteria.”

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California Health Care Almanac

December 23, 2011 in HC Statistics, Quality | No comments

The California Health Care Foundation (CHCF)’s Health Care Almanac provides some unique insights on trends in health care quality in California and for the United States as a whole.  Many of the national figures for the Almanac come from the CDC (BRFSS and Vital Stats) and AHRQ’s National Healthcare Quality Report.  California quality figures come from the California Department of Public Health, the Office of Statewide Health Planning and Development and the California Health Interview Survey.

Although not discussed in this post, another portion of the Health Care Almanac looks at quality by site of service.  Much of this data comes from Hospital Compare, CMS OASIS data, AHRQ’s National Healthcare Quality Report, and the Dartmouth Atlas.

Today I highlight 3 topics related to clinical quality:

  • Cesarean Deliveries
  • Infant Mortality
  • Cancer Incidence.

More detail is below.

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Inpatient Rehabilitation Facility’s Quality Reporting Program

November 23, 2011 in Medicare, Quality, Rehabilitation | No comments

Medicare’s push to evaluate all types of providers is being extended to Inpatient Rehabilitation Hospitals (IRFs).  According to Health Reform bill (specifically, Section 3004 of the Affordable Care Act), CMS is required to start publishing quality measures for IRFs by October 1, 2012. This newly created IRF Quality Reporting Program (QRP) currently has proposed two measures.  These include the following:

  • Presentation of Urinary Catheter-Associated Urinary Tract Infections (CAUTI)
  • Presentation of Percent of Residents with Pressure Ulcers that Are New or Have Worsened

CMS will hold an Open Door Forum on Tuesday, November 29, 2011, 2pm-4pm ET to discuss these measures.  It is disappointing that CMS only has two quality measures for the IRF program.  Thus, the QRP is far less comprehensive then Health Reform intendend.  Hopefully, the number of quality measures increases over time.  The Healthcare Economist does realize, however, that rehabilitation services are much harder to evaluate than more procedure based services with more observable outcomes.  Specifically, improvement in patient functioning is a key measure for IRFs.  However, if the IRFs themselves self-report this data, the quality measures will not be unbiased.  I am assuming that the data for the IRF QRP come from the IRF Patient Assessment Instrument (PAI), and thus the quality data will be self-reported by the IRFs themselves.  Here is the form used by IRFs as part of the PAI.

One problem with any quality system is cases where the provider fails to report the quality data.  In the QRP, however, IRFs will have a strong financial incentive to report these measures.  Specifically, if an IRF fails to report their quality measures, Medicare will reduce their payments by 2 percentage points.

 

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Medicare to Hospitals: The Patient is Always Right

November 10, 2011 in Health Reform, Hospitals, Medicaid/Medicare, Medicare, P4P, Quality | 4 comments

Starting in fiscal year 2014, Medicare will start rewarding hospitals with high quality care and penalizing hospitals with low quality care.  The rewards and penalties will be financial in nature. High-quality hospitals will receive a bonus and low-quality hospitals will receive a financial penalty.  There is a lot of existing documentation on this hospital value-based purchasing (HVBP) program such as:

One component of the HVBP is patient satisfaction.  Some policy experts believe that patient satisfaction is of the utmost importance.  If Medicare evaluates hospitals based on patient satisfaction, then hospitals will compete to improve how well patients are satisfied. A New York Times article already mentions some of the efforts hospitals are undertaking to improve patient satisfaction.  For example,

  • Improving the quality of food
  • Renovating units
  • Creating more single units (compared to shared units)
  • Having nurses visit rooms hourly
  • Creating scripts for doctor-patient and nurse-patient interactions
  • Quicker response time ["Jefferson Regional Medical Center in Pittsburgh expects all employees, from maintenance workers to doctors, to respond to a patient’s call light or find someone to offer assistance."]
  • Building more elevators.

Elevators!?!?!  It turns out that “NYU found that long waits at its elevators drove down its scores, so now it is building a new bank of elevators.”

Hospitals complain, however, that they may only have a limited ability to influence ratings.  This is certainly true in some cases. For instance, patient expectations of the standard of care they receive may vary regionally.  For example,

“…some of the nation’s most prestigious hospitals, including Cedars-Sinai Medical Center in Los Angeles and the University of Chicago Medical Center, get lower marks from patients on most areas of patient experiences, according to the government’s Hospital Compare Web site.

So do many of New York City’s elite institutions…Some hospitals, like NYU, get bad patient reviews even as they score average or superior in measures of clinical care from the government and accreditation groups.

‘People in New York have very high expectations about what it means to be taken care of,’ said Dr. Katherine Hochman, an NYU physician. ‘When they don’t get their food on time and have to spend eight hours in the emergency department, well, that’s just not their image of what a world-class institution is.’”

Further, many providers believe that indigent patients give physicians lower quality scores even though these patients receive the same care as do richer patients.  Hospitals with more Medicaid-eligible patients could receive lower patient satisfaction scores due to case mix alone rather than due to actual quality.

To account for these confounding factors, Medicare can institute a risk adjustment mechanism.  By including patient income (or Medicaid) status in their model, however, Medicare would implicitly be allowing hospitals to provide a lower standard of care to the poor. Alternatively, if the poor do in fact give lower satisfaction scores, than hospitals may have an incentive to avoid these patients.

Similarly, including regional indicators in the risk adjustment model can also be problematic.  If New Yorkers have higher standards than individuals from Iowa, then one may want to normalize performance regional.  If CMS adopts this specifications, hospitals in essence would only be compared against their local peers.  Areas which have consistently below average care–in terms of patient satisfaction–may not be punished if they are the ‘best of the worst’ in their area.

Although patient satisfaction is not always correlated with high quality medical care, paying hospitals more for care that meets their patients’ needs does seem to be a sensible solution.

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Does getting cancer incentivize individuals to switch from Medicare managed care to FFS?

November 8, 2011 in Cancer, Medicaid/Medicare, Medicare Advantage, Quality | No comments

Medicare beneficiaries have a choice: pick the standard Medicare fee-for-service (FFS) benefit or rely on managed care plans to supply their healthcare through the Medicare Advantage (MA) program.  Many Medicare beneficiaries prefer MA because it offers them lower out-of-pocket costs and provide benefits not available in the traditional FFS Medicare program. Other beneficiaries prefer the FFS benefit because MA plans typically restrict provider choice in an effort to control costs.

The quality of care in Medicare MA relative to FFS, however, has still not yet been consistently evaluated.  Because beneficiaries can switch from MA to FFS each year, if quality is low, healthy individuals may prefer MA to reap the reduced cost sharing benefits, but when they become sick they may switch to Medicare FFS.

A study by Elkin and co-authors evaluates whether or not this is the case for beneficiaries who get cancer.

Data and Methodology

“We identified Medicare managed care enrollees aged 65 years or older who were diagnosed with a first primary breast (n = 28 331), colorectal (n = 26 494), prostate (n = 29 046), or lung (n = 31 243) cancer from January 1, 1995, through December 31, 2002, in Surveillance, Epidemiology, and End Results (SEER) cancer registry records linked with Medicare enrollment files. Cancer patients were pair-matched to cancer-free enrollees by age, sex, race, and geographic location. We estimated rates of voluntary disenrollment to fee-for-service Medicare in the 2 years after each cancer patient ’ s diagnosis, adjusted for plan characteristics and Medicare managed care penetration, by use of Cox proportional hazards regression.”

Results

The authors find that MA beneficiaries with cancer are less likely to switch to FFS than a cancer-free beneficiary. The hazard ratios range from 0.78 for colorectal cancer to 0.86 for prostate cancer. The results were consistent across various age, sex, race, cancer stage and region strata.

The likely reason for this finding is that people who have a serious disease do not want to change coverage. Even if the FFS benefit offers improved access to better care, there are significant costs of switching coverage. The new FFS providers may have less knowledge of the individual beneficiary’s health condition and the change can be stressful for the beneficiary as well. A worthwhile analysis to confirm whether this is the case would be to examine whether FFS beneficiaries who contract cancer are more likely to switch to a MA plan after contracting cancer. If the transaction cost/care coordination is driving Elkin’s results, then FFS beneficiaries with cancer should also be less likely to switch to MA than cancer-free FFS beneficiaries.

It could also be the case that MA provides high quality care for the most prevalent cancers (i.e., prostate, lung, colorectal, and breast), but there is a significant improvement in quality when beneficiaries visit FFS providers when they have rarer diseases. To confirm whether or not this is the case, the authors examine whether beneficiaries with non-Hodgkin lymphoma, acute leukemia, and soft tissue sarcoma are more likely to switch to FFS. The authors found no effect of these cancer diagnoses on the likelihood of disenrollment from a managed care plan.

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Why don’t patients care about quality?

October 10, 2011 in Nursing Homes, Quality | 6 comments

For nursing homes at least, patients do not seem to have much choice.  According to an article by Grabowski and Town:

The introduction of the NHQI was generally unrelated to facility quality and consumer demand. However, nursing homes facing greater competition improved their quality more than facilities in less competitive markets…The lack of competition in many nursing home markets may help to explain why the NHQI report card effort had a minimal effect on nursing home quality. With the introduction of market-based reforms such as report cards, this result suggests policy makers must also consider market structure in efforts to improve nursing home performance.

In general, there are many reasons why patients do not respond to provider report cards.  It could be the case that the provider is a monopoly, and thus the patient has little choice of providers.  Alternatively, patients may not be aware of the quality metrics.  One would thing that high quality providers, however, would spend money advertising their high quality ratings to make patients aware of their services.  In other cases, the patients may not be the ones directing care choices.  Providers may be the ones who are the de facto selectors of care.

Patients could also not believe that the CMS quality ratings are very useful.  They may prefer other sources of information on medical quality such as their friends, relatives, or physicians.  Thus, it may be the physician who actually chooses to which nursing home the patient will go.  If the physician has incentives to sent the beneficiary to nursing homes in the network or simply does not wish to spend the time analyzing nursing home quality, then patients may be less likely to be allocated to high quality nursing home.

 

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Healthcare Cost and Utilization Project Databases

August 15, 2011 in Data | 1 comment

The Agency for Healthcare Research and Quality’s (AHRQ)  Healthcare Cost and Utilization Project (HCUP) is a family of databases and tools intended to improve the quality, safety, efficiency, and effectiveness of the U.S.   health care system.  HCUP results from Federal-State-Industry partnership to build a comprehensive all payer data system.  A summary of the databases available from HCUP can be found here.  A summary is also provided in the table below.

Abbreviation

 File Description States Participating

Available From:
SID State Inpatient Databases Data on 95 percent of community hospital discharges 44 1990
SASD State Ambulatory Surgery Databases Ambulatory surgical center data (hospital and free-standing) 29 1997
SEDD State Emergency Department Databases ED visits that do not result in hospitalization 29 1999
NIS Nationwide Inpatient Sample All-payer inpatient care database. A 20% stratified sample of U.S. community hospitals. varies by year 1988
NEDS National Emergency Department Sample All-payer inpatient ED database. A 20% stratified sample of U.S. community hospitals. 2006
KID Kids’ Inpatient Database All-payer inpatient database for children.  Contains 3 million discharges form 3,500 community hospitals. 1997

 

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