Hospital Quality Report Cards: Ready for Prime Time?
Thomas Jefferson University Health Policy Newsletter, December, 2005
By SUSAN WYNNE and RICHARD WELLS
For generations, hospital administrators and doctors have closely guarded information about hospital outcomes and physician effectiveness, if they measured them at all. Sharing this Information with the public would be unheard of. Patients were expected to do what they were told and not ask questions. In the absence of other sources, patients came to rely almost completely upon physician recommendation or word-of-mouth from friends and family when choosing options for care. Lacking hard data on clinical outcomes or safety, most patients would chose doctors or hospitals based on bedside manner, or the friendliness of staff, or a vague sense of a doctor's or hospital's reputation.
The shift in this paradigm — only now gathering steam — began just over a decade ago. When a few states (Pennsylvania, for one) began to collect and publish outcome data for doctors and hospitals, and popular media such as US News & World Report started publishing "top hospital" listings.
Since that early trickle of hard data, however, a confluence of factors have gathered force and created an increasing stream of hospital and doctor effectiveness data now available to any patient. Aging, health-conscious Baby Boomers, the Internet, concerns over safety and cost, and a growing public expectation for "transparency" from businesses and institutions have made hospital and physician quality report cards a growth industry.
Google the phrase "healthcare quality report cards" and more than 1.5 million references appear. In addition to US News & World Report, one can visit the Leapfrog Group, HealthGrades®, Consumer Checkbook, Select Quality Care, and the federal government's Hospital Compare site, just to name a few. Almost every one of these programs touts the value of creating better-informed patients who will make better decisions about purchasing healthcare, which will lead to lower costs and better clinical outcomes. "Our goal is to educate and empower members to make informed and appropriate healthcare decisions and engage in practices that support the development of their prevention and treatment plans," stated one health insurance executive, describing the quality data on physicians and hospitals now available to subscribers.1
Given their growth and the increasing attention they receive from hospital administrators, doctors, payors, and politicians, it is reasonable to ask: does public reporting of quality data change patient behavior about hospital and doctor selection? The short-term answer: not yet. The long-term answer: maybe.
Our own research among who use Main Line Health hospitals has consistently shown that—even after a decade of hospital report cards—word-of-mouth remains by far the most popular and important source of information for patients choosing a hospital. This includes recommendations from the patient's physician.
Main Line Health's findings are consistent nationally. In a 2004 survey by the Kaiser Family Foundation, 65 percent of respondents listed word of mouth as their likeliest source of information, while 76 percent said the convenience of the hospital's or doctor's location would influence their choice "a lot." To be sure, some healthcare consumers are very interested in and influenced quality data (up to 18 percent, according to a study by Solucient.2 Nevertheless, while the number of consumers who report seeing this kind of information has increased, seeing this kind information increased, "vast majority are still not using quality using information to make health care decisions."3
Why does information that seems so powerful to payors and regulators, have so little influence on most consumers'? For one thing, health report cards are seeking to change behaviors that have been engrained in the public for over a century. These attitudes will not change quickly.
More problematic is that consumers lack the medical vocabulary to understand much of the information presented in quality report cards. Hospital Compare, the Medicare quality web site, for example, lists as one of its quality measures "Percent of Heart Attack Patients Given ACE Inhibitor for Left Ventricular Systolic Dysfunction (LVSD)."4 Most patients have no idea what an ACE Inhibitor is, what LVSD is, or that the latter requires the former.
When the Kaiser survey asked respondents to list what is most important to them in defining healthcare quality, only two percent identified "patient outcome." Almost a quarter (23%) said they did not know, while 14 percent (the next highest result) listed cost and affordability.
Another impediment to the effectiveness of report cards is the sheer number of health issues for which patients turn to doctors and hospitals for care. Medicare alone lists more than 500 different diagnostic related groups, which only begins to hint at the number and variety of diseases and injuries to which patients are subject.5 A hospital may score well in treating heart disease, but that might not mean much to the patient with cancer or in need of a hip replacement, to say nothing of the patient suffering from some obscure disorder. Report cards will not be fully effective until they can find a way to be more comprehensive, in a way that patients and the public can readily understand.
Even with a decade or more behind them, healthcare report cards are still in their infancy, as IS public awareness of and appreciation for the data. We anticipate in the coming years that quality ratings and rankings will become better understood and more widely accepted by patients. Reporting agencies will continue to refine their analyses and the public should become more sophisticated and comfortable using report card information in the decision making process. Word-of-mouth will remain powerful, but rather than neighbors trading, stories about the doctor with the great bedside manner or the hospital with the great nurse, they may also swap mortality rates, error rates, and costs. Whether this shift will actually lead to greater efficiency and lower costs, as some predict, at this point is unknown.
- I. Steven Udvarhelyi, MD, senior vice president and chief medical officer, quoted in the Independence Blue Cross Update newsletter, Summer 2005.
- National Trends in Healthcare Consumerism. Solucient study, 2004.
- National Survey on Consumers' Experiences With Patient Safety and Quality Information. The Kaiser Family Foundation/Agency for Healthcare Research and Quality/Harvard School of Public Health, November 2004.
- www.hospitalcompare.hhs.gov
- www.cms.hhs.gov