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Article Excerpt
Public reporting of quality information is a potentially powerful tool to improve health care quality. Moving quality information into the public domain may improve quality of care by giving consumers the information necessary to choose high-quality providers. Additionally, health care providers may respond to this information by improving the quality of care they provide. Because improving quality in this way is theoretically appealing and the potential for a positive effect on quality is substantial, public reporting is increasingly being adopted for hospitals, health plans, nursing homes, home health agencies, and physicians.
While public reporting has the potential to improve quality of care in areas that are being measured and reported, one potential limitation is the impossibility of measuring all the important aspects of care. By necessity, measures of clinical care are limited to what is measurable, and what is measurable is not always what is most important. The impact of quality improvement incentives on unreported care is unknown, and some policy makers and clinicians have expressed concern that there may be unintended and negative consequences to public reporting, including causing providers to focus their attention on measured aspects of care while neglecting unmeasured but important areas of care (Casalino 1999; Werner and Asch 2005).
Our objective is to examine the effect of publicly reporting quality information on unreported quality of care. We do this in the setting of Nursing Home Compare, a public reporting initiative launched by the Centers for Medicare and Medicaid Services (CMS) in 2002 to address quality deficits in nursing homes. Using clinical measures of quality, Nursing Home Compare publicly rates all Medicare- and Medicaid-certified nursing homes in the United States on the care they provide for short-stay and chronic-care residents. In this setting, we examine how unreported aspects of clinical care changed in response to public reporting of other aspects of care.
PRIOR EVIDENCE
Little prior work has examined the impact of performance measurement on unmeasured quality of care. One randomized, controlled trial (Mohide et al. 1988) examined the impact of a quality improvement intervention in nursing homes on areas of care that were not targeted by the intervention. The study found that while care for the targeted conditions improved, there was no change in the care for the nontargeted condition. More recently, Asch et al. (2004) examined the effects of performance measurement in the Veterans Health Administration (VHA) on targeted and nontargeted conditions. For areas of care that were targeted by performance measurement within the VHA, they found that patients from the VHA were more likely to receive recommended care than non-VHA patients. However, the difference in care between VHA and non-VHA patients in conditions that were not targeted by VHA performance measurement were smaller and barely reached statistical significance. Another recent study tested whether a quality improvement intervention changed nontargeted care for vulnerable elders in an ambulatory care setting (Ganz et al. 2007). This observational study of a practice redesign intervention found that while targeted care processes improved in the intervention practices compared with control practices, there was no change in the nontargeted care processes in either practice setting. Finally, one prior study has tested the effect of quality improvement incentives on targeted and nontargeted care, examining a hospital pay-for-performance program for acute myocardial infarction (Glickman et al. 2007). The study found that neither targeted nor nontargeted care processes significantly changed in response to pay-for-performance.
Our study contributes to this existing literature in two important ways. First, only one prior study has examined changes in nontargeted quality of care in the face of market-based quality improvement incentives (Glickman et al. 2007), but in finding no improvement in targeted measures, it provides little evidence of how nontargeted care changes when health care providers improve care in targeted areas. While other work has not found a significant change in nontargeted care, quality improvement from market-based incentives such as public reporting of quality may provide stronger incentives for improving targeted quality and therefore stronger potential for effects on nontargeted quality. Second, prior work has not directly correlated changes in targeted care to changes in nontargeted care within health care providers.
While others have answered the question, "Does nontargeted quality change on average?" in this study we ask the question, "Does nontargeted quality change in response to changes in targeted quality?"
METHODS
Conceptual Framework
Holmstrom and Milgrom's (1991) theory of multitasking predicts that measuring and rewarding quality in some areas may harm quality in other areas. This is specifically the case when quality is multidimensional and when quality improvement efforts target only some dimensions of quality.
In the setting of health care, market-based quality improvement incentives, such as public reporting and pay for performance, typically reward only a subset of all measures. In addition, some aspects of health care quality are difficult to measure. Thus, large segments of health care quality are currently unrewarded, and in some cases unmeasured. Because quality is multidimensional, multitasking theory predicts that providers will divert resources away from these unrewarded and unmeasured aspects of quality.
The degree to which rewarded and unrewarded measures evaluate the same dimension of care may predict whether unrewarded measures improve in response to improvements in rewarded measures. If rewarded and unrewarded quality measures are related to the same quality dimension, we may expect that efforts focused on improving quality tied to incentives will spill over to unrewarded areas, causing both to improve. Conversely, measures related to different quality dimensions may be more likely to diverge when incentives are related to only one measure, as focusing limited resources on rewarded care may crowd out unrewarded care.
The approach to quality improvement may also predict whether unrewarded care improve in response to improvements in rewarded areas. If improvements in quality are driven by structural changes, such as by hiring more professional nursing staff, we may expect both rewarded and unrewarded areas of care to improve (to the extent that both are related to nurse staffing). Alternatively, if improvements in quality are driven by targeted changes, such as changes in protocols and work organization, resources may be diverted away from unrewarded quality, resulting in worsening of unrewarded quality while rewarded quality improves.
Empirical Approach
We test the effect of public reporting on unrewarded care in the setting of public reporting of nursing home quality,...
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