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Article Excerpt
Recent evidence about the poor quality of health care delivered in the United States (Kohn, Corrigan, and Donaldson 1999; Institute of Medicine 2001; McGlynn et al. 2003) has caused an outcry among health care consumers, providers, and policymakers. In an effort to improve quality of care, policymakers have mined to market-based reforms across the health care system. For example, the Centers for Medicare and Medicaid Services (CMS) have begun reporting health care quality through their websites, such as Nursing Home Compare, which publicly rates the performance of nursing homes on certain quality measures.
Public reporting is designed to improve health care quality in two ways. First, public reporting may motivate improvements in the quality of individual providers, increasing provider-specific quality of care. Second, public reporting may increase the likelihood that patients select high-quality providers, thus increasing the number of patients receiving high-quality care. If either of these effects is realized, quality of care will improve on average.
Because public reporting has tremendous face validity, it has been widely adopted in many health care settings (Fung et al. 2008). Yet there is mixed evidence on whether these efforts truly improve quality of care and, if quality does improve, the mechanism by which this occurs--provider-driven quality improvement efforts or consumer use of the information to choose high-quality providers (Werner and Asch 2005; Fung et al. 2008). In addition, there remains concern that observed improvements in quality under public reporting may not represent "true" quality improvement but, rather, are the result of providers selecting healthier patients under public reporting so that they appear to have improved quality outcomes (Werner and Asch 2005).
Our objective in this paper is to test whether public reporting in the setting of postacute care in skilled nursing facilities (SNFs) stimulates provider-driven quality improvement while controlling for changes in market share and changes in patients' health risk.
BACKGROUND AND PRIOR LITERATURE
Poor quality of care has been pervasive in nursing homes for decades (Institute of Medicine 1986). Major regulatory policies have been implemented to improve nursing home quality, including the 1987 Nursing Home Reform Act or the Omnibus Budget Reconciliation Act (OBRA), which mandated that each Medicare- and Medicaid-certified nursing home be regularly inspected and submit regular comprehensive assessments of each resident. While OBRA led to some quality improvements (Kane et al. 1993; Shorr, Fought, and Ray 1994; Castle, Fogel, and Mor 1996; Fries et al. 1997; Mor et al. 1997; Snowden and Roy-Byrne 1998), significant problems with quality of care remained (Wunderlich and Kohler 2000).
More recently, with regulation failing to fully reform nursing home quality, the persistent problems of inadequate quality have been attributed to the lack of information about quality with which to stimulate consumer choice of care and provider competition for high-quality care (Mor 2005). Accordingly, quality improvement efforts have increasingly turned to market-based incentives such as public reporting of quality information. In 2001, the Department of Health and Human Services announced the formation of the Nursing Home Quality Initiative, with a major goal of improving the information available to consumers on the quality of care at nursing homes. As part of this effort, on November 12, 2002, CMS released Nursing Home Compare (http://www.medicare.gov/NHcompare), a guide detailing quality of care at over 17,000 Medicare- or Medicaid-certified nursing homes (Centers for Medicare and Medicaid 2002). When Nursing Home Compare was launched, it included 10 quality measures, three of which were measures of quality for patients in postacute care (Centers for Medicare and Medicaid 2002; Harris and Clauser 2002). For the postacute care measures, small SNFs, with fewer than 20 patients over 6 months who qualify for the denominator of a quality measure, are excluded from Nursing Home Compare.
Studies of the effect of public reporting in nursing homes have thus far been mixed. Upon the release of Nursing Home Compare, Zinn et al. (2005) used data published on the Nursing Home Compare website to descriptively examine whether trends in the published quality measures improved in the postpublication period. They found that while 9 out of 10 published measures had statistically significant trends toward improvement, only pain control, use of physical restraints, and rates of delirium seemed to exhibit clear and clinically meaningful trends toward improvement. However, because the study used publicly reported data, it was unable to compare postpublication trends with preexisting trends and, thus, attribution of these trends to Nursing Home Compare was not possible. Similarly, work by Castle, Engberg, and Liu (2007) examined published nursing home quality measures in the post-Nursing Home Compare period with mixed results. A more recent study by Mukamel et al. (2008) overcame the limitation of only examining the post-Nursing Home Compare period by reconstructing the quality measures during the period both before and after the launch of Nursing Home Compare. They examined changes in trends of a subset of quality measures among a small group of nursing homes and found that two quality measures (physical restraint use and pain control) improved after the launch of Nursing Home Compare. However, without a concurrent control group, it is difficult to attribute these changes to Nursing Home Compare. In addition, as with most studies of public reporting, it is unknown whether observed improvements are associated with improvements in quality of care more broadly and to what extent observed improvements in quality measures were due to changes in patient case mix.
Our work adds significantly to the existing evidence of response to Nursing Home Compare, and to the public reporting literature more generally. First, we explicitly examine within-SNF or SNF-specific changes in quality (versus changes in market share). Second, we use a difference-in-differences framework to compare trends in quality before and after Nursing Home Compare was launched and control for secular trends using a group of small SNFs not included in Nursing Home Compare. Finally, we also employ a broad measure of quality in addition to the individual reported measures, enabling us to examine whether improvement on Nursing Home Compare measures translated into broader improvements in quality of care for postacute care patients. Because the release of Nursing Home Compare may cause SNFs to select patients based on clinical characteristics, we also control for this changing pool of patients using propensity score matching. Thus, our estimates of the quality impact of Nursing Home Compare can be more definitively attributed to true improvements in quality rather than the result of a changing group of patients.
METHODS
We limit our analyses to quality of postacute (rather than long-term) care because the higher turnover rates and younger and less cognitively impaired residents in postacute care make it more likely to find...
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