To Bring Consumers to the Table, Simplify the Review

In the past decade, a significant push has been made for more transparencyinqualityreporting, includingmanynewtransparencyprovisionsinthePatientProtectionandAffordableCareAct, alsoknownas“Obamacare.” It ishardtoarguewiththeconcept. Transparencyworks in other fields. For example, after LosAngelesCountyrequiredrestaurants to publicly display a letter-grade card in their front windowswith anA,B,orC,correspondingtothe results of their latesthealth inspection, the countywitnesseda 20%dropinhospitalizations for food-related illnesses.1Thedramatic improvementwas attributed to a change in the behavior of restaurant owners andoperators, aswell as their customers. Public reporting provided a strong incentive for restaurant operators tomake actual improvements in hygiene—less than an Agradewasseenasadisasterforbusiness.Consumerswerelikely also votingwith their feet—decreasing their selectionof lowerrankingrestaurants.Changes inthequalityof thesupplyandthe quantity of the demand achieved a dramatic outcome. Does thisphenomenontranslate tohealthcare? It is easy to arguethatrestaurantsarenothospitals—thatsimplifyingthequalityofacomplexplacesuchasahospital,whichtreats thousands of patients for hundreds of different conditions, cannot bedistilled intoa single letter grade.But researchhas shownthat the samepublic reporting pressure that leads restaurant operators tocleangrillsandbetterregulatethetemperatureoffoodwillalso motivate hospital staff towashhands andprescribe timely antibiotics, tworelativelyeasy interventions thatcansignificantly dampenthespreadofdangerousinfections.2Whatwasmeasured wasindeedbeingmanaged.Similarpatternsareemergingamong physicians. A recent study by the Wisconsin Collaborative for HealthcareQuality,whichexaminedwhetherparticipatingphysician groups improved performance in the face of publicly reportedquality-of-caremeasures, is encouraging.3Most groups participatinginthecollaborativeeffortreportedinvestinginquality improvement projects in response to public reporting. So, it makes sense that the publicly reported comparisons of quality could help transform our health care system. Like the restaurant example, we can expect to see the same drivers of change, with both suppliers (providers of care) and customers (patients) influenced by the reports. Given reliable, easily obtained quality information, hypercompetitive providerswill improveperformance in thequest for anAgrade in their windows. And using the same information, consumers can vote with their feet, abandoning low-quality providers (and the equivalent of the C-graded diner). Theinterplayofthese2driversofchangeis important.Without the credible threat of consumerengagement, performance measurement is like the proverbial tree falling in an uninhabited forest. But theevidence that consumers actuallyusequality informationhas been thin.4Although someconsumers are willingtospendcountlesshoursresearchingprovidersandtreatments, they are a smallminority.Whenaskedwhy theydonot shop for care, oneof theprincipal reasons givenby consumers is that theavailable information isnot specific enough for their needs.5 Does itmatter how a hospital does on cardiac surgery when you are going in for hip replacement surgery? Apparently it does.Thearticle in this issuebyMcCrumand colleagues6examineswhetherperformanceonasmallsetofpublicly reportedmeasures ispredictiveofoverall hospital quality. Usinga largesampleofhospitals, theresearchers foundthathospitalsperforminginthetopquartileonthesetofpubliclyreported measureshad5 timesbetter oddsof alsobeing in the top set on more global measures of quality—specifically, overall risk-adjustedmortality.This isextremely important—wedonothaveto measureeveryaspectofquality toget a senseofoverall quality. The recent Institute ofMedicine consensus report,which oneofus (M.D.S.)washonored tochair,BestCareatLowerCost, included among its 10 recommendations the need for performance transparency.7 To be effective, such transparency requires the commitment of everyone who contributes to the health care transaction—health care delivery organizations, professional specialty societies, public andprivatepayers, and consumer and patient advocacy organizations. Knowing that we do not have to have an encyclopedic set of measures to achieve this goal brings us one step closer.