Publication of quality report cards and trends in reported quality measures in nursing homes.

Quality report cards have become a major component of initiatives to enhance the quality of the American health care system. In addition to numerous private and state report cards, the Centers for Medicare and Medicaid Services (CMS) now provides web-based reports on the quality of health maintenance organizations (HMOs), nursing homes, home health agencies, hospitals, and renal dialysis clinics (CMS 2006). The motivation for publishing report cards is the expectation that making information about quality easily accessible to patients will increase the sensitivity of demand for quality, and thus generate positive incentives for providers to invest in quality improvement (Mukamel and Mushlin 2001). Some argue that even in the absence of a demand response to report cards, providers who receive information about their performance relative to their peers will be motivated to improve quality because of professional pride, or if these providers are a nonprofit organization, because of their organizational mission (Gormley and Weimer 1999; Hibbard, Stockard, and Tusler 2005; Robinowitz and Dudley 2006). Thus, the anticipated impact of report cards is three-fold: (1) changing consumers' choices—a demand response; (2) incenting providers to improve quality—a supply response; (3) improving overall quality levels—an equilibrium result. The last two could be subverted if some providers choose responses that improve their published scores, but do not actually improve quality. Such responses typically would include “cream skimming,” i.e., selecting patients who are less frail and sick and therefore likely to have better health outcomes, or deception, i.e., manipulating documentation of data used for report cards (Gormley and Weimer 1999). There is now a large body of empirical studies examining the demand response, with mixed conclusions (Marshall et al. 2000; Mukamel and Mushlin 2001; Schauffler and Mordavsky 2001; Dafny and Dravnove 2005; Werner and Asch 2005; Jin and Sorensen 2006). Some find no demand response and others find a statistically significant but relatively small response. Although there are important methodological reasons that may explain the inability of these studies to document a strong demand response even if it exists (Mukamel and Mushlin 2001; Mukamel, Weimer, and Mushlin 2007c), these studies do raise concerns that report cards may not generate sufficient incentives to motivate providers to offer higher quality. There is less direct empirical evidence about providers' responses. Several studies based on surveys or case studies find that report cards spurred providers to improve their scores through enhanced and targeted quality-improvement programs (Scanlon et al. 2001; Hibbard, Stockard, and Tusler 2003; Barr et al. 2006; Mukamel et al. 2007b), although there seems to be high variability in the efficiency of these efforts (Pham, Coughlan, and O'Malley 2006). These studies generally rely on self-reports and as such are susceptible to response bias that is likely to result in overly optimistic conclusions about providers responding favorably to report cards. A few studies have attempted to ascertain whether reports cards induced cream skimming. Physicians surveyed in Pennsylvania (Schneider and Epstein 1996) and in New York State (Narins et al. 2005), two states that publish physician-level risk-adjusted mortality scores for cardiac procedures, indicated that after report cards were introduced they were less likely to offer care to the most risky patients, because of concerns about the impact on their published scores. The findings about the impact of report cards on quality levels are also mixed. While mortality rates of CABG patients have declined more in New York than in other states, a decline attributed to the presence of report cards (Peterson et al. 1998), similar trends were found during the same period in Massachusetts (Ghali et al. 1997), a state without a report card, thus raising questions about the causal relationship between the publication of the report card and improved outcomes (Epstein 2006). Some have argued that the improved mortality outcomes in New York State might be due to cream skimming by hospitals and surgeons, rather than true improvement in care (Werner and Asch 2005), although other findings seem to contradict this explanation (Peterson et al. 1998). Evidence about the effectiveness of HEDIS, a quality report card for health plans, suggests that quality has improved since the report was first published (Lied and Sheingold 2001; Trivedi et al. 2005). However, these studies also only document improvement trends in reported measures, and therefore cannot eliminate other explanations for the improvements that may have occurred during the same period. More robust evidence is provided by Hibbard, Stockard, and Tusler (2005), who find that obstetric and cardiac hospital outcomes have improved more for hospitals who participated in a public report card than those in a control group that did not. Moreover, they find more improvement among those who had poor scores in the report. In this study, we provide evidence regarding the impact of the Nursing Home Compare report card published by CMS since 2002. We focus on the question of whether quality of care has improved following publication of the report. We hypothesize that the report card creates several incentives for nursing homes to take actions to improve quality (Zinn et al. 2008; Mukamel et al. 2007b). First, nursing homes may anticipate that their customers, either patients and their families or their agents (physicians and social workers), will pay attention to reported quality and will, therefore, expect shifts in demand toward the better scoring facilities. This creates incentives to undertake investments in quality improvement. Second, nursing homes may anticipate that state quality regulators will use the reports to identify areas for special attention in their annual inspection of the facility, and may therefore take action to prevent deficiencies. Third, facilities, in particular nonprofit nursing homes that regard provision of high-quality care as an important component of the organizational mission, may use the information in the report to guide quality improvement initiatives. Thus, we expect that following the Nursing Home Compare publication nursing homes have undertaken actions aimed at improving quality, and to the degree that these efforts have been successful, we would expect improvement in the quality measured and reported in the report card relative to the prereport card period. Specifically, we examine changes in five quality measures (QMs), comparing them in the period before publication of the report card to the period following. To guard against the possibility of incorrectly attributing secular changes in the QMs to the publication of the report card, we examine the changes observed for the postreport period in relation to specific actions reported by nursing homes as taken in response to publication. This addresses the limitations of prior studies that failed to rule out alternative contemporaneous events as causing improvement in quality, and offers more robust evidence about the impact of these reports. This study also has a more specific contribution because it is the first to investigate the impact of a report card on quality of nursing home care. Studies of report cards to date have focused on health plans, hospitals, or physicians. The response of nursing homes might, however, be different. Nursing homes treat a much more frail and clinically complex population, in a long-term rather than acute-care setting, with different processes of care, and different market conditions, including a much larger involvement of public payers (Mukamel and Spector 2003). All of these factors may differentially affect the effectiveness of report cards in the nursing home setting.