Will Using Medicare Data to Rate Doctors Benefit Patients?
Authors: Rachel M. Werner
Journal: Annals of Internal Medicine (2012)

Ideas and Opinions3 April 2012Will Using Medicare Data to Rate Doctors Benefit Patients?FREERachel M. Werner, MD, PhDRachel M. Werner, MD, PhDFrom the Philadelphia Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-156-7-201204030-00396 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail On 5 December 2011, the Centers for Medicare & Medicaid Services (CMS) announced that it will make its claims data available to rate health care providers on their quality of care (1). The goal of availing these data to the public is to enable consumers to make more informed choices about their health care providers. Many have hailed this as an important and necessary step to improve health care in the United States.The final rule will give qualified organizations (such as consumer groups, employers, and insurers) access to all billing data from Medicare parts A, B, and D to create performance reports. To gain access to these data, organizations must apply to Medicare to become a qualified entity, demonstrating that they have appropriate experience and expertise in using such data to rate performance. The qualified organization can then use these data to identify high-quality health care providers or create online tools to help consumers choose a provider. Each qualified organization will determine the specific uses and how and to whom the performance measures will be disseminated, but the expectation is to substantially increase the availability of performance ratings for consumers.Performance ratings of health care providers have been made increasingly available to the public over recent decades, yet comprehensive ratings are available for only a few types of providers and are sometimes based on a limited portion of each provider's patient pool. For example, the CMS has publicly rated hospitals, nursing homes, and home health agencies since the mid-2000s; however, comprehensive ratings of individual physicians' care of common medical conditions are not available.The availability of Medicare data for performance measurement has the potential to be a game-changer as Medicare covers more office visits, medical procedures, and hospitalizations and insures more patients than any other program. Use of these data on health care interactions provides the opportunity to expand the quality and breadth of available performance measures. Marilyn Tavenner, acting administrator of the CMS, called the availability of these data "a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs" (2).The availability of Medicare data to rate health care providers is undoubtedly an important step, but increasing competition, accountability, and quality while lowering costs is a tall order. Could this data release possibly do all of that?Certainly, the rationale behind use of this information is sound. Decades of research document large variation in health care quality, suggesting that all too often patients do not receive high-quality care. The persistence of this problem—at least in part—is because patients cannot easily recognize high-quality health care and are therefore forced to choose physicians with little information. As a result, physicians don't compete for patients on the basis of the quality of care they offer. Measuring and publicly reporting information on physician quality is a straightforward solution to this problem. It makes quality more visible to patients, which in turn gives physicians (or other health care providers) greater incentive to deliver high-quality care. The intuitive logic of this approach has led to increasing adoption of public reporting to improve health care.However, the evidence that publicly reporting quality information improves quality of care is mixed (3). Although modest quality improvement in some settings with public reporting has been identified (4), other studies report no significant effects (5). When quality does improve under public reporting, the gains are often small and limited to areas that are specifically targeted by public reporting.Even if quality of care does not improve under public reporting, patients may nonetheless receive higher-quality care if they choose higher-quality providers; however, support for this is also mixed. Many studies have found no evidence that report cards influence consumer choice (3), although more recent studies—particularly those done in hospitals and health plans—suggest that consumers do incorporate this information into their decision-making process (6–8). More robust consumer response has also been noted in areas where consumers are sensitive to the cost and quality of care (such as in choosing a fertility clinic [9]), or when patients have access to patient satisfaction ratings rather than ratings based on processes of care (such as how often patients received appropriate mammography) (7).Potential pitfalls in public reporting could hamper its effects. First, public reporting can only improve quality if the measures accurately reflect that quality. However, performance measures can provide inaccurate or misleading information. For example, if providers change their documentation but not the way they practice, this could result in the appearance of quality improvement without true change (10, 11). Even if performance measures are accurate, many process-based performance measures poorly predict a provider's ability to improve long-term outcomes (4, 12). Newer measures that can be developed from Medicare data, including physician procedure volume and complication rates, may perform better in this regard.Second, the validity of outcome measures in identifying quality of care depends on the adequacy of risk adjustment. If physicians do not believe that adjustment for severity of illness and other patient factors that influence outcomes is adequate, they might avoid patients that could reduce their measured performance. Physician groups fought vigorously to prevent release of Medicare data over concerns that illness severity will result in misleading information about quality of care (13). Although physician performance rankings are typically adjusted to account for differences among patient risk profiles, risk adjustment can be imperfect. If physicians believe that they are being unfairly penalized by caring for sick patients, it could influence them to turn away patients at higher risk for poor outcomes (14, 15) and potentially limit access to care for the sickest patients.Finally, public reporting may limit access in other ways. Some evidence suggests that it could widen the gap between the haves and the have-nots in health care—harming poorly financed providers who disproportionately care for poor and other disadvantaged patients (16, 17). These safety-net providers often struggle with financial viability as they struggle to deliver high-quality care. To the extent that patients respond to quality information by choosing high-quality providers, the proliferation of performance reports could drive some patients away from these low-performing providers. Although this is desirable for patients who have access to higher-quality care, some patients served by safety-net providers unfortunately have limited choice and limited access to other providers. Financially penalizing these providers under public reporting could in turn worsen care for persons who remain in the safety net, as resources are diverted away from them.On balance, the release of Medicare claims data for performance rankings is a major step forward in the effort to improve health care quality. It will unquestionably improve transparency. Whether it will also improve quality, reduce costs, or increase accountability remains to be determined; currently, the evidence does not seem to indicate that it will. Potential pitfalls exist that may prevent patients from truly benefiting from the availability of these data. The response of patients and physicians to this newly available information will determine the success of the policy in the short term. In the long term, monitoring and understanding the responses will help shape further public reporting initiatives to foster meaningful improvements in health care.References1. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; availability of Medicare data for performance measurement. Final rule. Fed Regist. 2011;76:76542-71. [PMID: 22165169] MedlineGoogle Scholar2. Centers for Medicare & Medicaid Services. Medicare gives employers, consumers information to make better health care choices [press release]. Baltimore: Centers for Medicare & Medicaid Services; 5 December 2011. Accessed at www.cms.gov/apps/media/press/release.asp?Counter=4206 on 2 January 2012. Google Scholar3. Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med. 2008;148:111-23. [PMID: 18195336] LinkGoogle Scholar4. Werner RM, Konetzka RT, Stuart EA, Norton EC, Polsky D, Park J. Impact of public reporting on quality of postacute care. Health Serv Res. 2009;44:1169-87. [PMID: 19490160] CrossrefMedlineGoogle Scholar5. Tu JV, Donovan LR, Lee DS, Wang JT, Austin PC, Alter DA, et al. Effectiveness of public report cards for improving the quality of cardiac care: the EFFECT study: a randomized trial. JAMA. 2009;302:2330-7. [PMID: 19923205] CrossrefMedlineGoogle Scholar6. Jung K, Feldman R, Scanlon D. Where would you go for your next hospitalization? J Health Econ. 2011;30:832-41. [PMID: 21665300] CrossrefMedlineGoogle Scholar7. Dafny L, Dranove D. Do report cards tell consumers anything they don't know already? The case of Medicare HMOs. Rand J Econ. 2008;39:790-821. [PMID: 19013864] CrossrefMedlineGoogle Scholar8. Pope DG. Reacting to rankings: evidence from "America's Best Hospitals". J Health Econ. 2009;28:1154-65. [PMID: 19818518] CrossrefMedlineGoogle Scholar9. Bundorf MK, Chun N, Goda GS, Kessler DP. Do markets respond to quality information? The case of fertility clinics. J Health Econ. 2009;28:718-27. [PMID: 19328568] CrossrefMedlineGoogle Scholar10. Green J, Wintfeld N. Report cards on cardiac surgeons. Assessing New York State's approach. N Engl J Med. 1995;332:1229-32. [PMID: 7700321] CrossrefMedlineGoogle Scholar11. Werner RM, Konetzka RT, Stuart EA, Polsky D. Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming? Health Serv Res. 2011;46:555-71. [PMID: 21105869] CrossrefMedlineGoogle Scholar12. Werner RM, Bradlow ET. Relationship between Medicare's hospital compare performance measures and mortality rates. JAMA. 2006;296:2694-702. [PMID: 17164455] CrossrefMedlineGoogle Scholar13. Alonso-Zaldivar R. Feds to allow use of Medicare data to rate doctors. Associated Press. 5 December 2011. Accessed at www.aarp.org/health/medicare-insurance/news-12-2011/us--medical-report-cards.html on 2 January 2012. Google Scholar14. Schneider EC, Epstein AM. Influence of cardiac-surgery performance reports on referral practices and access to care. A survey of cardiovascular specialists. N Engl J Med. 1996;335:251-6. [PMID: 8657242] CrossrefMedlineGoogle Scholar15. Dranove D, Kessler D, McClellan M, Satterthwaite M. Is more information better? The effects of "report cards" on health care providers. J Polit Econ. 2003;111:555-88. CrossrefGoogle Scholar16. Casalino LP, Elster A, Eisenberg A, Lewis E, Montgomery J, Ramos D. Will pay-for-performance and quality reporting affect health care disparities? Health Aff (Milwood). 2007;26:w405-14. [PMID: 17426053] CrossrefMedlineGoogle Scholar17. Werner RM, Kolstad JT, Stuart EA, Polsky D. The effect of pay-for-performance in hospitals: lessons for quality improvement. Health Aff (Millwood). 2011;30:690-8. [PMID: 21471490] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Rachel M. Werner, MD, PhDAffiliations: From the Philadelphia Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0066.Corresponding Author: Rachel M. Werner, MD, PhD, University of Pennsylvania, 1230 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104; e-mail, rwerner@upenn.edu.Author Contributions: Conception and design: R.M. Werner.Drafting of the article: R.M. Werner.Critical revision of the article for important intellectual content: R.M. Werner.Final approval of the article: R.M. Werner.Obtaining of funding: R.M. Werner.Administrative, technical, or logistic support: R.M. Werner. 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