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The impact of public reporting on unreported quality of care

The impact of public reporting on unreported quality of care. Rachel M. Werner R. Tamara Konetzka Gregory B. Kruse Funding: AHRQ (R01 HS016478-01) University Research Foundation of the University of Pennsylvania. Performance measures and quality improvement.

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The impact of public reporting on unreported quality of care

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  1. The impact of public reporting on unreported quality of care Rachel M. Werner R. Tamara Konetzka Gregory B. Kruse Funding: AHRQ (R01 HS016478-01) University Research Foundation of the University of Pennsylvania

  2. Performance measures and quality improvement • Performance measures are frequently tied to quality improvement incentives to improve quality of care • Targeted care often improves • Large parts of care are not measured • Unknown how non-targeted care changes

  3. Multitasking “…if an employee is expected to devote time and effort to some activity for which performance cannot be measured at all, then incentive pay cannot be effectively used for other activities.” • P. Milgrom (1992) Economics, Organization, and Management

  4. Objective • Examine the effect of publicly reporting quality information on unreported quality of care

  5. Setting: Nursing Home Compare • Launched November 12, 2002 • Publicly release quality information: http://www.medicare.gov/NHCompare • All Medicare- and Medicaid-certified NHs • 17,000 nursing homes • 10 quality measures • 4 post-acute care • 6 chronic care • Staffing, inspections

  6. Data • Minimum Data Set (1999-2005) • All Medicare- and Medicaid-certified nursing homes • Detailed clinical data • Source to calculate quality measures for Nursing Home Compare • Used to calculate a larger set of quality measures over study period

  7. Empirical approach SNF-level fixed effects model: Qualityjt= β1NHCjt + βXjt + j • Qualityjt = quality for SNF j in quarter t • NHCjt = indicator of Nursing Home Compare ▪ pre-post (2000-2002 vs. 2003-2005) ▪ set of year dummy variables • Xjt = set of SNF-level covariates • j = SNF fixed effects

  8. Empirical approach • Stratify by SNF-ranking on reported measures • Improvement • Ranking • Huber-White estimators of variance

  9. Quality measures • Technical definitions of measures from CMS • Follow CMS conventions • 2 quarters • 14-day assessment • Facilities with greater than 20 cases during target period • 13,683 SNFs

  10. Reported quality measures

  11. Unreported quality measures

  12. Covariates • Time varying SNF-level covariates • Mean Cognitive Performance Scale • Mean RUG-ADL • % SNF residents in each RUG group • 14-day censoring rate

  13. Adjusted changes in reported quality

  14. Adjusted changes in unreported quality

  15. Adjusted changes in unreported quality

  16. Relative changes in quality

  17. Summary • Unreported quality improves with public reporting in most cases • Improvements in unreported care largest among high-ranking facilities • Low-ranking facilities failed to improve or had worsening unreported quality

  18. Implications • Fears of “crowd out” may be overstated as market-based incentives positively impact non-targeted care • May be a growing divide between high- and low-quality facilities

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