The Impact of Performance Reporting on Consumer and Physician Organization Behavior
Grant Description: How are public “report cards” on consumer and physician behavior being disseminated? The researchers evaluated PacifiCare’s Quality Index report cards that provide a relative performance assessment of provider groups in selected areas of clinical, service, and administrative quality. The researchers tested: (1) how new and continuing health plan enrollees used comparative quality information to select a physician group; (2) how mobilization of consumer choice based on comparative quality information drove physician group performance improvements; and (3) how physician groups responded to performance measurement when data were used for confidential benchmarking only while other dimensions of quality were reported to consumers. The objective of the project was to fill an information gap concerning the value of publicly reported quality information and to provide guidance to public and private decision makers on the measurement and dissemination of provider quality information.
Policy Summary: Recent efforts to improve the quality of health care in the United States and elsewhere have looked to performance reporting to guide consumer choice and provide the impetus for changes in the delivery system. As public and private health benefit purchasers invest in measuring and reporting provider performance to stimulate quality improvement, further research is needed to support and inform these efforts. A review of the current literature yields several important conclusions. First, while there are a growing number of studies of the impact of report cards on consumer choice, most relate to health plans, a few to hospitals, and only one relates to physician groups (citations omitted). Second, while the evidence is mixed, report cards have generally shown little impact (citations omitted). These disappointing results, however, may not be generalizable to report cards that rate an individual’s regular source of care on measures of the quality of preventive care and care for high-prevalence chronic conditions as well as patient experiences. In this study, the researchers examine the impact on consumer behavior of the introduction of public reporting of physician group quality data by PacifiCare of California. They take advantage of a natural experiment in which PacifiCare began publicly releasing performance data to their commercial HMO enrollees several years after they began tracking health care quality and sharing the data confidentially with the physician groups. The researchers’ data set includes information on physician group performance on a set of quality metrics both before and after a subset of these were publicly released as well as a continuous record of enrollee physician group selections. They also examine physician group selections by a cohort of enrollees in the same market that did not receive the report cards as a further source of identification. Prior to public reporting, PacifiCare enrollees were more likely to select a physician group with lower quality scores than one with higher quality scores, suggesting that factors negatively correlated with health care quality were driving consumer choices. Among commercial members, both new enrollees and enrollees that voluntarily switched their physician group after the Quality Index became available increased their likelihood of choosing a physician group by about 1.5 percent for each percentile of clinical quality rating and roughly 0.3 percent for each higher percentile of service quality. The main effect of the Quality Index, therefore, was to make consumer selections more sensitive to clinical quality. Analysis of provider performance trends before and after the Quality Index was released showed no overall change in the rate of quality improvement for reported measures. At the same time, the trends in unreported measures showed no signs of deterioration as might be expected given the incentive for groups to focus on maintaining or improving performance in reported areas of practice. The findings support the notion that public reporting can be an effective tool for increasing the market share of the best performing providers and thus improving the average quality of care in the population. This is really the first study to document any meaningful change in consumer behavior from a provider quality report card. Importantly, however, the report cards and ensuing changes in market share appear to have stimulated only a limited amount of quality improvement by the physician groups, however. This finding might indicate that the profit margins on the additional enrollees that could be gained from improving quality were insufficient to justify the expense of undertaking quality improvement. Alternatively, physician groups might require technical assistance to identify effective quality improvement strategies. Further exploration of the financial and non-financial barriers to quality improvement is needed for payers to leverage fully the increased consumerism initiated by public reporting.