October 12th, 2012
PCI Public Reporting Programs: Incentivizing Better Decisions?
Public reporting of health care quality and outcomes has become the norm. Fifteen years ago the idea that nearly all health plans, hospitals, and physicians would be subject to reporting programs would have been considered implausible.
However, despite its growing prevalence and the specter of quality evaluation being used as part of reimbursement decisions, the science of public reporting remains in its infancy.
For surgery, research has strongly suggested that public reporting leads to improved surgeon and hospital outcomes. The most likely explanation is that providers respond to objective feedback, motivating quality-improvement efforts to maintain or develop a “high-quality” reputation.
But skeptics of public reporting programs have raised concerns, centrally that physicians and hospitals caring for the sickest patients will be disincentivized to provide care for the highest-risk patients, potentially leading clinicians to avoid offering care.
Surgeons have generally disagreed, but some early studies have supported these concerns.
This month’s JAMA provides some much needed evidence to inform this discussion, as Joynt and colleagues used CMS administrative claims data to examine whether several state public reporting programs of PCI outcomes (Massachusetts, New York, and Pennsylvania) were associated with differentially lower rates of PCI and mortality for acute MI patients.
In essence, use of PCI was lower in these three states compared to seven control states in the same region of the U.S. However, there was no difference in overall acute MI mortality between states with and without public reporting.
The reduction in rates seems largely attributable to lower PCI use among STEMI patients, patients in cardiogenic shock, and patients 75 years of age or over; PCI use was no different among NSTEMI patients.
And there was no differential increase in CABG surgery rates with states that had PCI public reporting programs, so higher-risk patients did not migrate to a higher-risk surgery (although there is a question of whether this finding held true for Massachusetts or only New York and Pennsylvania).
Nevertheless, there was no difference in 30-day mortality rates for acute MI patients in states with and without PCI public reporting programs.
So what does this pattern of care imply about the care decisions being made in states with PCI public reporting programs?
Are physicians in these states simply doing a better job of risk-assessment and avoiding PCIs for patients where outcomes were futile?
Or, are they doing a better job of judging appropriateness and the likelihood of patient benefit from the procedure?
Or, have the concerns of public reporting skeptics been realized, such that physicians and hospitals are avoiding offering care for the sickest patients because of concerns about their publicly reported outcomes?
What do you think these new data mean for practice?
If public reporting programs are the new norm, are they driving efforts to genuinely improve quality or merely incentivizing ways to game the numbers, perhaps by not offering care to the highest-risk patients?
And if you are in a state that publicly reports PCI outcomes, can you share any stories of your experiences?