Public Reported Health Outcomes: A National Initiative to Improve Care

“recent research demonstrates that hospital mortality rates can vary by a factor of 3 to 1 and health plans by 4 to 1, and publicly available quality ratings of health care plans and services do not correlate well with outcomes. What is more, lack of transparency among health plans and provider organizations prevents purchasers from making informed choices based on relative quality of provider organizations and health plan networks. Currently available outcomes data are limited to Medicare fee-for-service. [..]

For at least five decades, the public health care conversation has focused primarily on rising costs, while the US has lagged behind other OECD countries in numerous measures of mortality and morbidity. Yet, while the US reports jobs and gross domestic product growth, inflation, and unemployment on a regular (monthly or quarterly) basis, no effective reporting system holds health plans and provider organizations accountable to the public for health outcomes. But if the US published a few key risk-adjusted measures of mortality and morbidity for payers and provider organizations, purchasers, government officials, consumers, and voters would have the necessary information to pinpoint responsibility. [..]

The industry standard for health plans, the Healthcare Effectiveness Data and Information Set (HEDIS), only tracks process measures, not outcomes. Indeed, no rating system for health plans and provider groups provides outcomes information in a usable way. If purchasers, consumers, and government officials had timely data on mortality and morbidity of procedures, hospital-acquired infections, and medication errors, they would have the tools to choose best performers. This would also drive poor performers to improve, thereby improving the overall quality of care in the US. A robust outcomes reporting system is needed to change the purchase paradigm. [..]

To succeed, the PRHO [Publicly Reported Health Outcomes] program would need to incorporate the following design principles:

  • A scoring system based on outcomes rather than processes
  • Comparative risk-adjusted outcomes with breakdowns by race, ethnicity, and related variables
  • Clear communication of the significance of those outcomes to non-health care professionals
  • Comparisons of mortality and morbidity among health plans and provider organizations
  • Availability at the point of purchase, such as health insurance exchanges and provider selection sites
  • Functionality allowing users to drill down to greater levels of detail, comparing plans and providers using multiple criteria
  • Incorporation of advances in outcome measures as they become available over time

[..] [What To Measure] Existing quality reporting bodies use process-oriented measures that, according to an analysis conducted by one of us (Wadsworth), do not correlate well with comparative performance based on outcomes. We suggest developing a starter list of outcomes beginning with the following sources: the Centers for Medicare and Medicaid Services (CMS) hospital outcomes (deaths, readmissions, and infections) augmented with maternal and infant mortality and morbidity measures; and OECD or the World Health Organization (WHO) measures of mortality and morbidity. Patient reported outcomes can be incorporated when a methodology has been developed to ensure comparability among organizations. CMS has targeted 2030 as a completion date. To be useful and credible, outcomes must be risk adjusted for age, sex, comorbid conditions, and health equity determinants.

[Usability] Many provider selection services today list large numbers of provider organizations with little or no differentiating criteria. And even when that information is available, it isn’t presented in a way that the user can understand it and “filter” based on their preferences. To illustrate, we have to look beyond health care sites., for example, provides huge amounts of data and choices in a way that need not overwhelm users. The site enables the user to limit their search to new, used, or certified cars of a specific make and model and refine the search by specifying additional criteria, such as colors and various features to narrow the choices. Many retail shopping sites follow a similar approach.

[Scoring] Letter and star grades (for example, A through F or 1 to 5 stars) tend to downplay the substantial differences in mortality rates (3 to 1 or greater) that exist among hospitals and health plans. Numerical grades, such as FICO credit scores, are a much more effective way to highlight the differences that exist. [..]

[Accessibility and Public Awareness] To be useful and used, quality ratings must be widely available to the intended users at their decision points—such as health insurance exchanges, employer intranets, and public sites—and become as widely known as Consumer Reports, Amazon, Google, and Facebook. [..]

[Potential Obstacles] America’s Health Rankings annual state rankings demonstrate the feasibility of PHRO at the state level. CMS collects hospital outcomes, but the data are typically one and a half to two years old before they are made public and only account for Medicare fee-for-service patients, a population that continues to shrink as Medicare Advantage grows in popularity. Medicare and Leapfrog both dilute the CMS outcomes with process measures so that CMS mortality outcomes represent less than 20 percent of the basis of Leapfrog’s Hospital Safety Grade and 22 percent of Medicare hospital ratings. [..]

Public reporting of mortality and morbidity outcomes offers the potential to transform the national conversation and move the country’s health care results closer to those of other OECD countries. But development and implementation of a PRHO system will require a long-term commitment.”

Full post, P Wadsworth, S Shortell and J Toussaint, Health Affairs Forefront, 2022.7.19