Health care ratings
Technological advances played a key role in facilitating the data collection and number crunching needed to generate health care ratings.
Health care ratings are coming of age in a time of rising levels of consumer health literacy. Surveys consistently show that consumers rely heavily on friends and family when making healthcare decisions. With social networking and global connectivity, some of these family and friend referrals will include a wider network and will increasingly rely on quality data retrieved from multiple sources. Government, non-profit and private organizations are building public-private collaborations focused on the development of a nationwide system in the United States.
Types of measures
Quality measures are standards that are used to assess the various aspects of the healthcare system. Using the Donabidien framework, these measures evaluate process of care, healthcare structures and/or outcomes of a healthcare services. This information is translated into report cards that are generated by quality organizations, nonprofit,consumer groups and media. This evaluation of quality is based on:
Measures of Hospital quality
Measures of Health Plan Quality
Measures of Physician Quality
Measures of Quality for Other Health Professionals
Measures of Patient Experience
Measures are collected and disseminated by a number of quality reporting organizations.
The Robert Wood Johnson Foundation (RWJF), the largest philanthropy in the United States dedicated to improving health and health care, provides support for multiple efforts dedicated to increasing public awareness of the performance of health professionals:
- Aligning Forces for Quality is a national initiative that is focused on improving the overall quality of care in local communities. As part of this initiative, collaborative teams in 16 targeted communities work to make information about hospital and physician performance available to the public.
- Consumer-Purchaser Disclosure Project is a collaboration of leading consumer, employer and labor organizations working to ensure that all Americans have access to publicly reported health care performance information.
- National Quality Forum is a nonprofit membership organization created to develop and implement a national strategy for health care quality measurement and reporting.
Organizations are sensitive to public reporting As the healthcare system moves from supply driven to demand driven, transparency of such quality reporting is important for informed decision making and efficiency improvements 
A 2001 retrospective cohort study found that health plans voluntarily generating public reports had higher quality ratings than those that chose not to publicly report. Another retrospective study of HMO’s yielded similar results, revealing that HMOs with lower quality scores were more likely to stop public reporting while higher performing HMOs continued to publicly report. Analysis of hospital performance reporting and consumer selection found mixed results about public perception and market share. A 1997 study “reported that releasing hospital-specific mortality rates was associated with small but statistically significant effects on utilization, whereas press reports of single, unexpected deaths were associated with a relatively large effect.”
More recent studies have identified the potential of public disclosure of performance in encouraging providers to focus on gaps in quality and stimulate performance improvement  In addition, from a consumer perspective, health quality reports can encourage patients to preferentially choose high quality healthcare such as best health plans  or assess the performance of providers 
Low use of ratings
A 2007 survey of factors impacting individual consumer health professional selections found that only 11 percent of American adults looked for a new primary care physician. Of those 11% went online for information, 38% used doctor or healthplan information. Nearly 40% used multiple sources. 28 percent needed a new specialist physician and 16 percent underwent a medical procedure at a new facility. Few of those relied on price or quality information and relied almost exclusively on physician referrals. Only 3% of patients undergoing procedures and 7% choosing a specialist went online for information.
A 2008 survey of public awareness and use of healthcare quality reports reported that: 20% of Americans surveyed said they had seen quality information about hospitals and only 7% said they used the information to make a decision. 12% of Americans surveyed said they had seen quality information about doctors and only 6% said they used the information to make a decision.
Although public reporting has taken center stage in qualitative and health policy research, there has been a slow uptake. Barriers identified are related to consumer behaviors and challenges with the conceptual framework. Health literacy is a key component to comprehend and use performance data. However, complexity of the performance data, technicality and presentation of the quality data makes the quality reports difficult to understand. Another impediment to the development of health quality reports is the challenge associated with measuring performance at the individual physician level (due to inadequate sample sizes, difficulty adjusting for the severity of patients medical condition) . This has led to group-level reporting which makes these reports less useful for consumers.
Thus, given the changing healthcare landscape, further research to understand consumer behaviors will be important to inform the development and increased uptake of health grade reports.
There appears to be a breakdown in creative use of technology to get the information in the hands of those interested in using it. As pointed out by Kristen Madison, Senior Fellow at the Leonard Davis Institute of Health Economics, searching the Internet for “the term ‘hospital quality’ or’ hospital report card’ does not always turn up relevant report cards, even if they do exist”. To make these reports more accessible, large philanthropies, including the Robert Wood Johnson Foundation, have funded major initiatives that are focused on performance measurement like the Aligning Forces for Quality program.
History of health quality reporting
The earliest efforts to report on health professionals or facilities date to the mid-1980s when the Health Care Financing Administration (HCFA) – now the Centers for Medicare and Medicaid Services (CMS) – published nationwide hospital-specific mortality data. The information was controversial at the time and HCFA ended publication of the mortality information in the early 1990s.
The media, state governments and the employer community have also contributed to the development of public reporting. Newsday published mortality rates for heart bypass surgery for 140 New York surgeons in December, 1991. The information resulted from a Freedom of Information lawsuit seeking data from the New York State Department of Health. State agencies in California, New York and Pennsylvania also published cardiac surgery hospital and physician information in the early-mid-1990s. Some states also report on other types of hospital and physician information in their licensing and regulatory roles. Information on complaints, sanctions and other disciplinary actions has slowly become available through state licensing boards and Departments of Health. The Cleveland Health Quality Choice Coalition was an early collaborative effort between hospitals, physicians and purchasers that provided public information on hospital quality, though it is no longer in operation.
Largely at the urging of employers implementing managed care plans in the late 1980s and early 1990s, the development of health plan measures and reports began to emerge. Prompted by concerns about possible quality of care problems in managed care plans, the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) was developed to capture information about health plan quality of care. This measure set has been widely used by large employers, states and the Federal government as the basis for accrediting plans and for public reporting. At the same time, the Agency for Healthcare Research and Quality (AHRQ) funded the development of a survey instrument to assess patient experience with receiving care from their managed care plan. The tool, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) has been widely embraced and was embedded in NCQA’s health plan accreditation program. The CAHPS program has expanded over time to include a suite of survey tools to assess patient experience, including the CAHPS Hospital Survey (H-CAHPS) and the Clinician and Group CAHPS Survey.
The federal government re-entered the public reporting field in the late 1990s and the early years of the 21st century with the launch of the Compare websites , including Health Plan Compare and Nursing Home Compare, and subsequently Home Health Compare and Dialysis Compare. During the same period, AHRQ was building on its quality indicator work through the Hospital Care and Utilization Project (HCUP) (now Healthcare Cost and Utilization Project) with the development of the AHRQ Quality Indicators in 2001 and the AHRQ Patient Safety measures in 2002. Starting in 2007, AHRQ launched a learning network of community collaboratives (i.e., the Charter Value Exchanges), which were committed to measuring and publicly reporting on provider performance in their communities. Those efforts were supplemented by the regional collaborative work of the Robert Wood Johnson Foundation's Aligning Forces for Quality in 17 communities nationwide.
Other key organizations were also forming or expanding their portfolio to include measure development – particularly related to hospitals. The National Quality Forum (NQF) became operational in 2000 with the mission of standardizing health care performance measurement and strategies. Following on the release of the Institute of Medicine report To Err is Human, employers formed the Leapfrog Group, whose mission was to push hospitals to adopt safe practices. Leapfrog asked hospitals to voluntarily complete an annual survey to report on their safety practices, and these results were made public and, in some cases, became embedded in pay-for-performance programs. The Joint Commission was incorporating performance measurement into their accreditation process and multi-stakeholder groups such as the Hospital Quality Alliance (HQA) were working with Centers for Medicare and Medicaid Services on the development of Medicare's Hospital Compare.
Measure development and reporting on the physician side lagged measurement efforts at the plan and hospital level. In part due to methodological challenges involved in reporting given smaller sample sizes at the physician level, and also due to provider resistance. Recognizing increased pressure to measure performance and reduce variation, physician organizations began their own efforts to develop a set of performance measures. In 2000, the American Medical Association convened the Physician Consortium for Performance Improvement.page (PCPI) to develop, test and maintain physician performance measures. In September 2004, the American Academy of Family Physicians, the American College of Physicians, America's Health Insurance Plans and AHRQ created the Ambulatory Care Quality Alliance (AQA) to implement performance measurement at the physician level. Legislation in 2006 created the Physician Quality Reporting Initiative (PQRI), now termed as the Physician Quality Reporting System (PQRS), sponsored by Centers for Medicare and Medicaid Services. This “pay-for-reporting” program provides incentive payments to physicians who report quality data; however, to date individual physician performance results are not publicly available for use by consumers. Similar to the hospital compare website, the new Physician Compare website, provides information on physicians and other healthcare professionals who are currently enrolled in Medicare. Data on their affiliation, certification status and participation in CMS quality improvement programs is also made available to the Medicare beneficiaries 
The Patient Protection and Affordable Care Act passed in 2010 also calls for more public reporting of information about health professionals. As efforts by employers and health plans to assess the performance of both the quality and efficiency of individual physicians have grown, physicians have challenged these efforts for lack of transparency on the methods used to score them. In response to a settlement by the New York Attorney General, a coalition of purchasers and consumer groups developed the Patient Charter for Physician Performance Measurement, Reporting and Tiering (The Patient Charter”), which was released in 2008. The Patient Charter provided a process for reviewing the methods used to score providers and a framework for making the methods transparent.
Today, there are hundreds of public reporting activities across many types of health facilities and professionals including hospitals, physician groups, nursing homes, home health agencies, dialysis facilities, hospices and nurses. Some of these reporting activities result from government action, some from internal health professional or facility efforts to become more transparent, some from investigative journalism, some from community collaboratives, and others from employer or consumer groups. The ability to publish and update information through the Internet has facilitated the dissemination of information about health care performance. However, the information available to any given patient or family member still varies substantially in terms of its breadth, relevance and accessibility.
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