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: Quality jt = β 1 NHC jt + βX jt +  j –Quality jt = quality for SNF j in quarter t –NHC jt = indicator of Nursing Home Compare ▪ pre-post (2000-2002 vs. 2003-2005) ▪ set of year dummy variables –X jt = 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 MeasureDefinitionMean (SD) No pain % of residents who did not have moderate or severe pain 76 (15) No delirium% of residents without delirium96 (5) Improved walking % of residents whose walking improved 8 (7)

11. Unreported quality measures MeasureDefinitionMean (SD) Improved pain % of residents whose pain improve or remained free from pain 53 (15) Locomotion % of residents whose level of locomotion improved or remained independent 32 (15) Shortness of breath % of residents who did not have shortness of breath 83 (12) Bladder incontinence % of residents who improved their bladder incontinence or remained fully continent 49 (14) Respiratory infection % of residents who did not develop a respiratory infection or had a respiratory infection that got better 95 (5) UTI% of residents without a UTI77 (10) ADL % of residents with improving ADL functioning 51 (20)

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

16. Relative changes in quality OverallHigh- ranked Low- ranked Reported measures Pain4.0%10.4%-2.3% Delirium1.5%2.6%-0.3% Walking11.6%40.3%-13.6% Unreported measures Improved pain3.7%8.9%-3.0% Shortness of breath1.3%2.6%-0.6% UTI-1.2%-0.5%-2.2%

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