Public Reporting of Long-Term
Care Quality
R. Tamara Konetzka, PhD
University of Chicago
June 2009
Motivation for Public Reporting

Simple economic theory of markets
assumes:
– Perfect information
– Perfect competition
– Consumers choose price/quality combination

Absence of typical market attributes in
health care:
– Information Asymmetries
Difficult for consumers to judge quality
Little incentive for providers to compete on quality
Goals of Public Reporting

Public reporting of quality is intended to
improve quality by:
– Giving consumers information needed to shop
on quality
– Giving providers incentive to compete on
quality

If either or both occurs, quality should
increase
Potential Unintended Consequences
“Cream-skimming” or selection of patients
based on risk
 “Teaching to the test” or decreased
attention to unreported aspects of quality
 Increased disparities in quality

– Some consumers less able to access and use
quality information
– Some providers less able to invest in quality
improvement to improve scores
Additional Challenges for LTC

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Markets historically have not been very
competitive; nursing home beds not always
available
Pervasive cognitive impairment
Choice of provider tied strongly to residence and
proximity to family
Segregation and disparities are entrenched
Most providers depend on public payers,
especially Medicaid
Quality of life is crucial yet difficult to measure
Nursing Home Compare

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Launched November 12, 2002
Publicly release quality information:
http://www.medicare.gov/NHCompare

All Medicare- and Medicaid-certified NHs
– 16,000 nursing homes

10 quality measures
– 4 post-acute care
– 6 chronic care

Staffing, inspections, ownership, size
Subsequent Adjustments
9 quality measures added over time
 5-star rating system

– Added in December 2008
– Star ratings on:
 health inspections
 staffing
 clinical quality measures
 all three combined
– Intended to be an accessible summary of data
Home Health Compare
Launched fall 2003
 Publicly release quality information:

http://www.medicare.gov/HHCompare

All Medicare-certified Home Health
Agencies
– 9,000 agencies

11 quality measures initially (now 12)
Empirical Evidence:
Intended Effects

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Early studies of trends post-NHC: positive for
some/most clinical measures, modest in
magnitude (Zinn et al. 2005; Castle et al. 2007)
Pre-post trends in a subset of nursing homes:
2/5 clinical measures showed significant but
modest improvement (Mukamel et al. 2008)
Most providers reported looking at and taking
some action in response to public reporting
(Mukamel et al. 2007)
With additional identification
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Using small facilities as a control group: 2/3
post-acute care measures show modest but
significant improvement (Werner et al. 2009)
Nursing homes in more competitive markets
showed significant and positive improvement in
clinical measures (Grabowski 2008; Castle et al.
2008)
Magnitudes range from 1-10% decrease in
adverse outcomes
Empirical Evidence:
Teaching to the test
Little spillover to unreported care found in
post-acute setting on average
 Nursing homes that do very well on
reported care see larger spillovers to
unreported care
 Nursing homes that do not do well on
reported care may worsen quality of
unreported care
 (Werner Konetzka Kruse 2009)

Adjusted changes in unreported quality
Empirical Evidence:
Inadequate risk-adjustment and
cream-skimming
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More extensive risk adjustment would change
the quality rankings of nursing homes (Mukamel
et al., 2008)
– but not of home health agencies (Murtaugh et
al., 2007)
Some evidence of limited cream-skimming as
indicated by changes in admissions
characteristics (Mukamel et al., 2009)
Changes in admissions characteristics are also
consistent with improved sorting (Werner et al.,
2009)
Empirical Evidence:
Disparities
Percent of Residents Without Moderate/Severe Pain (adjusted)
0.77
0.765
0.76
0.755
black
0.75
hispanic
w hite
0.745
0.74
0.735
0.73
Pre-NHC
Post-NHC
Empirical Evidence:
Consumer Use

In a survey of 4,754 family members of
nursing home residents (Castle, 2009):
– 31% reported using the Internet to choose a
facility
– 12% recalled using Nursing Home Compare
– Most seemed to understand the information

Evidence is still emerging on whether
improvement is due more to consumer or
provider response
Conclusions
Public reporting can play a positive but
modest role in improving reported aspects
of quality
 We should not expect substantial
spillovers to unreported aspects of quality
 Evidence is still incomplete/emerging
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Unanswered Questions
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Consumer use of report cards
Production functions of quality improvement in
response to report cards
Unintended consequences/ disparities
Sorting and price effects
Longer-run and dynamic effects
Improved risk-adjustment
Non-nursing-home settings
Effects on quality of life