Comments on Werner et al.,
“C
“Consumer
response tto public
bli
reporting: Changes in market
share in nursing
g homes”
Alan Zaslavsky
Dept of Health Care Policy
H
Harvard
dM
Medical
di l S
School
h l
Do consumers respond to reported
quality information?
• Heroic efforts for at least 15 years to show
consumer response
p
– Epstein & Schneider 1998, Pennsylvania
cardiac surgery reports: <1% of patients knew
and used their surgeon’s rating
– Guadagnoli et al
al. 2000: CAHPS reports read
more by consumers who are considering
switching plans; impact unknown.
unknown
– etc.
Typical difficulties
• Quality info distributed simultaneously, no
comparison
p
g
group
p
• No quality info available prior to reporting
• Hard
H d tto conclusively
l i l show
h
effects
ff t off
reporting, distinct from response to quality
through other channels of info
Werner et al
al. strategy
• Reconstruct quality measures before and
after reporting
p
g
• Difference in differences (before/after by
low/high quality) in linear model
• Outcome: market shares to various
nursing homes (NH)
– Market
Market-level
level fixed effects
Technical concerns (1)
• Market
M k t shares
h
a problematical
bl
ti l metric
ti
– Especially in linear model
– HSA #1 with 2 NH: before=50%, 50%,
after=55% in good,45% in bad
– HSA #2 with 10 NH: before=10% each,
after=15% in good, 5% in bad???
• Alternative specifications of outcome
– log(market share) →proportional effects
– Occupancy rate
Technical concerns (2)
• Estimation of measure of residual demand
– Not in p
paper
p draft
– Role in model not clear
– Why needed for diff
diff-in-diff
in diff analysis?
• Falsification test with small NH
– No public quality report
– Test has low power (small samples/home)
Things I would like to know!
• Practical significance: How many were
moved to higher
g
q
quality
y nursing
g homes?
• Associations of “noticed” measures with
overall (“front
( front page”)
page ) quality summary
summary.
Some NH-specific analytic concerns
• Complications of capacity/occupancy
– Certification of beds for Medicare, Medicaid
– Competition for private/commercial pay
– Post-acute versus long-term
g
• Community-dwelling vs long-term postacute
Nursing home interpretive issues
• Quality measure interpretation
–
–
–
–
–
Outcomes, not processes.
Adequacy of risk adjustment???
Subjectivity of pain measure; upcoding??
Walking might be most relevant for many
many.
5-star reporting system.
• Who makes the decision?
Who uses the information?
– Families, patients have little input
– Discharge planners have major role
• More use of quality info (38%) than by family members (12%)
– Complex incentives
incentives, uncertain agency
• What did they actually see?
Long-stay
Short stay
Short-stay
Broader issue about quality
reporting
•Why?
•To
To whom?
Rationales for quality reporting (1)
Improve quality by providing information to
consumers for informed choice
 Consumers migrate
g
to higher-quality
g
q
yp
providers
 Market pressure for quality improvement
 Standard competitive
p
economic model assumes:
Competitive markets with low switching costs
Availability of appropriate information
Information processing capacity at minimal cost
Unconflicted agency of intermediaries
Improvement, not just selection (→ disparities?)
 Ideology of “Consumerism”
Rationales for q
quality
y reporting
p
g ((2))
1. Improve quality by providing information to
consumers for informed choice
2. Other motivational aspects




Appeal to provider professionalism
Accreditation
Regulatory/administrative sanctions (or threat)
P4P: monetary incentives
3. Value of information to facilitate QI
 Realistic self
self-assessment
assessment of weaknesses
eaknesses
 Regulatory/administrative direct action
Conclusions
• Naïve “consumerism” model may be hard to
justify
– Empirically or as policy
• There are other rationales for quality
measurement and reporting
– … ranging
g g from national p
progress
g
assessment to QI
implementation
• Public reporting of quality data may be an ethical
and political necessity
– Applaud efforts to improve and better understand
reporting
ti
• Thanks to
– David Grabowski
– David Stevenson
for helpful discussions