Author + information
- Hadley Wilson, MD, FACC, Chair, ACC Board of Governors∗ ()
- ↵∗Address for correspondence:
Dr. Hadley Wilson, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
The concept of collecting and publicly reporting information about the cost and quality of health care has been a source of debate and discussion for more than 3 decades. On the one hand, public reporting is viewed as a means of rewarding health care providers for providing quality, cost-effective care; helping hospitals and providers compare their performance with others; and offering patients information that they can use to make informed health care decisions. On the other hand, questions remain about the accuracy and type of data used, and very real concerns exist about how patients, payers, lawmakers, and others will use the data (1).
The Early Days of Public Reporting
One of the first public reporting efforts started in 1984 with the Health Care Financing Administration, now the Centers for Medicare & Medicaid Services (CMS), reporting hospital mortality rates of Medicare patients using data from administrative and claims information. The Health Care Financing Administration published a list of 269 hospitals at the extreme ends of the mortality rate spectrum—an effort that generated much criticism from hospitals and providers about the accuracy of the data, as well as the usefulness of the data to hospitals and consumers (2).
In the 1990s, a handful of states, including New York and Pennsylvania, developed their own reporting systems focused on mortality rates for coronary artery bypass graft surgery by hospitals, surgeons, and in some cases, health plans. Since then, Massachusetts, California, Wisconsin, Washington, and Texas have followed suit.
Fast forward to 2001, when the Institute of Medicine released its infamous Crossing the Quality Chasm: A New Health Care System for the 21st Century report calling for a safer, more effective, patient-centered, timely, and equitable health care system that included a focus on knowledge and shared information, as well as transparency of information (3). In 2002, CMS launched 3 quality reporting initiatives targeted at nursing homes, home health, and hospitals, and by 2003 the Agency required public reporting on measures addressing hospital infection rates, volume, and hospital readmissions (4).
The mid-2000s brought companies like HealthGrades and ConsumerHealthRatings (5) into the mix. Using proprietary and public databases, the publicly traded HealthGrades compiled quality reports on hospitals, physicians, nursing homes, and home health agencies, whereas ConsumerHealthRatings leveraged the Internet to provide consumers with links to more than 300 organizations providing ratings or performance reports.
CMS also launched its Hospital Compare website during this period. The site, which provides results of patient surveys regarding hospitalization experiences, core measures for cardiac patients, and risk-adjusted mortality and readmission rates for acute myocardial infarction and heart failure, currently provides quality information on 4,000 Medicare-certified hospitals across the United States, including over 130 Veterans Administration medical centers. It was in 2010, following the passage of the Patient Protection and Affordable Care Act, that CMS launched the physician-focused counterpart to Hospital Compare, aptly called Physician Compare. The goal? Help consumers “find and compare physicians and other clinicians enrolled in Medicare so that you can make informed choices about your health care” (6).
Other CMS endeavors during the early to mid-2000s included the launch of the Physician Voluntary Reporting Program (2006) and the Physician Quality Reporting System (2007). Both programs were efforts launched by the Agency to collect physician-specific quality data using incentives, and ultimately penalties, for participation. To help both hospitals and physicians navigate this evolving and often confusing public reporting landscape, the American College of Cardiology (ACC), working with its leadership and state chapters, formally got involved in the debate.
Public Reporting and the ACC
“The ACCF as a professional society, together with its state chapters and individual members, has a tradition of quality measurement and improvement. The College's approach—a combination of information and quality improvement tools—has proven effective in improving cardiovascular care without employing public reporting,” wrote Joseph P. Drozda, MD, FACC, and colleagues in a 2008 health policy statement outlining the College’s principles for public reporting (7). The statement went on to outline 6 key principles based on the ACC’s experience. In particular, the statement notes that public reporting programs should be developed in partnership with physicians, should be based on performance measures with scientific validity, and should include a formal process for evaluating the impact of the program. Additionally, “every effort should be made to use standardized data elements to assess and report performance,” with the “driving force” behind any program being quality improvement (7).
Over the last few years, the College also launched its own public reporting program that allows hospitals to voluntarily report process of care measures from the CathPCI Registry and the ICD Registry. U.S. News and World Report encourages hospitals to partake in either or both of these National Cardiovascular Data Registries (NCDR) and enroll in ACC’s public reporting program. Participating hospitals earn a transparency credit of 3 additional percentage points toward their annual Best Hospitals Rankings and Review. Hospitals participating in ACC’s ACTION Registry will be able to participate in the program in the following year.
Data from the NCDR registries more directly reflect clinical care than claims data and are more current than administrative data, which can lag 1 to 2 years behind. All sites participating in the CathPCI Registry and/or the ICD Registry have an opportunity to review their data a minimum of 30 days before they are released to the public and decide whether to opt in or out of the public reporting program. Since 2015, the reported metrics are listed in Table 1.
“There are several important reasons for hospitals to participate in the NCDR public reporting programs,” wrote Gregory J. Dehmer, MD, FACC, and colleagues in a 2016 interim report from the NCDR Public Reporting Group published in the Journal. “First, the public has a growing desire for this information; thus, providing these NCDR data demonstrates a good faith effort to deliver high-quality clinical data to assist patients’ health care decisions. Second, value-driven purchasing, which will include public access to provider performance, will be dominant within several years… Finally, all major cardiovascular professional organizations support patient advocacy, serve members’ practice advancement, and promote quality education programs for their members, and many support clinical databases” (8).
Patients can also benefit from ACC’s Public Reporting effort with the Find Your Heart a Home tool housed on the College’s online CardioSmart portal. Patients and caregivers can search, compare, and select the right hospital to fit their cardiovascular needs based on a hospital’s commitment to quality through participation in the NCDR and the voluntary public reporting program. Over time, participation in additional registries will be included, as will participation in ACC Accreditation Services, providing consumers with a complete picture of the number of ways a hospital is showcasing its commitment to transparent, cost-effective, and evidence-based cardiovascular care.
Dehmer at al. (8) note that “the medical community continues to have an understandable degree of anxiety over the unintended consequences of public reporting and the ability of the public and others to misuse or misinterpret the results.” However, public reporting is not going away. In fact, the Medicare and CHIP Reauthorization Act (MACRA) only further cements the transition to a health system focused on payment for quality and outcomes versus the age-old fee-for-service system. Under MACRA, payment adjustments will be based on 4 performance categories: clinical quality, meaningful use, resource use, and clinical practice improvement. This, coupled with the increasing demand from consumers, lawmakers, and payers alike to have health care information at their fingertips, only increases the likelihood that public reporting will continue to gain traction.
The ACC and the NCDR recognize that every advancement in transparency is not without debate. For years, publicly reporting outcomes after procedures on the sickest patients has been a double-edged sword. The old conundrum of the highest-risk patients being transported for care to tertiary or quaternary centers for the best chance of survival, often at the expense of the hospital’s outcomes data, has been a difficult problem to solve (9). The next version of the CathPCI Registry, due out next year, seeks to rectify these issues with a more well-defined risk model for comparison. Additional future efforts may be directed at establishing universal definitions for cardiac arrest, cardiogenic shock, and surgical “turn-down” patients that may level the playing field further.
The ACC is committed to continuing to engage in the public reporting debate. The College will continue to find ways to build on its existing public reporting efforts to ensure that high-quality clinical data are used and that any reporting program fairly and accurately characterizes the care being provided to patients by hospitals and physicians. More importantly, the College is committed to ensuring that patients and the public at large have transparent and trusted information they can use to make informed decisions about their care. While the conversation continues to unfold, the College has built a firm foundation on which to grow.
- 2017 American College of Cardiology Foundation
- ↵Colmers JM. Public reporting and transparency. The Commonwealth Fund. January 2007. Available at: http://www.commonwealthfund.org/usr_doc/Colmers_pubreportingtransparency_988.pdf. Accessed September 27, 2017.
- Institute of Medicine
- ↵Leonard K. America’s health care elixir. U.S. News & World Report. July 30, 2015. Available at: https://www.usnews.com/news/the-report/articles/2015/07/30/medicare-changed-health-care-in-america-for-the-better. Accessed September 27, 2017.
- ↵Consumer Health Ratings. Available at: http://www.consumerhealthratings.com/about_us.php. Accessed October 2017.
- ↵Centers for Medicare and Medicaid Services. About Physician Compare. Available at: https://www.medicare.gov/physiciancompare/#about/aboutPhysicianCompare. Accessed September 27, 2017.
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