Patient-centered, Purposeful Public Reporting

1. Patient-centered, Purposeful Public Reporting David Share, MD, MPH vice president, Value Partnerships Blue Cross Blue Shield of Michigan dshare@bcbsm.com

2. Purpose: Empowering Consumers to be Full Partners in Their Care • Information/knowledge = power • However, there is scant evidence that consumers use provider performance information to select doctors and hospitals • Except for a few high risk/complex, non-urgent services for a modest number of people • Available data shine a narrow spotlight on limited and technical aspects of care quality and efficiency • Not likely that clinical performance measures are relevant to consumers

3. Purpose: Catalyzing Provider Performance Improvement and System Transformation • Publicly reporting performance data has more impact on providers than consumers • Evidence exists that improvement is catalyzed by publicly reported data • Available data shine a narrow spotlight on limited and technical aspects of care quality and efficiency, limiting impact to these areas of care

4. Unintended Consequences of Public Reporting • One-size-fits all measures and rigid measurement goals can cause harm • e.g., focus on outcomes seems sensible, but reporting on blood sugar control can lead to overly aggressive treatment of diabetes, with increased complication rates • More good results from reducing A1c levels from 9.5 to 8.5, but reporting only focuses on % below 7 or 8 • One goal for all patients (e.g., cholesterol below a set point, BP below a certain level) puts sub-sets of patients at increased risk (especially the elderly or people with complex chronic illness)

5. Unintended Consequences of Public Reporting: Avoiding Challenging Patients • Comparison of Percutaneous Coronary Intervention (PCI), i.e., cardiac angioplasty, in Michigan (no public reporting) and New York (public reporting at individual provider level) • Unadjusted mortality: MI: 1.54%; NY: 0.83% • % with PCI for heart attack: MI: 14.4%; NY: 8.7% • % with cardiac shock: MI: 2.6%; NY: 0.38% • Adjusted mortality: no difference • Cardiologists in NY actively avoid high risk patients even though the patients have lower risk of death and heart damage with PCI than without Moscucci, et al, JACC Vol. 45, No. 11, 2005

6. Frame of Reference for Public Reporting • Problems with individual provider public reporting • Limits accuracy because of small numbers and non-random distribution of patients • Amplifies fear of treating challenging patients and serving at risk populations • Performance quality and improvement are more dependent on the system in which an individual practices • If system improvement yields greater value for patients and society, shift reporting to system performance

7. Separate Reporting for Providers • Limit clinical/technical measurement-based reporting to providers • Focus on preventive services; essential care processes for chronic conditions; ambulatory care sensitive condition admission and ED use; cost measures; patient experience measures • Discover new ways to report at individual provider level to avoid adverse, unintended consequences • Report publicly on system performance • Hold providers accountable for system performance • Report individual performance to system leadership for action within the system’s “Community of Caregivers” • Significant social leverage • Guided by more nuanced understanding of variation in performance

8. Separate Reporting for Consumers • Inform consumers on overall system performance • Identify Patient Centered Medical Home-based practices and their performance • Aggregate performance measures into summary measures • Focus reporting on “Communities of Caregivers”, identifying their level of overall value (cost, quality and patient experience) • Engage consumers in selecting medical homes, and “Communities of Caregivers”, by linking out of pocket costs to level of value delivered by the provider group from which the consumer seeks care