Medicare

Medicare's Public Reporting Initiative Fails to Reduce Mortality

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Since 2005, Medicare has run a data collection initiative known as Hospital Compare. The program paid eligible hospitals to self-report a number of predetermined quality measures, which were then tracked and made accessible in a public database. The program also provided some information to patients and medical consumers. But a study in Health Affairs by researchers from Cornell Medical College and the University of Michigan reports that the program has not had much effect on health outcomes. Mortality rates dropped, but only in line with preexisting trends.

"Our analysis indicates that the fact that hospitals had to report quality data under Hospital Compare led to no reductions in mortality beyond existing trends for heart attack and pneumonia and led to a modest reduction in mortality for heart failure," the authors write. "We conclude that Medicare's public reporting initiative for hospitals has had a minimal impact on patient mortality."

All else being equal, there is nothing wrong with increased transparency and data analysis. But I suspect that, at least within Medicare, hopes for this sort of procedural reform have long been calibrated too high. As Congressional Budget Office Director Douglas Elmendorf testified last summer, Medicare's demonstration projects frequently produce disappointing results. "It turns out to be pretty hard to take ideas that seem to work in certain contexts and proliferate that throughout the health care system," he told members of Congress. "The results are discouraging."

Not surprisingly, this is far from the first or only failure of various technocratic tweaks to Medicare and other government health programs. 

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  1. “It turns out to be pretty hard to take ideas that seem to work in certain contexts and proliferate that throughout the health care system,”

    Isn’t this the heart of the problem with most governmental initiatives?

    1. it’s a problem with scaling up in general. Engineers have known this for pretty much forever.

      1. it’s a problem with scaling up in general. Engineers have known this for pretty much forever.

        You mean I can’t really make a jumbo jet by folding a giant piece of paper?!
        Time to find something else to do with my federal grant money.

    2. The problem is that they didn’t want it to succeed bad enough! If they had just loved more, it all would have been OK!

      /emotive idiot

  2. You might be a king or a little street sweeper, but sooner or later you dance with the reaper.

    1. Unless you’re white. Then you sit around the perimeter of the dance floor, and Death walks around and taps you on the shoulder when it’s your time.

      This is for the best. Which you know if you’ve seen white people dance, even with the Reaper.

  3. You mean that government bureaucrats publishing statistics not necessarily relevant or based on reality don’t cause people to become healthier?

    I am shocked, SHOCKED at this totally unexpected outcome.

  4. Let’s not overlook that this isn’t free, either. In order to justify its costs, it should move the needle. If it doesn’t, that doesn’t mean its harmless, that means its bad and should be eliminated.

    1. I don’t entirely disagree. But I would prefer to see spending reductions elsewhere before ditching reporting initiatives that can help us see what’s happening within the system.

      1. I disagree completely. Unnecessary and useless reporting is one of the biggest wastes in business, and is worse in the govt. As RC notes, if it doesn’t directly impact some outcome (improve care, improve results, reduce cost, etc) then it’s worse than useless – it siphons time and effort from things that actually matter.

        We went through this when I was in the logistics business. A change from “internal-looking” to “customer-focused” objectives alone improved our results by ~20%. Why? Cause now we were measuring stuff the CUSTOMER cared about, not what we THOUGHT they cared about (but only WE cared about).

        This one’s like an iron law of bidness – “That which is measured gets done.” Therefore, you damned well BETTER be measuring the “right” things, esp in something like healthcare, where life and death are literally at stake.

        LITERALLY…:)

  5. But I would prefer to see spending reductions elsewhere before ditching reporting initiatives that can help us see what’s happening within the system.

    Take two — Peter: “But I would prefer to see spending reductions elsewhere before ditching government-mandated reporting initiatives, using data self-reported by hospitals with a financial incentive to have good numbers, and with said numbers not closely related to how people choose a physician or hospital — numbers that very few people will see or base decisions upon — and the collection of said numbers siphoning money away from actual patient care — numbers that can help a handful of nerds like me see what’s probably not actually happening within the system.”

  6. I wish I had the studies in front of me, but quite a number of hospitals have had reductions in mortality/infection and improvements in patient recovery/outcomes by essentially implementing the same things we do in manufacturing to standardize work:
    – checklists
    – operator instruction sheets
    – visual organization
    -“a place for everything” so it’s obvious when something’s not right
    – value stream mapping to ID and elim waste in the process or places where errors can occur
    – “poke a yoke”/”idiot-proofing” processes
    – etc

    I’ll look for the linkys. I just remember that the results were amazing. It’s interesting stuff, and totally replicable, albeit only from a process standpoint (outcomes will vary based on each hospital’s starting point).

    Of course, the biggest barrier to everyone doing this stuff? Not in the culture, not invented here, “we’re not a factory”, etc….

  7. Qualitative comparisons are only useful if alternatives exist. It doesn’t matter much if your local hospital sucks if it’s the only one in town.

    1. MY hospital is OK. It’s the healthcare SYSTEM that’s the problem….

      See Also: Congresspersons

  8. The biggest barrier to improvement, in my estimation, is the cartelized structure of medicine, and the circling of the wagons mentality.

    Try to get truly useful qualitative information about a doctor. All you get is “is” / “is not” a Guild Member.

    1. The trouble is, what constitutes useful qualitative information? Pretty much all of the “quality measures” for physicians that are tracked by Medicare have very little basis in research and have not been shown to change patient outcomes. If you track how well patients do, then the doctors that treat the least sick, on average, will look better than those that treat the critically ill, even though that may not be true. People want a number that makes decision making easy. If you want a good outcome, the best approach is to shop around, but don’t think there’s going to be a metric, now or ever, that shows reliably that you have a good doc. It’s too easy to game the system.

      1. You sound like a teacher.

  9. Also, Smiley Face Alt Text, Mr. Suderman 🙂

  10. the biggest barrier to everyone doing this stuff?

    I’ll go with, “You cannot expect the High Priesthood to accept standardization of process. That’s demeaning.”

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  15. I deeply appreciate Medicare for being transparent in informing people about their data. This is a sensitive topics that clear information, exact data and fast information are all needed. Great job for your management.

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