Report Cards, Hospitals and Physicians

The term report cards in the context of healthcare has come to be used to describe comparative data on quality and cost of care, particularly when such data are made available to the public. A common view is that greater transparency will drive improvement and guide patients to the best care. Although not the only stakeholder group that is subject to scrutiny, this entry focuses on report cards on providers, specifically hospitals and physicians.

Few would argue with the importance of provider efforts to measure performance internally for the purposes of improvement. For example, a practice may perform a peer review of physicians based on adherence to recognized care standards and make such information available to all providers within a practice. The controversy grows, however, with increasing levels of transparency. Sharing that same information with patients, health plans, purchasers, and other stakeholders brings both opportunity and risk. While several years ago the controversy centered on whether report cards should be issued at all, in more recent years the debate has centered more on what measures are best and what are the most productive ways to use the information.

Measuring and sharing data on provider performance on a large scale is a relatively new development. There were a few pioneers in the field of healthcare quality improvement who saw the importance of measuring results long ago. For example, Florence Nightingale kept meticulous records of mortality rates in military hospitals during the 19th-century Crimean War, and in so doing, she blazed trails both in quality measurement and the field of nursing. In a later example, Ernest Codman famously established the End Result Hospital, in early 20th-century Boston, in which he maintained and shared detailed records of outcomes for his surgical patients. But despite the courageous efforts of a few, who at times were subjected to scorn and ridicule, the real effects of the work of healthcare providers have often been shrouded in secrecy. Not until the soaring costs of healthcare in the 1980s and beyond has serious, [Page 978]widespread attention been given to measuring quality.

One of the primary reasons for the emergence of report cards is the growing demand for value in healthcare. Although defined in various ways, the basic concept of value has two components: (1) quality and (2) cost. High-quality care increases the likelihood of a desirable outcome and is in line with patient preferences, according to a widely cited Institute of Medicine definition. The broad concept of cost needs no definition, but actual measurement of cost poses many challenges. Value can be thought of as the ratio of quality to cost. While the feasibility of actually decreasing healthcare costs over the long term can be debated, many would agree that purchasers of healthcare should at least expect value for the healthcare dollar spent.

There is a great deal of evidence, however, that healthcare purchasers in the United States do not consistently get value for the healthcare dollar. Errors that bring harm to patients and drive costs up, missed opportunities to provide preventive care, and failure to bring the benefits of evidence-based treatments to patients, particularly for chronic disease, are clear indicators of problems.

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