Public Reporting of Clinical Outcomes-The Data Needs of Health Care Stakeholders

As insurance carriers evolve into managed care organizations, they are challenged to offer the right products at competitive prices with good consumer satisfaction. These organizations must strengthen their historical relationships with doctors and hospitals to form stronger partnerships, while building large infrastructure to deliver comprehensive health services. The information needs of these organizations has rapidly been transformed from transactional databases designed to pay individual claims to decision support technology to manage provider networks. In this evolving environment the Council can play a vital role in contributing clinical data to supplement the rich administrative databases already available internally within these organizations. The ability to serve as a data repository and broker of information, facilitating ad hoc internal and external reporting, is an untapped potential for PHC4.

The ability to accurately adjust for case-mix and severity and to define "episodes of care" can be used by managed care organizations to both educate their clinicians and to enhance the marketability of managed care products. The managed care organizations must improve measures of quality of both products and of provider networks. Provider profiles must be accurate and consistent and include case mix and severity adjustments. They must measure quality in terms of both process (e.g., HEDlS) (6) and outcomes. They must provide primary care physicians, and other providers with i;"formation about practice patterns, cost effective treatments, patient outcomes and other measures. They must integrate external databases such as the Council's data into their own internal information systems.

The advantage of the Council's data to managed care organizations is that they add clinical depth to their own data and provide information about patients other than their own. They would also benefit from information about ambulatory care quality, developed with the same high standards the Council used for the assessment of inpatient care. In addition, the data need to be more timely.

The Council has had its greatest impact on the providers of health care. This outcome was not anticipated when the Council was established in 1986. The hospital community viewed early efforts by PHC4 with skepticism and disdain. Today, in an increasingly competitive environment hospitals recognize the need for well validated comparative outcome data and data for competitor analysis. Consequently, the hospital community is engaged in the activities of the Council to assure its data and reports are of value. Hospitals utilize PHC4 data to identify service areas which are appropriate targets of process improvement initiatives ⁽7^, 8⁾ and understand and assess the competition in the marketplace.

Hospitals have accepted the validity of the process of public reporting of outcome information, even if they occasionally take exception to the methodology. Hospitals are most interested in the continued evolution of risk adjustment and severity of illness tools. Specialty hospitals in Pennsylvania such as the rehabilitation and psychiatric hospitals have expressed an interested in a mandated uniform outcomes assessment tools. In addition, hospitals recognize that the care provided during acute hospitalization occurs within the context of treatment for an episode of illness. These episodes may span a considerable period of time and can include multiple interactions with a variety of health care institutions and providers. Consequently, the importance of outcome data specifically related to hospitalization is becoming only one component of the overall assessment of health care delivery.

Although the Council's data provide useful comparative outcome data, they are less useful for evaluating resource utilization in comparison with other institutions. Identifying best practices and the most efficient resource utilization would be important to hospitals. Finally, the financial burden associated with collecting, editing, and submitting data to PHC4 has been carried by hospitals. Hospital executives continue to strive for approaches to minimize expenditures and that includes assuring that the Council requests for data are reasoned and realistic and avoid duplication with other reporting requirements.

The medical community also recognizes the benefit of improved and accurate predictive models to assess clinical performance to permit the comparison of performance between institutions. Physicians utilize data to assess practice outcome variability. Reducing practice variability with feedback from measured outcomes is a useful tool to provide the highest quality of care at the lowest possible cost.

Physicians continue to seek ways to interact with the Council. Such interaction stimulates doctors to become more familiar with the intricacies of outcome data collection and analysis. It also facilitates the continuing education of patients by physicians about publicly available performance information.

The medical community remains concerned that proper efforts to maintain patient confidentiality are implemented. It is important that data be used as a method to provide feedback to the actual providers of care and not merely as a punitive tool. In view of efforts to profile physician activity by many components of the health care industry, physicians are committed to assuring that initiatives of the Council have clearly defined goals and that reports disseminated by PHC4 indicate the complexity involved in assessing clinical performance. This is important in an environment where patient care is organized around a health care team which often includes multiple professionals and institutions.

Finally, much of what has been reported publicly to date can be considered a measure of the "science" of medicine. Physicians are recognizing that measuring the "art" of medicine will require greater attention to patient satisfaction. This may not be most appropriately performed by the Council but it should be a factor in deliberations regarding any future assessments of the changing health care system.

To serve the data needs of its stakeholders the Council needs to understand the information needs of its end users. These users include business and labor and their health benefits professionals, insurers, managed care organizations, hospitals, physicians, and the general public. Their needs for information vary as do their analytical capabilities. The tensions created by these differing expectations and capabilities can be ameliorated with efforts such as those undertaken by the Council for the assessment of outcomes from the care of acute myocardial infarction ⁽5^, 9⁾. These reports present complex outcome information in a format de­ signed to be understandable to both consumers as well as more sophisticated users. The Council's challenge is to produce information that bridges these differences and provides useful data which monitors change in the health care system and fosters continuous quality improvement.

The Council must balance the needs of purchasers and consumers for easy to understand information with the needs of providers and payers who demand the most rigorous methods available for adjusting for case mix and severity of illness. The Council must also balance the need for timely information which facilitates decision making and the need for highly accurate data. The diverse constituents do agree that the Council must begin to shift its focus to measure health plan performance in addition to individual provider performance.

As the Council expands its data reporting and exploits new technologies to improve the timeliness of it. data, PHC4 can serve the needs of multiple stakeholders as they struggle to more fully understand the health care delivery system in a rapidly changing health care delivery environment.

The authors thank Ernest Sessa, Executive Director, Pennsylvania Health Care Cost ContaInment Council, Harrisburg, PA; Patricia Coyle, Manager, Employee Benefits, Rohm & Haas, Philadelphia, PA; Dennis Sar­nowski, Administrator, Laborers Combined Funds of Western Pennsylvania, Pittsburgh, PA; Joseph Reilly, Benefits Consulting Director, Pennsylvania Blue Shield, Camp Hill, PA; Robert Mandell, M.D., Vice President for Clinical Integration, Capitol Health System, Harrisburg, PA; and Lee McCormick, M.D., ChaIrman, American Medical Association Organized Medical Staff Section, Chicago, IL, and Medical Director, Prime Medical Group, Pittsburgh, PA, for participating on the panel, the Data Needs of Stakeholders at the PHC4 National Symposium on Outcomes and Quality Assessment­State of the Art and Future Directions, June 2, 1995.