Study Finds that Hospital Quality Measure Reporting Did Not Lead to Quality Improvement in Germany

Recently, a study was conducted that found that the public reporting of hospital quality measures did not lead to overall quality improvement in Germany. The study’s authors found that the German hospital market “presents a unique opportunity to examine the relationship between public reporting and high-quality improvement in the absence of performance-linked payment incentives in a high-income country.”

Background

The study was conducted because the authors felt that while the quality of care in hospitals has been measured for more than two decades in the United States, that measurement and public reporting has led to only modest improvements in health outcomes and the improvement has come slowly over time. Not only that, but the authors note that differing payment models have not helped to achieve quality improvements, nor has the Hospital Value-Based Purchasing Program. The authors also take issue with the “fifty-four models launched by the Center for Medicare and Medicaid Innovation since its inception in 2010,” which have largely “led to neither cost savings nor improvements in quality.”

In performing the study, the authors considered quality indictors from several categories of health services, including hip, knee, obstetrics, neonatology, heart, neck artery surgery, pressure ulcers, and pneumonia. They pulled data from structured hospital quality reports from 2012 – 2019, focusing on risk-adjusted outcome indicators.

The authors note that the belief behind public reporting to greater outcomes has two paths: one path is that patients select providers with greater reporting numbers and the other path is that hospitals make changes to their care in an attempt to increase their quality rankings and lead to greater patient selection.

Findings

The study found that when hospitals use reported indicators for benchmarking and target the achievement of average quality, hospitals with low quality tend to take actions to improve their quality ratings while hospitals with high quality services tend to pay less attention to quality, and their quality actually declines.

Additionally, the study also found that on average during the study period, hospitals with low quality ratings were more likely to move to a higher quality category when compared to hospitals with quality ratings, which were more likely to move to a lower category. Hospitals that had average ratings typically had marginal changes. Overall, the probability of a low-quality hospital improving its quality was higher than the probability of a high-quality hospital experiencing a decline in all indicators.

Looking at the market categorization in Germany (best hospital in oligopoly, ordinary hospital, or monopolistic hospital), monopolistic hospitals were significantly less likely than ordinary hospitals to move to a lower quality category for hip, knee and heart indicators, but significantly more likely than the best hospitals in an oligopoly to move to a lower quality category for obstetrics and neonatology.

Conclusion

Overall, the study concluded that public reporting does provide a quality benchmark and prevents providers from providing very low-quality health care services. However, the findings did not support the idea that patients change their hospital and/or provider selections based on changes in quality.

Additionally, while hospitals’ intrinsic motivation and market forces tend to help improve quality, they are not alone sufficient to sustain quality of high-performing hospitals. As such, the study recommended rewarding high-performing institutions and aligning quality incentives with the intrinsic professional values of clinical care to help achieve quality improvement.