It's almost become an event, and the public is taking notice, as are providers. The Allentown Morning Call, for instance, splashed the results across the front page when they were announced May 7.
Now in its fourth edition, the state of Pennsylvania's 1994-95 Guide to Coronary Artery Bypass Graft Surgery shows real results that its backers say justify the time and expense of collecting the data.
The guide shows in-hospital mortality dropped 22% from 1991 to 1995, while risk factors remained steady and the number of CABG surgeries rose 25% over the same period. And for the first time, charges for CABG actually declined, by 3.9% over the previous year, to an average of $52,465.
Two new indicators this year are health plan data and hospital length of stay. "To our knowledge, this is the first time outcome-based information, risk-adjusted mortality rates and length of hospital stay are available to the public according to the specific plan that patients belong to," says Joe Martin, spokesman for the Pennsylvania Health Care Cost Containment Council, which publishes the report.
The council issues the consumer guides every two years. The 1994-1995 report includes data for 43 hospitals and 32 health plans in Pennsylvania.
All the health plans (broken down by fee-for-service, Medicare HMO, Medicaid HMO and commercial HMO) fell within the expected range of mortality, except Greater Atlantic Health Service, which had a rate of 8.3%. Its expected mortality rate should have been no higher than 5.6%.
Charles Inlander, president of the People's Medical Society in Allentown, a widely known consumer advocate, says publishing the health plan guide is "far more significant than the HEDIS (Health Plan Employer Data and Information Set) and other data that's out there, because it's real events with real docs against real plans." This, he says, should "move things up to the next level. This is a lot better than saying 90% of the people get immunized."
The Managed Care Association of Pennsylvania, Harrisburg, has given technical support and suggestions to the council in preparing the CABG guide. "It's groundbreaking stuff, reporting on specific hospitals and health plans and specific surgeons," says Kimberly Kockler, executive director. "I think those three things in one report is pretty awesome."
But she points out that the reports need to be made more timely. "Our industry evolves dramatically in a week," she says.
A key finding was that there's no link between a patient's insurance plan and hospital mortality. Length of stay was slightly shorter in HMO plans, which Kockler says didn't surprise anybody.
However, the relatively small sample size of HMO procedures-only 11% of the total-means penetration has not started to affect the overall medical or hospital marketplace. However, HMO*penetration has increased greatly since 1995, Kockler says, so current data might show a greater disparity. Similarly, it's probably too soon for patients to start using this kind of data in choosing an HMO. But over time, Inlander suggests, managed care will have to show a difference in quality to justify its role.
The report also shows the percentage of total CABG surgeries each health plan sends to each hospital. This strips away the proprietary veil of the volume relationship between hospital and plan. There appears to be less funneling of patients to a particular hospital than one might expect in a more mature managed-care marketplace.
For example, U.S. Healthcare sent 27% of its CABGs to Hahnemann University Hospital, and Aetna's HMO (then a separate company) sent 24% to Hospital of the University of Pennsylvania. They distributed the rest of their patients to other hospitals.
Conceivably, publication of this information could motivate hospitals with good mortality and low charges to use the data to approach insurers and try to swing more business. It may speed up market stratification and increase the marketing alliances that higher managed-care penetration typically brings to a hospital marketplace.
The council hasn't analyzed longitudinal rates of mortality at the various hospitals and among surgeons, but Martin says anybody can line up the reports and compare results. For example, he says, they show Allegheny General Hospital had significantly lower-than-expected mortality rates in four out of six years, and Lehigh Valley Hospital had lower-than-expected rates in three out of four years. "You certainly can see some consistency," he says.
Consistency, and it's hoped, improvement, of outcomes is what the medical quality movement wants over time.
"The more this data comes out, year after year, the better the facilities get at doing what they do," Inlander says. Some hospitals have dropped certain physician practices from privileges because results were not up to snuff; others have cut departments or stopped doing procedures. And they've become more cost competitive because of the data, slashing $4,000 to $6,000 from charges for some procedures, he says.
Hospitals have found the data useful in recruiting medical staff, setting up internal quality monitoring programs and marketing to payers, says David Nash, M.D., a quality expert at Thomas Jefferson University and a consultant on the state study. Nash also notes high-volume, good-outcome surgeons continue to attract more cases. "That is clearly a trend. That would argue that the report is working," he says.
Inlander predicts hospitals will soon begin to use these results in direct-to-consumer advertising. Bed counts are dwindling, and administrators will become desperate, he says. "They have merged, purged, done everything they can do," he says. "The next thing is to really get customers, boost the volume."