My oldest son Ben, 5, came down to the office the other day to visit, and he brought with him his favorite computer game, "Backyard Football." It's this nifty little sandlot football game on a CD that lets players choose sides by picking from a grandstand full of real professional athletes and fictional neighborhood kids. Ben takes the game wherever he goes, hoping to find another sucker to beat. He's defeated me dozens of times while I've managed to win only twice.
One reason why Ben has such a stellar win-loss record at "Backyard Football" is that whenever I pull ahead in a game, he gets "bored" and quits before the game is over, with the incomplete score never to enter the record books. Or when he's behind he'll distract me by saying something like "The pizza is here" and quickly hits ctrl-alt-delete to end the game.
The way Ben plays "Backyard Football" is a lot like the way hospitals participate in voluntary quality-reporting projects. If they think they'll look good, they'll participate. If they think they'll look bad, they won't. Why take a chance? In today's pressure-cooker healthcare management environment, voluntarily getting a hospital ranked near the bottom of some listing could cost a CEO his or her job.
In last week's issue, reporter Laura B. Benko wrote about the third annual effort by the California HealthCare Foundation and the California Institute for Health Systems Performance to publicly disclose the level of satisfaction patients have with their hospitals and their hospital care (Sept. 20, p. 12). Between the first and second year of the survey project, the number of participating hospitals jumped 60%, to 181 in 2003 from 113 in 2002, and the percentage of eligible hospitals that participated rose to 47% in 2003 from 30% in 2002. But this year, hospital participation seemed to lose steam. Some 200 hospitals participated in this year's project, representing 51% of hospitals in the state. The numbers were up but only slightly, to the huge disappointment of the sponsor organizations, patient advocates, employers and insurers.
As Benko reported, 63 hospitals joined the voluntary reporting project for the first time this year. But, 44 hospitals that participated last year dropped out in 2004. Of those, 42 scored average or below-average in the satisfaction rankings, and the other two hospitals closed.
The California experience reminded me of the Medicare pay-for-performance demonstration project agreed to last year by the CMS and the Premier health alliance. Top-performing hospitals are eligible for up to a 2% bonus on top of their Medicare payments for certain procedures while bottom-performing hospitals can be penalized with as much as a 2% reduction in Medicare payments for those procedures. The catch is, if a hospital senses that it is at risk for getting penalized, it can drop out of the program before the final results are in and sidestep the pay cut.
Did you ever wonder why hospitals by the thousands continue to voluntarily seek accreditation from the Joint Commission on Accreditation of Healthcare Organizations? They do so despite all their moaning about whether the JCAHO is a regulator or a peer. They do so despite all their questioning of whether the accreditation process improves patient care. They do so despite all their complaining about high survey fees. They do so because of the Joint Commission's "deemed status" relationship with Medicare. If a hospital is accredited by the JCAHO, it automatically qualifies for Medicare (and Medicaid in many states). A typical hospital depends on the two government-run health insurance programs for more than half of its annual revenue. The Joint Commission established a huge financial incentive for hospitals to volunteer to be inspected by a private accrediting agency.
Most hospitals won't participate in voluntary outcome reporting programs without such an incentive. Absent that, such reporting programs may have to be mandatory to be of any use to patients.