In the study states, state officials expressed their hope that public reporting of deficiencies will improve quality by stimulating competition and sparking change in facility culture. Of the states we studied, however none have formally evaluated the impact of their public reporting programs on quality of care. Maryland plans to perform an analysis on the impact of their public reporting initiative, and the state has made some modifications to the public report based upon feedback.
Doubts were already being voiced in several states we visited, however, about the potential effectiveness of public reporting to effect change. As discussed above, some stakeholders questioned whether the report cards could have an impact on consumer decisions, since the public is not sufficiently aware that the report cards exist. In most states, agency staff are able to measure how many people use the website, although they cannot identify whether these are consumers, policymakers, researchers, or others. Further, as suggested above, additional education may be necessary to raise consumer awareness of the report cards and promote consumer use of available nursing home quality information more generally.
Another factor that may limit the impact of report cards on quality improvement is that nursing home placement choices are limited in some states. However, some providers and other stakeholders voiced the opinion that access to quality reports is increasingly important in states where falling nursing home bed occupancy rates are expanding consumer choice.
Of most fundamental importance is the concern is that public reporting of inadequately risk adjusted quality indicators could limit access for heavy care patients even at the best performing facilities. For example:
In Maryland state officials said that some members of the nursing home industry have complained that they are being penalized for admitting heavier care residents.
In Texas, some stakeholders were concerned that providers are refusing to admit certain types of residents that may negatively impact the provider's quality measurement score.
Although public reporting has been promoted as a means for facilities to identify problem areas and target initiatives aimed at improving quality of care, none of the providers we spoke with identified it as such. Some stakeholders expressed concern that it is primarily the facilities already considered to be top-performing that will make necessary changes, while a certain percentage of providers in each state simply do not have the resources to initiate or sustain these improvement programs. In Florida, for example, consumer advocates noted that some facilities have been on the Watch List many times, and that this does not appear to have provided sufficient motivation for those facilities to do a better job. Nonetheless, some stakeholders with whom we spoke suggested that public reporting is a necessary, but, not sufficient step to improve nursing home quality.