Free the Data: Public accountability sorely needed for Medicaid providers

This post was produced for the USC Health Data Accountability Project, a joint initiative of the USC Center for Health Journalism and the Gehr Family Center for Health Systems Science. — Ed.

For years, consumers have been able to consult a host of websites for health care quality information for hospitals, nursing homes and many medical providers who care for privately insured and Medicare patients.

But if you are poor, you aren’t entitled to the same privilege.

Low-income families who receive their health insurance through Medicaid – the fastest growing segment of health care today – have almost no way to find information on the quality of the care they receive in clinics, the frontline where most Medicaid-paid care is delivered.

Transparency has become a key mantra of the health care industry, and it’s hard to find anyone in medical circles who doesn’t espouse it as a value. President Obama made it one of his signature promises for health reform. But while progress has been made in the commercial sector, it’s fallen short for low-income families. Without it, mediocrity – or worse – can persist with little pressure for poor performers to improve.

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Massachusetts pioneers making quality a public priority for safety net patients

The Center for Health Journalism at the USC Annenberg School of Journalism and the Gehr Center for Health Systems Science at the USC Keck School of Medicine set out to bring greater transparency starting in one California county – our own. In a more than yearlong effort, we sought to obtain and publish health care quality data for the clinic groups that serve 3.9 million people, 30 percent of the state’s 13.3 million Medicaid recipients.

The Gehr Center, for which Michael is the inaugural director, focuses on helping health systems deliver better and more efficient care. The Center for Health Journalism, for which Michelle is the founding director, helps reporters nationwide produce impactful health journalism projects and supports reporting on underserved and low-income communities. Data transparency is built into the DNA of both of our centers.

“I know transparency makes people uncomfortable, but providers should draw some insight from the observation that everyone wants transparency for everyone else other than themselves. That should tell them that others expect it from us, too.” — Dr. Thomas Lee, chief medical officer for Press Ganey Associaties

In Los Angeles County, where our USC centers are based, the public health department posts notices in restaurants indicating whether they have “A,” “B” or “C” ratings. We hoped to make similarly user-friendly ratings available for healthcare provider groups caring for those covered by Medicaid—called Medi-Cal in California--the publicly funded insurance program for low-income families.

In L.A. County, the data we sought is currently collected and compiled into a simple and easy-to-understand report card for most Medi-Cal provider groups, and it includes rankings on several sets of quality metrics. But to date, in L.A, and most other parts of the country, after it is collected, this information has been kept under wraps.

One set of measures on the report card indicates whether certain procedures or screenings have taken place – such as regular tests for breast or cervical cancer or routine childhood vaccinations. Another set of metrics focuses on patient experiences, such as whether a patient got an appointment for care as soon as it was needed or had information explained in a way that was easy to understand. The scorecard also includes rates of emergency room and hospital visits by clinic patients (adjusted based on their age and health).

Such data would be valuable for patients served by Maternal and Child Access, a health care advocacy organization in Los Angeles for low-income families, says its executive director, Lynn Kersey. “I know of people who have had missed breast cancers without proper screening and who should have been made aware,” she said. “I would hope knowing that a clinic is in the bottom quartile would help them determine they didn’t want to go there. The more this would be out in public and is used, the more on their toes the clinics and providers would need to be.”

We sought to be collaborative in our quest for health care quality data, asking medical groups and clinic chains that serve low-income families to disclose their scorecard results to us voluntarily for public release. Ultimately, we hoped to build an interactive app that would help patients decide where to seek care.

But we ran into one roadblock after another. The same health care sector that preaches about the value of transparency proved unwilling to risk image or reputation by making quality data public, even if it might lead to more empowered patients.

Over the course of months, we reached out to the leadership of associations of health care clinics and the county’s two major Medicaid health plans, as well as to the county’s major Medicaid health care providers, including Los Angeles County’s Department of Health Services.

We also asked leaders of the Los Angeles County Clinic Association – a group that represents community health centers that receive heavy public subsidies – to support our effort. The clinic association declined to help.

Many closed doors

Some health care leaders shut their doors gently. Others slammed them shut.

Even clinics and county organizations that are heavily subsidized by – or even entirely funded by -- taxpayer dollars felt no obligation to share information with the public that funds them.

That was the case with Iris Weil, executive director of Health Care LA – one of the county’s largest practice associations, which is affiliated with the county’s publicly supported community health centers. She emailed us about our request for patient quality data: “I discussed your request for releasing our Quality Data with my Board of Directors this morning. The vote was not to do it at this time.”

When asked why, she emailed her reply: “Basically we do not know what we have to gain by sharing the info! What’s in it for us?”

Similarly, Los Angeles County’s Department of Health Services declined to participate. The agency serves 600,000 patients annually at 19 clinics and four hospitals.  “Please be apprised that DHS has chosen not to voluntarily produce copies of the documents you seek,” an agency official wrote.

Some health care leaders were willing to talk with us more openly about releasing their data.

We discussed our request with Cástulo de la Rocha, the President and CEO of AltaMed Health Services, the largest community clinic chain in the state and one of the largest Medicaid providers in the country. (Michael was the medical director for innovation at Altamed from 2012-2015 and continues to collaborate with the company on a variety of research projects.)

Asked whether he would support our transparency effort, de la Rocha told us: “I embrace the idea. I think it is absolutely essential for the safety net providers in general. He added that quality metrics “serve as an incentive to push providers to do a better job – not only for our patients – but it also helps us in engagement of our workforce.”

Warned not to cooperate with us

Later, however, Altamed’s chief medical officer told us that the chain would not release its scores.

Another community clinic leader, Corinne Sanchez, president and CEO of El Proyecto del Barrio, also told us that she believes in transparency and was open to the idea of sharing clinic scores but wanted to know if other medical groups would be releasing theirs. After we told her that she might not have much company if she disclosed her clinic data, Sanchez did not reply to our follow-up correspondence.

Both Sanchez and de la Rocha may have had another reason to decline our request. Shortly after we began reaching out to Medi-Cal provider groups, the CEO of a health care organization that controls millions of dollars in health care contracts in Los Angeles County (including contracts with Sanchez’s and de la Rocha’s organizations) sent out an extraordinary letter warning groups not to cooperate with our request to share data.

We’ll share more on that in our next post.

Concerns about dirty data – or the fallout of disclosure?

In our quest to obtain Medi-Cal data, the health care leaders we spoke to offered up a variety of other reasons for not sharing quality data. The most pernicious of those arguments, in our view, was that it would be harmful for poor performing clinic chains to be identified, as that could lead to their closure, leaving parts of the county without a provider.

Those with long memories will recall that this same line of reasoning was used by defenders of the now-shuttered Martin Luther King Hospital/Drew Medical Center in South Los Angeles, known by the moniker “Killer King.” As chronicled compellingly by the Los Angeles Times, “Killer King” lived up to its nickname, with a culture of mismanagement and some providers committing medical errors that left patients dead or maimed. Its closure in 2007 led to the rebirth of a new medical center that is being praised for offering an innovative model of care for an underserved population.

Other health care leaders pointed to flaws in how quality scores are calculated, potentially leading to imprecise results. Some also criticized the validity of the standard quality metrics, built around patient outcomes and patient satisfaction, which have been utilized for decades.

The methodology has well-documented flaws, but the commercial sector has relied upon and made public its quality scores for these measures in California since 2007. Likewise, Medicare has published quality scores for its providers nationwide since 2010. Shouldn’t low-income families have access to the same information?

To gain a broader perspective on the criticisms of quality methodology, and the resistance of L.A. health care leaders to publicizing their data, we reached out to Dr. Thomas Lee, chief medical officer for Press Ganey Associates, a consulting firm, and a nationally renowned champion for health care improvement and patient satisfaction.

“There are no perfect data and no perfect datasets,” he told us. “Transparency drives improvement among the parties who are being measured.” Providers, he added, “should use the data to try to get better than they currently are."

We also spoke to Dr. Nirav Shah, a leader in patient safety and quality at Stanford University’s Clinical Excellence Research Center, who recalls the outcry that greeted him in medical circles in New York state when he served as state health commissioner.  In an effort to improve quality, he published data down to the individual doctor level on overuse of a stenting procedure.

“Physicians said the data was wrong. Our patients are sicker. We would scare patients and cause a lot of problems.” But, he said, improvements came soon afterward. “There were no problems. No downside. Only an upside for patients.

“Shining a light on metrics that matter drives changes faster than any other way I’ve known among physicians.”

 Such experiences teach us that unless pushed to publish quality data by state or local regulators, the medical community will not take the plunge on its own. And that’s a missed opportunity.

"I know transparency makes people uncomfortable, but providers should draw some insight from the observation that everyone wants transparency for everyone else other than themselves," Dr. Lee told us. That should tell them that others expect it from us, too.”

Next up: Stymied by the lack of cooperation, we wrote public records requests to a key player here in Los Angeles County. In our next post, we’ll share how that organization responded.

Olivia Henry contributed to this report.

[Image by Blogtrepreneur via Flickr.]