The impact of public performance reporting on health plan selection and switching: A systematic review and meta-analysis

Highlights

• Review the evidence on public performance reporting (PPR) and consumer selection and switching of health plans.

• PPR was associated with the selection of health plan and less health plans switching.

• However, both effects were not statistically significant overall.

• Differences were observed between employer-sponsored health insurance and Medicare/Medicaid insurance.

• The small number of included studies limits the strength of our conclusions.

Abstract

The dissemination of public performance reporting (PPR) cards aims to increase utilisation of information on quality of care by consumers when making health plan choices. However, evaluations of PPR cards show that they have little impact on consumer choices. The aim of this study is to undertake a systematic review and meta-analysis of the impact of PPR cards in promoting health plan selection and switching between health plans by consumers. We searched five online databases and eight previous reviews for studies reporting findings on PPR and health plans. We extracted data and conducted quality assessment, systematic critical synthesis and meta-analyses on the included studies. We identified eight relevant health plan articles related to selection (n = 2), switching (n = 4), selection/switching (n = 2). Meta-analyses showed that PPR was associated with an improvement in health plan selection and a very small deterioration in switching health plans though these changes were not statistically significant. Differences were observed between employer-sponsored health insurance and Medicare/Medicaid insurance. Given the small number of studies included in the review, further research examining the impact of PPR on health plan selection and switching in a range of insurance markets is required.

Introduction

The public reporting of hospital performance data (hereafter referred to as ‘PPR’) that occurs in Australia and other high income countries [[1], [2], [3]] is used to improve healthcare transparency and accountability, and as a mechanism to drive quality improvement and inform consumer decision-making [1,[4], [5], [6]]. PPR may improve quality of care either by triggering organisational change to improve quality or by enabling consumer, practitioners or funders to select away from poorly performing services [7].

Several systematic reviews have already been undertaken to identify existing peer-refereed research relating to the impacts of PPR [5,6,[8], [9], [10], [11], [12], [13]]. These reviews focused on different aspects of PPR and therefore yielded different results (see Appendix A). For example, some reviews focus on the mechanisms by which PPR exerts influence [12,14] while others focus on impacts [6]. There are numerous studies about the impact of consumer selection on health plans, hospital and clinician. The evidence concerning the influence on PPR on consumer behaviours is much stronger for selection of clinicians and health plans than for selection of hospitals [14], where the effect on consumer behaviour tends to be weak and transient, if observed at all [6,14]. One reason for this difference in effects may be, as Totten et al. [12] observed, that the characteristics of public reports and their context, have been rarely studied or even described. It is also not clear how constraints on consumer choice due to plans, geography, waiting time or clinician choice affect the magnitude of PPR effects. Greater PPR effects in studies of health plans may also reflect greater homogeneity among consumers in plan switching studies because the people involved in the studies have the same employer [[15], [16], [17]] or are eligible for the same schemes [18]. However this could be offset by the act that larger more diverse employers are the most likely to offer health plan choice [19].

In the current literature, studies looking at the impact of PPR at health plan level should therefore demonstrate the clearest link between PPR and the choices consumers are being asked to make. Evidence of the impact of PPR on consumer selection at health plan level may provide incentives for health plans to select away from lower quality providers [20]; thus, potentially increasing consumer’s power across different levels of choice. On a pragmatic level, there are sufficient comparable studies of health plans to make meta-analysis possible. Furthermore, previous reviews have tended to conflate studies of health plan selection and health plans switching [5,14]. While the parameters associated with these choices may be similar, it may be that different information or incentives are required to encourage a switch. Providing this greater conceptual clarity is a strong justification for a further systematic review and meta-analysis on health plans, given that the magnitude and type of impacts of PPR are not settled despite previous study.

This study was conducted as part of a wider systematic review and meta-analysis (where possible) of the impacts of PPR (e.g. process/structure measures, expert/peer assessed measures, healthcare outcomes and consumer experiences) on outcomes (e.g. selection, quality improvement, clinical outcomes, organisation change or unintended consequences) among healthcare purchasers (public and private), providers (organisations and individual clinicians) or consumers. In this paper, we described the impacts of PPR on consumer selection and switching of health plans that better meet their needs. Understanding whether consumer preferences for a particular health plan is influence by quality of care information can provide further insights into the mechanisms underpinning consumer choice processes and information needs. The availability of quality of care information and consumer sensitivity to such information may also stimulate health insurers to improve the quality of health plans on offer.