Prepared for The Commonwealth Fund/Alliance for Health Reform 2007 Bipartisan Congressional Health Policy Conference, this 22-page issue brief provides a short history of efforts to report information on health system performance and identifies policy issues to consider when advancing such efforts. Author John Colmers also offers lessons drawn from the experience of public reporting efforts to date.

According to Colmers, publicising information on health system performance can make the health care system more accountable. Policymakers and health care purchasers advocate for public reporting with 3 goals in mind, in addition to promoting competition. They are: 1) to help providers improve by benchmarking their performance against other providers; 2) to encourage private insurers and public programmes to reward quality and efficiency; and 3) to help patients make informed choices about their care. Specifically, the audiences for health performance information include:

• Consumers could use this information at various points of interaction with the health system, from the time they choose a health plan to the point of selecting a health care provider for a specific service.
• Employers/purchasers may want information to use in selecting from among various health plans or self-insured options, including the cost and outcomes of providers included in a given plan's network and the plan's record of performance in meeting service and quality standards.
• Health plans may need information in certain markets to bolster their own claims data so that they can evaluate the price and quality of all physicians, hospitals, and other providers. Plans may also want to benchmark their performance on service and quality measures to their competitors.
• Providers can benefit from more transparent price and quality information as a feedback loop for improved performance and for identifying the most efficient and effective referrals.
• Policymakers with responsibility for oversight and monitoring of system performance can benefit from accurate and timely information on providers and health plans to monitor changes in the overall system, pinpoint areas that warrant closer investigation, and encourage the reporting groups to monitor their own performance.

For these reasons, interest in collecting and publicly reporting information about the cost and quality of health care has been growing. Yet, as Colmers explains, while health care providers and payers face demands to conduct their business more transparently, questions remain about the accuracy of the reported price, process, and outcome information; the comparability of the results across different populations; and whether and how patients and others use the information in making decisions. To address these and other questions, health services researchers are providing feedback on how efforts to improve transparency in United States (US) hospitals, health plans, nursing homes, and physician practices have fared. In short, these studies have found that public reporting can add value, but that reports must be carefully designed. Research also shows the importance of automated and unobtrusive data collection, as well as collaboration among private and public bodies, and providers and purchasers. Specific lessons learned so far:

• Public reporting adds value: Some have argued that merely having a feedback loop that allows hospitals, physicians, or health plans to compare their own performance to reported averages, without going public, is sufficient to improve quality. Yet numerous studies point to the positive effects of public reporting. For example, public reporting of comparative data on patient satisfaction enhances and reinforces quality improvement efforts already underway, and appears to stimulate quality improvement activities in areas where performance levels are reported to be low.
• Reports must be designed carefully: For instance, research shows that providing comparative quality information to consumers can be counterproductive unless: 1) consumers are convinced that quality problems are real and consequential, and that quality can be improved; 2) purchasers and policymakers make sure that quality reporting is standardised and universal; 3) consumers are given quality information that is relevant and easy to understand and use; 4) the dissemination of quality information is improved; and 5) health plans pay for quality improvements and providers create the information and organisational infrastructure to achieve them.
• The most successful approaches to public reporting and transparency have resulted from partnerships involving the public and private sectors as well as purchasers and providers.
• State and local efforts have proven successful when the scale is manageable and local sponsors are able to account for factors that affect performance in the regional delivery system.
• Research and evaluation have played a critical role in actively informing the most successful efforts.
• Automated data collection is needed: When data are not routinely and unobtrusively collected as part of the ongoing care process, the result is an additional burden placed on providers and health plans.

Colmers reviews a number of legislative proposals related to public reporting and transparency that were expected to be brought before the 109th Congress. For instance, some seek to extend the use of health information technology and create an interoperable system for the nation, thereby building the infrastructure needed to support public reporting. Specific proposals include: establishing a national public–private collaborative to recommend uniform policies and standards; providing grants and/or loans to facilitate purchase and utilisation of technology systems; funding demonstration products to determine best practice in various areas related to health information technology (including information requirements of rural and frontier physicians and methods to integrate technology systems into clinical education); providing incentives to physicians to write electronic prescriptions; requiring all associated carriers to establish standardised electronic health records for individuals covered by the Federal Employees Health Benefits Program; and establishing independent health record banks to store individual lifetime electronic health records.

Colmers concludes that "[e]fforts to expand the availability of transparent quality and price information, particularly when this information is publicly reported, hold out the prospect of increasing accountability, enhancing and rewarding quality, and increasing efficiency. Although in the months and years ahead such information should be more readily accessible to all, there are substantial technical and political barriers that will need to be overcome....Notwithstanding these challenges, the movement to greater transparency is inexorable. Although much work is being done exclusively in the private sector, government at all levels can play an important role by supporting the infrastructure for reporting (e.g., through research, evaluation, and data interoperability standards); by leading by example (e.g., through disclosure of performance data for government health programs); and by working collaboratively with regional and national efforts in the private sector."