Hospital quality reporting rules can backfire on patients, researchers say 

As hospitals grind out paperwork on a growing list of quality measures, the burden has become “substantial and counterproductive, resulting in lower care quality and higher prices for patients,” said Ge Bai, a professor of accounting and health policy and management at Johns Hopkins University and a co-author of the study. “Clinicians are dedicating more time to reporting quality and less time for patient care, and hospitals are allocating resources to regulatory compliance instead of patients.”

Although the quality measures are “well intentioned,” there’s a general perception that “we’re spending too much time running around reporting too many things” and not enough time actually improving quality, said Dr. Stephen Berry, who led the study and is the vice chair for quality, safety and service and an associate professor of medicine at Johns Hopkins. 

Hospital quality metrics required by regulators or national rating organizations track measures like hospital-acquired infections, in-hospital falls and readmission rates. Requirements to report such measures have become more extensive in recent years, researchers say, amid a broader shift toward payment models that aim to optimize care quality while trimming costs, rather than simply paying providers a set amount for each service. 

Under this newer “value-based” payment approach, quality measures can offer insights on how much bang payers are getting for their buck, an issue that is getting more scrutiny as healthcare costs climb. U.S. healthcare spending reached $4.3 trillion in 2021, or 18.3% of gross domestic product — up from $2.7 trillion, or 17.2% of GDP, a decade earlier, according to federal government data. 

But the Johns Hopkins study adds to other recent research raising questions about the costs and benefits of pay-for-performance systems in U.S. healthcare. A Medicare incentive payment system, for example, affects reimbursement for hundreds of thousands of U.S. doctors but may not accurately capture the quality of care those doctors provide, Weill Cornell Medical College researchers found in a study published last year in JAMA.

While the shift to value-based care may be a good move for the country, “we want to get it right,” Berry said. “We don’t want providers sitting in front of computers for an hour documenting a single day with a patient,” he said. “I’d rather have the doctor in the room with the patient for a longer period of time and writing about it less.” The time spent on such documentation, he said, “may be the number one source of frustration among my colleagues.”

And instead of reining in costs, all the reporting may only be driving costs higher, Bai said. 

For the JAMA study, the Johns Hopkins researchers compiled a list of quality measures the hospital reported in 2018 to seven government and national healthcare rating organizations — including only adult inpatient and emergency department metrics — and assessed the time staff spent on collecting and validating the data, entering information and other reporting tasks. 

The study’s finding of 108,000 hours spent on reporting may be an underestimate, the researchers said. Because of the difficulty of estimating the hours involved, for example, the study doesn’t account for the time doctors spend responding to requests from clinical documentation specialists who review physicians’ notes and often suggest ways to make them more detailed in order to shed additional light on quality, Berry said. For example, a doctor might be asked to specify the type of heart failure a patient suffered, Berry said, purely for quality reporting purposes. Providers’ notes “aren’t meant to be 50-page essays on the exact quality of what’s going on,” he said, so a doctor might get thousands of staff requests each year asking for adjustments in documentation for quality reporting. 

While the $5.6 million estimated cost of quality reporting is small compared with Johns Hopkins Hospital’s $2.4 billion in annual expenses, the researchers said that such reporting likely consumes a larger share of the budget at smaller hospitals. And extrapolating the findings to the more than 4,000 acute-care nongovernment U.S. hospitals, the findings suggest billions of dollars are spent annually just on reporting quality data, the study said. The costs of that reporting, Bai said, will ultimately pass through to patients. 

With little coordination among the various organizations that require quality metrics, different groups may track the same measure using different methodology, which means hospitals can’t just copy and paste their reports, researchers say. “Many quality metrics are duplicative, expensive to generate” and offer no tangible benefit for improving care, Bai said. “Policymakers must consider the detrimental impact of the current quality reporting requirement on patients. Ultimately, patients will bear the consequences, experiencing lower care quality and higher prices,” she said.

One way to improve the situation, Berry said, might be to pull quality measures straight out of electronic health records. That approach, he said, would mean “no time spent bugging providers to write things up in their notes in more specific and oftentimes impractical language.”