Abstract
BACKGROUND: Quality report cards have been shown to be effective in influencing patients' referrals and promoting quality improvement in some instances and not others. In this study, we investigate one of the mechanisms that may detract from their effectiveness: voluntary versus mandatory participation of nursing homes in public quality reporting. OBJECTIVES: To answer 2 questions: (1) Were the nursing homes choosing not to participate low-quality performers relative to those who chose to participate? (2) Once participation became mandatory, did those that did not voluntarily participate initially, improve more than those that participated voluntarily? RESEARCH DESIGN: Massachusetts published the Massachusetts Satisfaction Survey report card for nursing homes for the years 2005, 2007, and 2009. Nursing homes' participation was voluntary in 2005 and mandatory in 2007 and 2009. We performed a retrospective statistical analysis of the relationship between nursing homes' decision to participate in quality reporting and 12 quality outcomes: deficiency citations, staffing, and 8 survey domains. SUBJECTS: A total of 424 Massachusetts nursing homes. RESULTS: Sixty-seven percent of nursing homes participated in reporting voluntarily. Volunteer nursing homes had better quality for all measures (significant at the 0.05 level or trending toward significance at the 0.10 level for all but 2). Once reporting became mandatory, nonvolunteers improved more than volunteers in all but 2 staffing measures (trending toward significance at the 0.10 level in 5). CONCLUSIONS: Report cards are more effective if nursing homes' participation is mandated. Nonmandatory reporting systems, as those implemented by some states and professional associations, lead to missed opportunities for quality improvements.