Chapter 7. Discussion
In this chapter we discuss the limitations of this evaluation, then briefly
review some of the top-level findings from our assessment and discuss their
implications for AHRQ's future growth opportunities.
This evaluation had several methodological limitations that should be considered
in the interpretation of the results. The most important limitation is
that the majority of interviewees were users of the AHRQ QIs. Organizations
that have decided not to use the AHRQ QIs for quality measurement may be more
likely than users to have negative opinions about the AHRQ QI program. For
this reason, we interviewed a small number of non-users. No unique, substantially
negative opinions of the AHRQ QIs were expressed by the non-users, but a larger
sample may have yielded different results.
A second limitation of this evaluation is that the environmental scan used to
identify users of the AHRQ QIs probably failed to identify a large number of
organizations that do not publicly release AHRQ QI results or publish descriptions
of their AHRQ QIs use. If these organizations differed consistently from those
identified in the environmental scan, our results could present a biased view of
AHRQ QI users' opinions.
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7.2. What is AHRQ'S Current
Our results show that the AHRQ QIs are regarded as the leading product in
the area of measuring the quality of hospital care from administrative data.
In fact, the QIs are currently the only comprehensive measurement system in
this area, as our survey did not identify any comparable offerings. The QIs
have gained a leading role not just within the United States, but also increasingly
in other countries. While a variety of vendors offer quality measurement systems
that use administrative data, their products often embed the AHRQ QIs (either
the actual software or the specifications).
The fact that the QIs are a free resource certainly helped them to gain market
share, but our interviewees were adamant that the excellent quality of the
product combined with AHRQ's reputation were the key prerequisites for the indicators' success.
Many interviewees commended AHRQ for the rigor and unbiased nature of its research
and felt that AHRQ would remain the natural home for the development of standards
for quality measurement. The AHRQ QIs were widely described as a scientifically
sound and well-documented set of measures that were easy to implement because
of user-friendly software and good user support. The complete transparency
of the indicator specifications, the risk adjustment methodology, and the underlying
evidence were all credited as crucial factors for the acceptance of the product
by various stakeholders.
Thus, the AHRQ QIs have achieved a strong position in their market segment
and no obvious alternative or competitor could be identified, although some
organizations (notably JCAHO, CMS, and Leapfrog) have complementary indicator
sets. This is unlikely to change: new users have an incentive to adopt the
prevailing product, because it makes their results comparable to a large number
of other users and because the widespread use lends legitimacy to the product,
which is critical in the often politicized debates about selecting quality
indicators for such uses as public reporting and pay-for-performance. Indicator
development based on rigorous science is also quite costly. As a result, other
developers would face substantial barriers to entry if they tried to establish
alternative measurement systems.
Our interviewees were quite comfortable with AHRQ having this position, although
they pointed to two potential risks. First, the dominance of the AHRQ QIs combined
with ease of access to administrative data might stifle innovation for indicators
that have more demanding data requirements. Second, the dominance also implied
a responsibility for AHRQ to maintain the program and to keep expanding it, which
was seen as challenging, given AHRQ's budget limitations.
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7.3. Where are the Growth Opportunities
for the AHRQ QI Program?
The market for the AHRQ QIs is large, growing rapidly, and changing as indicators
are being used in new ways. There are now a substantial number of users of
the AHRQ QIs for public reporting and pay-for-performance programs. As the
prevalence of those activities increases, we expect the number of users to
increase substantially both for the programs themselves and for internal quality
improvement programs and projects that will attempt to align their target measures
with standards for external accountability.
Our interviewees suggested that there is substantial demand for expansion of the
AHRQ QI program. The most common requests were for improvements to the current
sets, such as accommodation of non-UB-92 variables (e.g., present on admission
flags) and methods for composite formation, followed by additional QI sets to
close important measurement gaps, such as hospital outpatient care and emergency
room care. Interviewees were largely aware and appreciative of AHRQ's current efforts
to improve and expand the program, but expressed an interest in scaling up, and
speeding up, those activities.
7.4. How Could Growth Be Financed?
Interviewees recognized that expansions of the AHRQ QI program would require
additional resources and largely argued that this would be money well invested. Most
believe that federal funding should be used to support those activities, realizing
that this was a difficult proposition given the pressure on public budgets
in general, and on AHRQ's budget in particular. But the availability
of scientifically sound indicators in the public domain was seen as a precondition
for quality improvement efforts and policy innovations like public reporting
and pay-for-performance so that support by public funds seemed warranted.
was frequently stated that pay-for-performance and public reporting programs
in particular should be based on fully transparent methodologies to allow hospitals
to understand how they were evaluated and to identify opportunities for improvement.
Proprietary indicators, the likely outcome of private funding, were seen an
unsuitable for those applications.
We challenged interviewees to brainstorm about alternatives to increased
public funding for the QI program. One option was the re-allocation of existing
funds by reducing the scope of activities under the program and focusing on
core competencies - for example, giving up development and distribution of
free software to construct the QIs or stopping user support. Most argued that
indicator development was AHRQ's core competency and should never be
given up, and interviewees also tended to be reluctant to see AHRQ give up
software development and user support.
We heard consistently that only the
original developer of such specialized software is able to provide adequate
support. Even some vendors, who could consider trying to take on the support
role themselves, agreed with that assessment. Thus, continuing software development
but stopping user support does not appear to be a plausible option for AHRQ
as a means to free up funds for development activities.
Nor was there enthusiasm
for the even more radical alternative of AHRQ deciding to focus only on specification
development while leaving software development and user support to vendors.
Concerns centered on high fees, restricted access, and potential problems with
quality and comparability if different vendors implemented AHRQ specifications.
At a minimum, a rigorous certification program for vendors would be needed.
By and large, interviewees felt that this approach would only be slightly superior
to stopping the program altogether, and that it would greatly impede the proliferation
of quality measurement activities.
As an alternative, we discussed the option of AHRQ continuing to provide
specifications, software and user support but starting to charge for those
services. While there was little enthusiasm for this prospect, only a few stated
that they would stop using the product in that case. Most seemed to be willing to pay a reasonable
amount, so charging users would be a viable option to support expansions of the
QI program. However, the feasibility of implementing such an option would
depend on many yet-to-be-answered questions:
- How much would users be willing to pay? Our study was not designed
to investigate what users considered a reasonable charge. Thus, a market
research study would be required to elicit willingness-to-pay.
- How would a fee for use affect the willingness of new future users to implement
the QIs? We talked mainly to current users of the QIs, who have already invested
resources into implementing them for their particular purposes. Those current
users are unlikely to adopt a different indicator system, unless the cost
of the AHRQ QIs was to become prohibitive. But non-users might select another
product or abort their quality measurement activities entirely if they had
to pay for the AHRQ QIs.
- What are the rights of existing users who have invested in implementing
the QIs under the assumptions that they are a free resource?
- Should pricing be different for different users (e.g., researchers and
re-sellers) and by what degree?
- What is the best pricing model (e.g., fee-per-use, subscription)?
- How should fees for international users be handled? These users are probably
very price-sensitive because most of the current uses are actually small
initiatives of individual researchers. It is more difficult to collect
money from researchers, but fairness would require charging them if domestic
users are charged.
In summary, if AHRQ were to implement a charge-based model for the QIs, it
would face the challenge of developing a comprehensive business plan. The size
of the market needs to be determined to make sure that the expected revenue
could provide a meaningful contribution to the growth of the program, after
the added cost of operating a business is taken into consideration. AHRQ would
also need to consider the amount of additional revenue it could expect to obtain
in proportion to the potential negative effects on the spread of the program
to new users and usages.
In a sense, AHRQ is now in a situation comparable to that of other organizations
that have started out offering content or services on the Internet for free and
are contemplating whether to begin charging users. Thoughtful deliberations would
be needed to find a business model that generates sufficient revenue but is still
consistent with AHRQ's mission and values as a public agency.
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