Public disclosure of information about the quality of health plans, hospitals, and doctors continues to be controversial. The US experience of the past decade suggests that sophisticated quality measures and reporting systems that disclose information on quality have improved the process and outcomes of care in limited ways in some settings, but these eVorts have not led to the "consumer choice" market envisaged. Important reasons for this failure include limited salience of objective measures to consumers, the complexity of the task of interpretation, and insuYcient use of quality results by organised purchasers and insurers to inform contracting and pricing decisions. Nevertheless, public disclosure may motivate quality managers and providers to undertake changes that improve the delivery of care. EVorts to measure and report information about quality should remain public, but may be most eVective if they are targeted to the needs of institutional and individual providers of care. (Quality in Health Care 2001;10:96-103) Keywords: public disclosure; quality of health care; quality improvement BackgroundSince the first publication of hospital mortality rates in 1986 by the federal agency that administers the US Medicare insurance programme, public disclosure of information about the quality of health plans, hospitals, and doctors has provoked controversy.1 Publicly disclosed performance reports, sometimes called "report cards", are one manifestation of a health care marketplace in which competing providers would measure and report information about the quality of care they oVer.2 According to the proponents of market theory, US employers, who pay a major share of health care costs in the USA, would purchase prepaid comprehensive care through health plans rather than reimbursing providers for each service.3 Employers would use report cards to choose high quality health plans at a reasonable cost. Insured employees would select health plans, hospitals, and doctors using report card information about providers' quality, price, and accessibility. As a result, health plans, hospitals, and doctors with the best performance records

Background: Nursing home performance measurement systems are practically ubiquitous. The vast majority of these systems aspire to rank order all nursing homes based on quantitative measures of quality. However, the ability of such systems to identify homes differing in quality is hampered by the multidimensional nature of nursing homes and their residents. As a result, the authors doubt the ability of many nursing home performance systems to truly help consumers differentiate among homes providing different levels of quality. We also argue that, for consumers, performance measurement models are better at identifying problem facilities than potentially good homes.

To explore managed care plans' efforts to assess and improve quality of care for Medicare beneficiaries, the authors surveyed managed care plans with risk contracts for Medicare beneficiaries in 20 large metropolitan areas in January 1998. The survey inquired about: (1) the health plans' efforts to assess and improve quality of care for specific underuse, overuse, and misuse problems; (2) how the health plans assessed functional status of enrollees, and (3) the quality improvement program they believed had the greatest impact on the health of enrollees. The managed care plans reported a heterogeneous mix of quality improvement activities ranging from poorly developed to very sophisticated. The vast majority of the more sophisticated programs addressed problems with underuse of services rather than overuse or misuse.

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