Framing Health Care Quality Scores as Positive or Negative

Every time you make a decision on how to present an individual score or composite, you are “framing” the presentation. Framing refers to the emotional tone of the message you are communicating to consumers. For example:

• A positive frame would accentuate the benefits of choosing a high performing provider or plan.
• A negative frame would emphasize the risks of choosing a relatively poor performer.

We have known for some time that framing effects the decisions people make.^[1] When you present a score, you need to decide whether you want to tell people how well health plans or providers are performing or how poorly at least some of them are performing.

Examples of Positive and Negative Frames

Consider a mortality measure, such as hospital patients who died within 30 days of receiving a coronary artery bypass graft.

• A positive frame would report the percentage of people who did not die.
• A negative frame would be to report the percentage of people who died.

In this case, the negative frame seems more natural given the measure itself.

But in other cases, the decision is not as clear cut. Suppose you are reporting on whether medical groups provide their older patients with a pneumonia vaccine at least every 3 years. You could report the percentage of patients who got the vaccine in the previous 3 years or the percentage who failed to get the vaccine. There’s no right answer: What you choose to report will depend on the message you want to communicate.

Advantage of a Positive Frame

The advantage of positive framing is that it helps people identify the best performer, which is the goal of most reports. Providers also are typically more comfortable with this frame, as it highlights their strengths.

Advantage of a Negative Frame

Negative framing is more effective at getting and keeping the attention of users. An interesting early study tested the stated preferences of consumers against their choices when faced with a hypothetical decision. In this case, people were first asked which measures they would use in choosing a health plan. A large majority indicated a preference for measures that were “positive” in their framing, such as the percentage whose members received preventive services on time. However, when later given hypothetical data on health plans, the choices these same people made reflected avoidance of plans that performed poorly on one or more measures that were framed “negatively,” suggesting that negative framing was the more compelling way to present these data.^[2]

More generally, advertisers, the mass media, and political campaigns have all concluded that although people say they want the good news, they pay more attention to the bad. Further, one of the factors that keeps many people from looking at and using comparative quality reports is their belief that there is no problem with health care quality. A report that accentuates the positive may be more pleasant to produce and result in less grumbling from those being measured, but its impact may be reduced.

When a Negative Frame Can Be a Bad Idea

In most cases, a negative frame can be attention-getting. But in some cases, a negative frame can reduce people’s willingness to even look at a report. For example, most people already have negative views about nursing homes, especially since the media often feature negative stories about the care provided to residents in these facilities. Recent research indicates that potential residents or their family members might be more willing to use a comparative quality report on nursing homes if it focuses on helping them find a “high quality” facility. In this context, a positive frame may be necessary.^[3]

Note too that those being rated may be less willing to cooperate with report sponsors if their performance is consistently presented in a negative frame.

Avoid Changing Frames

Ideally, all the measures in a particular report should be framed the same way. This reduces the cognitive burden on users, since they don’t have to keep reorienting themselves to look for a high or low score as they move from measure to measure. If only one or two of your measures would typically be presented in the opposite manner, this may be the time to do reverse scoring, i.e., turning a negative frame (percentage of patients who died) into a positive frame (percentage of patients who survived) or vice versa.

^[1] Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981 Jan 30;211(4481):453-8.
^[2] Hibbard JH, Jewett JJ. Will quality report cards help consumers? Health Aff (Millwood) 1997 May-Jun;16(3):218-28.
^[3] Delmarva Foundation for Medical Care, Inc. and American Institutes for Research. Framing public reporting: determining whether publicly reported measures should be presented in a negative or positive construction. Report to the Centers for Medicare & Medicaid Services. 2005.

Also in "Generating Scores that Show Differences in Performance"

• Scoring Different Kinds of Measures
• Making Adjustments to Scores
• Combining Measures Into Composites or Summary Scores
• Framing Scores as Positive or Negative