Rating doctors: Who benefits?
The idea of giving doctors a “report card” to judge how well they are doing their jobs is gaining popularity in California and around the country. But could the practice also be leading some doctors to shy away from the sickest patients?
Although many doctors loathe the idea, several states require physicians to report medical outcomes for many procedures. Health insurers are increasingly rating doctors’ performance and tying doctors’ pay to their scores.
Next year, Californians will be able to go online to see how well individual physicians perform heart bypass surgery, and the state plans to add reports on other medical procedures.
The physician report cards are intended to motivate poorly performing doctors to do better, improving medical care and patient safety in the process. A growing body of research shows that such reporting is having the intended effects.
But two recent studies suggest that rating doctors also may have unintended consequences by influencing some doctors to withhold necessary care to the sickest patients.
Last week, researchers at the University of Michigan released a study of New York’s pioneering public reporting system, which for several years has tracked how well doctors perform two major types of heart surgeries.
The study, which included more than 80,000 patients from both states, found that doctors in Michigan were more likely than their counterparts in New York to perform angioplasties on very sick patients.
Because Michigan has no physician report card program, the researchers concluded that New York doctors may be shying away from treating their sickest patients out of concern that a poor outcome could adversely affect their grades.
A separate survey released in the Archives of Internal Medicine this year found that nearly eight of 10 New York cardiologists said public reporting of data made them less likely to treat severely ill patients.
“Public reporting is a good idea and has many benefits,” said Dr. Mauro Moscucci, associate professor of medicine at the University of Michigan and the lead author of last week’s study. But “we should be concerned that some doctors may be denying care to patients who need care.”
University of Michigan researchers point out their study may have some limitations. It’s possible patients in Michigan are actually sicker overall than those in New York. Also, doctors in New York, which has a large number of cardiologists in the New York City area, may be more aggressive about recommending preventive care, lessening the need for surgical interventions such as angioplasty.
But even supporters of public reporting acknowledge that it’s inevitable some doctors will try to game the system to improve their performance ratings.
One study suggests that some of New York’s sickest cardiac patients may be seeking treatment outside the state.
A 1996 study at the Cleveland Clinic found that, on average, heart patients from New York who were seen at the clinic were sicker than patients from other states and abroad. The study compared patients treated after 1991, when New York’s public report card program began.
“I agree this isn’t perfect and we are just at the beginning of this movement,” said Dr. Mark Smith, president of the California Healthcare Foundation, an Oakland-based philanthropic group that has advocated for greater doctor accountability in California. “We have to start somewhere. This is the wave of the future, and the upside is far bigger than the downside.”
Critics of physician report cards say the new research reinforces their concerns that patients are not always well-served by such rating systems.
“We are very much in favor of physicians looking at what they do and trying to improve it,” said Nancy Nielsen, a Buffalo internist and an American Medical Assn. official. But “we are worried about the unintended consequence of simply throwing this information out to the public.”
Many physicians worry public report cards can be easy to misinterpret. For instance, some doctors may work in hospitals with less sophisticated medical technology or with fewer nurses on staff.
Also, what happens if one doctor sees sicker patients than another? Most doctor-grading systems adjust the results to account for differences in the severity of patients’ illnesses.
The effort to hold doctors more accountable for care is part of a larger push to improve the nation’s healthcare quality. Research shows that as many as half of patients don’t get the appropriate care for many conditions.
A report released last year by the nonprofit National Committee for Quality Assurance found that as many as 79,000 Americans die each year because they don’t receive appropriate care for common conditions.
Reporting advocates say the U.S. healthcare system lags far behind most other industries, including automobiles and consumer electronics, in tracking outcomes, such as medical quality and patient satisfaction.
Without such efforts, some experts say that any broader effort to improve the nation’s medical care won’t work.
Either way, patients clearly want to be able to compare doctors. A survey last month from the Pew Internet and American Life Project, a nonprofit research group, found that 28% of Internet users reported looking for information on a specific doctor, up from 21% in 2002.
Many consumers, however, may find it hard to compare one report card with another. More than 10 agencies now rate doctors.
One emerging problem: a lack of uniformity in the rating systems. Some private healthcare rating companies’ websites, such as HealthGrades (www.healthgrades.com) and Subimo (www.subimo.com), may be easier to use, although they offer information only on hospitals, not specific doctors.
“The reasons doctors treat or don’t treat a particular patient are very complex, and most don’t have anything to do with a report card,” said Craig Narins, a cardiologist at the University of Rochester and lead researcher on the January survey on New York doctors.
“It’s just hard to believe this isn’t in the back of their mind,” he said. “Doctors are very competitive people at heart, and they don’t like to lose.”
