Prescription with side effects
It sounds like a great idea when you first hear it: Medicare is making its claims files available to insurers, employers and consumer groups so they can prepare report cards on individual doctors. The files will reveal such things as how many times doctors perform particular procedures as well as how often their patients develop preventable complications. Medicare itself will maintain a website to allow patients to compare doctors, and says it intends to one day include on the site patient satisfaction surveys for individual doctors.
I’m all for patients making informed decisions about which doctors to turn to, but these report cards may turn out to be highly misleading.
Consider this, from my own experience. Earlier in my career as a doctor, I was affiliated with Loma Linda University’s medical school. In many ways, I had a dream practice. Patients tended to be true partners in health. They typically cared about their health, ate lots of vegetables, actually used their gym memberships and came in for yearly checkups bearing pictures of their puppies and new grandchildren. Of course my patients sometimes had serious health problems, but when that was the case, most of them did everything they could to get better, following treatment instructions and adjusting diets or lifestyles as advised.
I’m now treating a very different population of patients. Most of them are poor enough to qualify for Medi-Cal, but even though they receive state insurance, many don’t bother to seek care until they are very ill. Few of my patients exercise regularly, and substance abuse is common. The problems they bring to the examining room are complex, and unraveling them often puts me far behind schedule.
Treating this kind of patient can be frustrating because many don’t comply with medical advice. They ignore admonitions to avoid salt and fats, which results in worsening heart problems and high blood pressure. They continue smoking despite chronic lung problems. I had one patient who wouldn’t do his rehabilitation exercises after a knee replacement and so is now wheelchair-bound. As might be expected, the medical outcomes for these patients aren’t nearly as positive as in my previous practice.
High-risk patients of the sort I now see have a great need for healthcare. Yet I know that treating them will have an effect on my “grades” in the new physician report cards, which don’t take the nature of the patients into account.
Not long ago, I saw a middle-aged woman who had clearly once been beautiful. But when she walked into my office, she looked about nine months pregnant. Her belly was filled with fluid that her liver could not process: It was too damaged from years of drug use, untreated infection and alcohol abuse. She also had diabetes and high blood pressure.
My colleagues and I spent a lot of time on her case. We tried to not only educate her about how to take care of herself but also to bring her family into the treatment picture. But she eventually drifted off, not showing up for appointments or responding to phone calls and letters.
The likelihood of “preventable complications” with such a patient are huge. And I shudder to think how she would fill out a patient satisfaction survey. Patients who don’t want to hear what a doctor has to say are rarely happy with their care.
Late last year, Marilyn Tavenner, the acting administrator of the Centers for Medicare & Medicaid Services, touted the release of information about doctors as an action that would make “our healthcare system more transparent” and result in “increased competition, accountability, quality and lower cost.”
But I’m predicting another outcome as well: that doctors will be increasingly reluctant to take on the toughest patients.
Outcomes in medicine depend on two main factors: the expertise and experience of the provider and the status of the patient. If you take two cardiologists, say, of equal skill, the one who treats healthier, younger, more compliant patients is likely to have better medical outcomes than the one treating older, substance-abusing or noncompliant patients. The patient is not a passive entity in the equation.
According to theAmerican Medical Assn., we are facing a scarcity of physician specialists, and this scarcity will be exacerbated as 32 million more people seek medical care under the Patient Protection and Affordable Care Act. Physicians will have to make choices about whom they provide care to, and I worry that the elderly, the noncompliant and those with multiple medical problems will be unable to find good doctors. Why risk a bad report card that could scare patients away?
Transparency is often a good thing. But the federal government must consider the possibility that physician report cards could dangerously reduce healthcare to those who need it most.
Katherine Schlaerth is a practicing physician and an associate professor emeritus at USC’s School of Medicine.
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