“Best Doctors:” Shaming Shirkers or Shunning the Sickest?
As lawyer-ratings sites start to proliferate, there are some important lessons to be learned from the more-established practice of doctor-ratings. Such sites aim to give medical “consumers” a better sense of how well practitioners perform–welcome knowledge in a world of uneven care. But it turns out that “gamers” have exposed several shortcomings in their early iterations.
On the positive side, the WaPo reports that “data-driven surveillance offers the prospect of using incentives to steer patients to care that is both effective and sensibly priced.” However, physicians “say that the data often contain errors and that doctors often lack the ability to correct them.” Conflicts proliferate, including “a lawsuit in Seattle, a physician revolt in St. Louis and a demand by a state attorney general that one insurer halt its planned program.” Given the breadth of the HCQIA safe harbors, I have a sense that physicians are not going to find it easy to deter questionable rankings sites.
The new rankings craze can also provide incentives for doctors to shun the sickest patients–or even to perform unnecessary procedures during a routine surgery in order to manipulate them.
For example, “An anonymous 1999 survey of bypass surgeons revealed that 62 percent of cardiac surgeons refused to treat at least one patient in the preceding year who was perceived to be high risk.” “Added procedures” are even more disturbing:
David Brown of SUNY–Stony Brook remembers a patient from 1999, a man in his early fifties who was athletic, a bicyclist, whom he referred to surgery for a bypass. On paper, the man was a low-risk patient—young, healthy, with just one vessel that needed repair. For some reason, however, the man went into cardiac arrest while being put under anesthesia. If he had died, the Department of Health would have scored the death with a very high mortality and no risk adjustment. But the man survived, and a week later Brown glanced at the report and noticed that the surgeon had performed an additional procedure while the patient was on the table. “He did a mitral annuloplasty, which is putting a little ring around the mitral valve,” Brown says. Because of this surgery, this patient no longer could be considered for the state data; he was knocked out of the sample. If the patient died, it wouldn’t affect that surgeon’s mortality rate. “I called him, and he sort of hemmed and hawed about it,” Brown remembers. “I was going to report it, because I thought it was assault. Certainly it was done strictly to manipulate the data.”
The NYM article mentions that many analysts considered New York’s statistical compilations a key to improvements in the state’s results in cardiac surgery….but even that conclusion is now questioned:
The first significant study to suggest that all was not right with the new system arrived in 1996, when researchers at the Cleveland Clinic suggested that some of the sickest New York heart patients were being shipped out of state. In the first few years after the report-card program began, the Cleveland Clinic received 31 percent more referrals from New York hospitals than they had previously received—and the study verified that the New York patients were sicker than those who were referred from other states.
Eventually, the state’s proudest achievement—the low mortality rates—also came into question. David Dranove of Northwestern released a study in 2003 suggesting that the patients being selected for surgery in New York were simply healthier than elsewhere. Dranove’s data revealed that of those patients in New York who came in for heart attacks, the sicker ones got operated on less often, and the healthier patients got operated on more often. The failure of New York doctors to operate on some sicker patients, Dranove’s study concluded, has led to poorer patient care overall. “Everybody was worse off,” he says. “Costs went up for all, and outcomes were a little bit worse.”
This could be yet another example of a badly designed competition making everyone worse off. Buyer beware when any authority tries to boil incommensurable values into a single number, set of stars, or “smiley face” (a particularly “user-friendly” interface employed by one insurance company).