Rating doctors and other health care providers

Dr. Tim Story, internal medicine specialist and co-founder of Firstline Personal Health Care in Carmel, recalls a case from a couple of years ago in which his group placed a new heart valve in an 87-year-old man. In spite of the patient’s advanced age, his doctors considered him fit enough for the procedure. In other words, he seemed like a good bet.

That bet paid off. The operation succeeded and the patient, with perhaps six months to live, had that span increased, potentially, by years.

But Story wonders what might happen if the same scenario presented itself this year, when a new rule providing volumes of Medicare data to third parties interested in compiling physician rating guides goes into effect.

Third-party reviewers can potentially determine how much individual doctors spend to treat various illnesses; their preferred treatment regimens; and most tellingly, how many of the patients under their care got better and how many died. Then they can make that information available to consumers.

The idea is to create guides for civilians seeking medical help. But many physicians see it differently. They think the idea of producing “report cards” is at best simplistic, and at worst wildly inaccurate and potentially damaging.

For instance, with cardiologists potentially “rated” for every procedure they undertake, helping an 87-year-old heart valve replacement candidate might not seem like such a good bet anymore.

“I think that’s where you might see physician behavior modified by this,” Story said. “There will be some surgeons who have second, third and maybe fourth thoughts about taking guys like that to the [operating room].”

Debatable usefulness

It might be too soon, however, to predict such consequences. It was only last December that the Centers for Medicare & Medicaid finalized new rules providing qualified organizations access to its volumes of formerly classified Medicare physician billing information. Groups that can show their experience in securing data, analyzing claims and evaluating performance markers (and that can fork over $40,000 for the electronic files) can sift through claims from 2009, 2010 and the first two quarters of 2011.

“I think it’s a great concept, but as with so many concepts in a complicated area, the devil’s in the details,” said Dr. Thomas Vidic, president of the Indiana State Medical Association.

The association—along with dozens of other state, regional and national medical groups—signed onto a voluminous, densely written note to the Centers for Medicare and Medicaid Services outlining their concerns with the new policy. Among a great many other things, the note asserts that “there must be a method for ensuring that any publicly reported information is: 1. correctly attributed to those involved in the care; 2. appropriately risk-adjusted; and 3. accurate, user-friendly, relevant, and helpful to the consumer, patient, physician or other stakeholder.”

Physicians will have at least 60 calendar days to request corrections to reports written about them and appeal quality scores. The problem is that, while medical experts are pretty clear about the program’s potential shortcomings, they’re far less certain as to how to run it properly.

Ask a doctor about the efficacy of ratings based on their Medicare stats, and you’ll almost inevitably get some version of the following cautionary tale. What if an extremely skilled physician who handled only complex, difficult cases was compared with another, less-skilled physician in his specialty who handled relatively simple ones? A layman might compare their stats, see that the skilled physician lost a higher percentage of his patients, and conclude that the less-skilled surgeon is better-qualified.

When pressed, Story can think of perhaps one way in which the stats could be useful. His office tracks patients who die of “unexpected cardiac mortality”—or, in other words, keel over from massive heart attacks for no previously diagnosed reason. Most years, he has none, some years one, and on one occasion two.

“I think that’s a meaningful statistic,” he said. “I think if you’ve got someone with a hundred guys who had unexpected cardiac mortality last year, that guy may not be the greatest risk manager of all time.”

Story thinks the Medicare data could be useful in detecting outliers—either someone who achieves stellar results with very ill patients, or someone on the opposite end of the spectrum who might as well have the county morgue on his speed dial.

“Everybody else, in the middle, without knowing their patient mix, you can’t be sure what’s happening,” Story said.

Perhaps that’s why the ratings service Angie’s List, which offers consumer reviews in some 150 health and wellness categories, hasn’t forked over the requisite $40,000 to take a crack at the Medicare files. Angie’s List’s bread and butter, after all, is consumer-written reviews, not number-crunching.

“We will be taking a close look at how those with initial access to the database plan to analyze it for physician grading,” said Cheryl Reed, Angie’s List director of communications. “At a minimum, we will be letting our consumers know about it and how they can access it.”

To no surprise, such consumer-oriented businesses and agencies are far more supportive of the Medicare data dump.

“I think it’s a positive move,” said Paul Chase, associate state director for public policy for AARP. “I think that consumers should have as much information as possible in deciding, to the extent they have the ability to decide where they can go for medical care.”

Making stats usable

The trick, just as the doctors assert, is serving up the raw numbers in a palatable way. The other trick is defining which of the data stream’s various ripples and currents offers relevant metrics.

The local entity with the most practical take on the issue is probably the not-for-profit Indiana Health Information Exchange—the nation’s largest health information exchange organization, serving more than 80 hospitals and 19,000 physicians statewide. Its services include an electronic clinical messaging delivery service, a preventive care and chronic disease management program that alerts physicians when a patient needs a screening for various chronic problems, and (most germane) a statewide network that collates patients’ disparate records, creating an overall digital picture of their health.

The exchange has served some 10 million patients and wrangled some 3.5 billion pieces of clinical data. And it’s keen on getting more from Medicare.

Kent Hiller, the exchange’s director of special projects, said his organization is most likely to use the information to measure quality and efficiency of the health care system in order to improve care and cut costs.

Hiller said the organization’s Quality Health First program already uses data from Medicaid and private insurance carriers to deliver reports to physicians. Medicare data is also used, but only for a nine-county area in central Indiana.

“Having the ability to include Medicare data for a larger geographic area would enhance that program greatly and offer physicians a more comprehensive view of their patient population,” Hiller said.

Indiana receives this Medicare data as one of two states participating in the Medicare Health Care Quality Demonstration Program, a five-year study attempting to improve care quality and efficiency. North Carolina is the other participating state.

“A larger geographic footprint of data results in a more robust data set from which more acuity can be woven into the quality scores,” said John Kansky, the exchange’s vice president of product management.

The Medicare data looks set to influence the debate on physician quality for years to come. Though for his part, Story, the doctor, isn’t all that concerned. Because when it comes to picking a physician, he figures few people stake their health on “best of” lists.

“In what I do, almost all of our patients are referred by other physicians,” he said. “And the patients put a lot more stock in anecdotal reports from their neighbors.”•

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