Rating the Raters: Physician Compare

Let’s say you’ve enrolled in a new health insurance plan and need to find an internist who participates. How do you decide which doctor to choose? My (long deceased) grandmother made her choices by using the following criteria: She looked for a male doctor with a Jewish-sounding last name who graduated from an American medical school—preferably one located in New York City. Nowadays her narrow (and culturally biased) criteria would have excluded some of the most esteemed practitioners around.

If you are like most people, you don’t depend on your grandmother’s advice to find a physician, but rather ask friends, colleagues or other doctors for recommendations. But taking one person’s experience with an internist or surgeon as a signal that he or she is “really good” is still far from the optimal way to choose a practitioner.

Over the years, several commercial websites like HealthGrades and Angie’s List have cropped up that provide such consumer-friendly information as the distance a doctor’s office is from the patient, and whether foreign languages are spoken there. They usually include ratings that reflect consumers’ personal experiences with the practitioner. For people who want to dig deeper, most state medical boards collect data that can be searched to find out where your doctor went to medical school, where he did his residency and what board certifications she has. In some states you can also search to see if the doctor in question has received disciplinary action or been sued for malpractice.

This is a lot of on-line legwork for the average person—a task that even professionals can find difficult. Chip Amoe, assistant director for federal affairs at the American Society of Anesthesiologists told a group recently, “When I tried to go find a primary care physician, I couldn’t. You know, it was very difficult. I had to go on several different Web sites to be able to find [one].”

In the end, you may pick a doctor who graduated from a prestigious medical school, hasn’t been sued often, is only a 10-minute drive away and has a nice, clean waiting room; but none of this information will necessarily increase the likelihood that he or she will provide high-quality, cost-effective care. That’s where the nascent Physician Compare website, designed by the Center for Medicare and Medicaid Services, comes in. The site, which is still under development and will be modeled after CMS’s existing “Hospital Compare” site, was mandated by the Patient Protection and Affordable Care Act and is slated to go up on-line on Jan. 1, 2011.

Don’t expect too much. Next year, the information posted on Physician Compare will be little more than that already available in CMS’s Healthcare Provider Directory . This directory, designed to be used by Medicare beneficiaries, lets consumers search for a physician or other health care professional by specialty and location. Additional search criteria allow the user to search by gender and whether or not the physician or other health care provider accepts Medicare reimbursement as full payment on all claims. Information about languages spoken, education, and hospital affiliation is also available for some providers.

For now, Physician Compare will post information only about physicians enrolled in the Medicare program, and will note those providers who participate in CMS’s voluntary Physician Quality Reporting Initiative (PQRI). The PQRI program requires that doctors report data for at least three of 170 or so evidence-based quality measures (examples include; giving aspirin to patients experiencing heart attack and recording vital signs for patients presenting with community-acquired pneumonia). By reporting this information (positive or negative) for at least 80% of patients over the course of a year, the provider earns an incentive payment from CMS that can reach 2% of total Medicare reimbursement.

This kind of information, if displayed in an easy-to-use format, will be more helpful perhaps than a friend’s recommendation, yet still limited. But over the next several years, the Physician Compare site promises to become something more. For one, health care reform legislation requires that by 2019, doctors must report and the public must have access to the following sources of physician quality and performance data:

• Measures collected under the Physician Quality Reporting Initiative
• An assessment of patient health outcomes and the functional status of patients
• An assessment of the continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use
• An assessment of efficiency
• An assessment of patient experience and patient, caregiver, and family engagement
• An assessment of the safety, effectiveness, and timeliness of care

According to Regina Raymond-Chell, a registered nurse who is part of CMS’s quality measurement health assessment group, January 2012 marks the beginning of the reporting period for more detailed physician performance information. A year later, in 2013, the agency will implement a plan for publicly reporting physician performance data through the Physician Compare Web site. By 2015, doctors who fail to report data on quality measures will face penalties—a 1.5% reduction to fee schedule payments the first year; a 2% reduction in 2016. Finally, in January 2019, a demonstration project will begin that will use this performance data to provide financial incentives (i.e. Medicare will reimburse patients’  medical charges at a higher rate) to beneficiaries who use “high-quality” physicians.

On October 17, CMS held a town hall style meeting to hear suggestions from stakeholders in the Physician Compare site about what kind of quality information should be included and where it should come from. Doctors groups insisted that performance information must be risk-adjusted to not penalize those who treat sicker patients. They also worried about how data will be presented for physicians who provide care in a hospital (hospitalists) versus those who see patients in an office or out-patient clinic setting. Finally, they want a physician to have the chance to review all information associated with his listing before it goes public.

The American Medical Association points out that even CMS’s basic physician directory (providing name, address, credentials for physicians) has had problems with accuracy, and the group says they often field complaints from physicians about interacting with this system.

Jennifer Shevchek, assistant director of federal affairs for the AMA said at the town hall meeting; “Physicians and other providers involved in the treatment of a patient must have the opportunity to prior review and comment and the right to appeal with regard to any data that is part of the public review process. Any such comment should be included with any publicly reported data. This is necessary to give an accurate and complete picture of what is otherwise only a snapshot and possibly…[a] skewed view of the patient care provided by physicians and other professionals or providers involved in that patient’s care.”

Meanwhile, consumer advocates want to put a limit on how long doctors can take to “review” their data so that the site is comprehensive and stays up-to-date. They also want Physician Compare to be user-friendly. At the October meeting, Tanya Alteras, associate director of the Consumer Purchaser Disclosure Project, a group that advocates for “a transparent health care market, in which, decision-making is supported by publicly reported comparative information,” said; “Physician Compare needs to be populated with information that’s meaningful to consumers and that is presented in a way that’s simple, intuitive and easy to navigate.” She continued, “We need measures on patient outcomes, patient experience, functional status, care coordination and resource use.”

Steven Findlay, a senior health policy analyst at Consumer’s Union added: “I think we all know that the existing CMS and HHS [Health and Human Services] Compare Web sites have been evolving and improving over recent years, but they’re still struggling to effectively support consumer choice.”

The other “compare” sites Findlay refers to include Hospital Compare, Dialysis Compare, and Skilled Nursing Home Compare. They have all been on-line for several years—although interestingly, they are not used very often by consumers. One study estimated that only 12% of consumers considering nursing homes for themselves or relatives actually used the CMS comparison site.

Why the low utilization? According to Findlay, “Nursing Home and Hospital Compare sites use extracted data from the Medicare database and although it is displayed in a way that’s meaningful and good, it tends to be packaged in a way that’s not easy to use for people who are not well educated or do not have advanced computer skills.” Considering that the majority of folks who would be using these sites are 65 and older, that is a real problem. This is especially apparent, says Findlay in CMS’s site that allows seniors to compare and choose a prescription (Part D) plan available through Medicare. “This site is god-awful,” he says, structured for a very sophisticated population but used primarily by senior citizens who are easily intimidated by on-line information. “I even find it intimidating,” says Findlay.

Besides being hard to use, some of the CMS sites have recently come under attack for providing consumers with inaccurate data or for using the wrong quality measures.

The Dialysis Compare site is one glaring example. This website allows patients requiring dialysis to find centers near where they live and then compare how the facilities rate in anemia control, hemodialysis effectiveness (how much waste is removed from blood), and patient survival.

But a new investigation by ProPublica along with The Atlantic finds that the Dialysis Compare site is not always providing accurate information about this costly medical service and that quality varies widely from site to site. Since 1972, Medicare has covered dialysis treatment for all patients, regardless of age or income. Each year, more than 100,000 Americans start dialysis treatment, according to Robin Fields, a senior editor at ProPublica and author of the report. “Taxpayers spend more than $20 billion a year to care for those on dialysis—about $77,000 per patient, more, by some accounts, than any other nation,” writes Fields. Yet the United States continues to have one of the industrialized world’s highest mortality rates for dialysis care: One in four patients will die within 12 months of starting treatment

Fields says that over the years, clinics have gotten better at hitting biochemical targets (anemia control, removing waste from blood, etc.) that are set by CMS and reported on the Compare site, but “overall rates of death and hospitalization have seen little change.” She continues; “Medicare’s record of making sure that clinics meet health and safety standards has been spotty. Clinics are supposed to be inspected once every three years on average, but as of October, almost one in 10 hadn’t had a top-to-bottom check in at least five years.” The ProPublica investigation found striking problems in some dialysis centers, including unsanitary conditions, high rates of patient infection and no nephrologists or other physician consistently on-site to oversee care.

The Hospital Compare site has also come under criticism recently. Researchers at the University of Michigan published a study this month in the Archives of Surgery that concluded; “Currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery. The Centers for Medicare and Medicaid Services needs to identify higher leverage process measures and devote greater attention to profiling hospitals based on outcomes to improve public reporting and pay-for-performance efforts.” The problem, according to the authors, is that CMS has put more emphasis on measuring processes (whether antibiotics were given or measures were taken to prevent blood clots) rather than outcomes—how patients fared after their surgeries.

One surprising result of the study is that there was little correlation between how well hospitals complied with Medicare’s process measures, (the information posted on Hospital Compare) and patient outcomes. In fact, according to a recent post on a blog published by the California HealthCare Foundation, “the hospitals with the poorest compliance rate with Medicare safety measures reported the fewest patient complications, while the hospitals with better compliance records had higher complication rates.”

The lesson from the shortcomings of current CMS Compare sites must be taken into account as Physician Compare develops. At the town hall meeting it was clear that decisions still have to be made about what quality measures will be included on the site and where this data will come from. Besides PQRI, groups like the National Quality Forum also have devised good quality metrics and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) devises free surveys that can help measure patient satisfaction and the communication skills of a given practitioner. Finally, in the next few years, “meaningful use” data generated by the widespread adoption by doctors of electronic health records could provide a powerful resource for measuring the quality of individual practitioners—especially in meeting process goals.

Consumer advocates want to see additional information included on the site that is not specified in the Affordable Care Act. CU’s Findlay believes consumers should know if their physician has kept up with the latest care available, so they will want to see evidence that their doctor’s certification is up to date. Also, he thinks consumers should have access to information about gifts and payments individual doctors and group practices receive from drug companies or device makers to help alert patients to potential conflicts of interests their physician might have. These figures will be publicly available under the Physician Payment Sunshine Act starting in 2013, and could be integrated into the Physician Compare site quite easily. “If they don’t do this, we will,” warns Findlay.

Finally, consumers should have access to some of the valuable volume and outcomes information that is gleaned by analyzing individual physician claims data—both from government insurers and private ones. This includes letting consumers know such relevant information like how many knee replacements a particular surgeon does a year, how many scans or other tests he or she orders compared to similar practitioners, and how much the physician is paid for these procedures.

Making claims information public will be a challenge. Three decades ago, the AMA successfully sued the government to keep billing and reimbursement data secret; citing privacy issues. And in the last year the AMA has fought and defended doctors against two other lawsuits from consumer groups that wanted to make physician claim information public to help detect fraud and overuse of certain procedures. In the interest of providing valuable information for Physician Compare, it may be worthwhile for the CMS to take the AMA back to court once again over this issue.

In the end, the short-term goal of Physician Compare is to empower consumers and give them truly useful information in an easy-to-use format so they can make important choices about their health care. One model to consider is the new healthcare.gov site, a comprehensive health insurance comparison website created by HHS that gets high marks from consumers and professionals for ease of use. “It’s a giant leap in the right direction,” says CU’s Findlay.

The longer-term goal of these Compare sites goes beyond consumer empowerment. Eventually CMS and even private insurers will begin using meaningful measurements and data from these sites to promote pay-for-quality schemes. The idea is to offer financial incentives (and disincentives) to encourage providers to improve the quality of their practice, or in the case of nursing homes, hospitals and dialysis centers, improve the quality of their facilities.The government has just begun to embark on its quest toward evidence and quality-driven medicine; for the public, it’s an early step toward making educated choices about care.

Naomi Freundlich writes for the Century Foundation, where she works with THCB author Maggie Mahar on the HealthBeat project. Prior to joining the Century Foundation, she served as Science and Medicine Editor at Business Week from 1989 – 1997. Her work has appeared in numerous publications, including the New York Times, Business Week, Real Simple and Parents magazine.