Of the many hidden gems in the Affordable Care Act, one of my favorites is Physician Compare. This website could end up being a game changer—holding doctors accountable for their care and giving consumers a new way to compare and choose doctors. Or it could end up a dud.
The outcome depends on how brave and resolute the Centers for Medicare and Medicaid Services (CMS) is over the next few years. That’s because the physician lobby has been less than thrilled with Physician Compare, and, for that matter, with every other effort to publically report measures of physician performance and quality.
I’d give CMS a C+ to date. Not bad considering it’s the tough task. The agency has been cautious and deliberate. But after the many problems with Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Facility Compare—not to mention the shadow of healthcare.gov’s initial rollout—that’s understandable. They want, I hope, to get this one right from the get-go. And competition from the private sector looms.
Congress mandated that CMS establish Physician Compare by Jan. 1, 2011 and that an initial content plan be submitted by Jan. 1, 2013. CMS met those deadlines, albeit with a rudimentary site that launched in late December 2010. The agency updated its plans in 2013 and 2014, even as it added more content and functionality to the site.
The law requires the site to have “information on physician performance that provides comparable information on quality and patient experience measures.” That’s to include measures collected under the Medicare Physician Quality Reporting System (PQRS), Medicare’s main quality reporting vehicle, and assessments of:
- patient health outcomes and the functional status of patients
- continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use
- the efficiency of care
- patient experience and patient, caregiver, and family engagement
- the safety, effectiveness, and timeliness of care
Notably, Congress set no deadline for the site to meet those specifications or be fully operational.
So what’s posted so far? The centerpiece of the site is a searchable directory of some 850,000 Medicare providers. That includes most of the practicing doctors in the U.S. with the exception of pediatricians and other physicians who don’t treat Medicare patients. This database predates the ACA and Physician Compare but its functionality, reliability and accuracy (a big complaint from physician groups) is being gradually enhanced.
Each doctor has his or her own profile page—a significant foundation that could accommodate quality and patient experience data in the future.
Consumers can also search three additional databases on the site. They identify doctors and other clinicians who participate in (a) PQRS; (b) the Electronic Prescribing Incentive Program; and (c) the electronic health record (EHR) incentive program (also called the meaningful-use program). About 350,000 physicians and other clinicians participate in the latter.
The bad news: these databases are separate and their content is not integrated. That makes searching for information on a particular group practice or individual doctor cumbersome and time consuming. And the databases aren’t user-friendly. On the plus side, for researchers and health administrators, the databases are downloadable.
In 2014, CMS added performance data from 2012 on diabetes and heart disease care for 66 group practices with 25 or more clinicians. These entities serve Medicare patients and participate in yet another quality improvement program called the Group Practice Reporting Option. While 66 doesn’t sound like a big number, many of these group practices are, in fact, among the largest in the country. In aggregate, they care for millions of people. Among them: Mayo Clinic facilities in Minnesota, Arizona, and Jacksonville, Fla.; the Cleveland Clinic in Ohio; the Sutter Medical Foundation in California; and the Henry Ford Health System in Michigan.
Also in 2014, CMS added to the site performance data for five measures of diabetes care and one measure of coronary artery disease care for 146 of the 360 accountable care organizations (ACOs) serving people enrolled in Medicare. About six million Medicare beneficiaries are enrolled in ACOs.
Coming in 2015 and 2016, CMS pledges:
- A database of clinicians who participate in Million Hearts, an HHS campaign to enhance heart disease preventive screening
- A database of doctors who pass maintenance of certification (MOC) exams. MOC tests assess how up-to-date doctors are in their specialty areas
- An update with 2013 data on all the quality measures now available on groups and ACOs
- Expansion of the number of quality measures for physician groups, including 20 PQRS measures reported in 2013
- A tab on individual physician profile pages indicating participation in the varying quality improvement programs mentioned above.
- “If technically feasible,” patient experience data for group practices of two or more doctors participating in a Medicare ACO
- Data on a limited number individual physicians from several disease-specific treatment tracking registries that CMS has sanctioned
- Composite scores that combine individual quality-of-care measures (for example, of diabetes care)
- Expansion of the use of the five-star ratings scale to more and smaller physician groups. The star ratings are already being used for physician groups and ACOs.
There are reasons to be both pleased and frustrated with this progress. Accurately and fairly measuring physician performance and quality-of-care is simply not easy to do. Debate continues to rage over whether the care rendered by individual doctors can and should be assessed—since much care today (other than routine) is rendered by teams of providers. And there are certainly technical barriers remaining to accurate measurement. For one, a lack of standardization haunts the field.
Not surprisingly, front-line doctors remain skeptical of the whole enterprise. And their trade groups argue vigorously that much physician performance measurement is still not ready for prime time. In an August 2014 comment letter to CMS, for example, the American Medical Association (AMA) said it would “adamantly oppose the multiple proposals to extensively expand the Physician Compare website, as serious and fundamental flaws and errors remain unaddressed.”
But it’s now clear—and a good thing—that this train has left the station, and that consumers have increasing interest in comparative information on doctors. A survey of 2,137 adults conducted in 2012 and published in the Journal of the American Medical Association (JAMA) found that one in four people had consulted a physician-rating site when picking a primary care doctor that year. Five percent had rated a doctor online. Healthgrades.com, the largest hospital and physician-rating site, says about one million people visit its site every day.
Indeed, one reason CMS ought not to tarry too long with Physician Compare is that physician-rating sites are fast cornering the market. While consumer reviews of restaurants, hotels, movies and books are fun and useful, reviews of doctors have to date been more specious. That’s because most of the ratings (on RateMDs.com, ZocDoc.com, Vitals.com, yelp.com and others as well as HealthGrades) are based on low numbers of reviews (usually fewer than ten), meaning the ratings for most doctors are far from statistically robust if not downright misleading. And there’s still debate on whether the ratings can be manipulated by doctors despite companies’ claims that they protect against this.
It’ll be great once millions of people are reviewing their doctor online, using good survey instruments. And Physician Compare plans to incorporate such data. But even so, consumer reviews and patient experience reports don’t assess actual outcomes. You need to measure what doctors (and health systems) actually achieve.
Adding to the worry: compared to the big consumer doc review sites, only a relatively small number of consumers so far have ever used the still-fledgling physician performance rating sites sponsored by states, the Robert Wood Johnson Foundation’s Aligning Forces communities, and other local efforts. In contrast to Healthgrades, for example, these initiatives have not been widely marketed, and word of their existence has spread slowly.
That’s another lesson for CMS. If the government wants Physician Compare to succeed, it’ll have to market it—and much better than it has Hospital Compare. Search engine optimization will be critical as will ads social media marketing and buzz.
But my advice would be: don’t do that before you fix the site itself. Take a page from the terrific job (in the end) that HHS (and contractors) did on healthcare.gov, even as you check out the latest user-friendly templates on the most popular and well functioning websites. Make it appealing and engaging, and explain what’s on the site and how the data should be used and interpreted.
CMS has to be a fair arbiter and steward in the ongoing debate about accurate physician performance measurement. But at the end of the day, the public interest is the priority and will be best served if the agency moves aggressively forward with the site, meeting both the letter and spirit of the law. Physician Compare will be a work in progress for years to come, like many websites, but 2015 should be the year it starts to make an impact.
This piece draws on a policy brief published in December 2014 on the Health Affairs web site and written by the author. Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology.