Logic, Science, and Rationale of Public Reporting


Public reporting of doctors is fiercely controversial. I’m vehemently opposed to it. So I decided to find out why its proponents favor it.

I discuss public reporting with Ben Harder, Chief of Health Analysis at U.S. News and World Report, for JACR Firing Line. We disagreed for most parts, though we agreed that there are bad ways to rate doctors, and better ways, too. Listen to our discussion here.

Key points made by Ben Harder:

a) Reporting of quality is a decision support tool for patients and their caregivers. It is NOT to penalize or shame doctors but to engage consumers in their healthcare decisions. This is an important distinction.

b) If methods to rate quality are so bad how is it that hospitals which look after the sickest patients also have the highest rating?

c) Newer methods to rate quality make a huge effort not to compare apples (hip surgeons) with oranges (knee surgeons).

d) We are still suffering the legacy of poor risk adjustment.

Key points made by me:

a) The logic of risk-adjustment is backwards. “Adjustment” makes it sound like we’re making the surgeon whole again. Rather, surgeons should be rewarded for taking on the sickest, poorest and most complex patients. Risk adjustment should be an “honor score” – each surgeon/ interventional cardiologist should have a score which is a measure of the complexity of the patient they treat.

b) There are some attributes, which lead to poor outcomes, which can’t be captured

Ben Harder and Saurabh Jha with Firing Line Recording Crew – Jessica Siswick (left) and Hannah Burson (right)

systematically. For example, the distribution of calcification in the iliac arteries of a transplant recipient is very important for transplant surgeons, because it’s the difference between success and failure. For cardiac surgeons, not all infected grafts are the same. Not all re-do sternotomies are the same. Not all revision hips are the same.

c) If public reporting, regardless of its intent, accentuates risk aversion, this is not a good outcome.

Saurabh Jha, aka @RogueRad, is a contributing editor to THCB and host of Firing Line Podcast, which is produced by JACR, and sponsored by Healthcare Administrative Partners.

4 replies »

  1. This is great discussion. Everyone has their own perspective and so you have too. Thanks for sharing this amazing article.

  2. Well written. There are healthcare IT solutions to close healthcare gaps. It is important to adapt to approaches to cover the gaps. For quality care and better patient health outcome, some solutions may be of great help.

  3. Need for quality transparency is going to get stronger with time, though the points raised by Saurabh can be a genuine concern. Doctors who take on complex cases should not be deterred from doing so because of quality transparency. How about also measuring the risk profile of an incoming patient along with the final outcome, similar to a cohort analysis. That may give some objectivity and depth to quality reporting, and would even benefit the patient in choosing the right doctor.

  4. What is your alternative? Surely we shouldn’t just let docs do whatever they want without any regard to outcomes. Do you monitor outcomes of providers where you work?

    “Risk adjustment should be an “honor score” – each surgeon/ interventional cardiologist should have a score which is a measure of the complexity of the patient they treat.”

    Isn’t that how we do it? Every hospital has an acuity index which is used to adjust its payments. This is the stuff that they look at. Your description of “Adjustment” is pretty odd and does not sound at all like the internal attempts we have used to track our staff. (Not really sure how you would do it to be honest. Maybe you have some examples of how or where people have done that?)