By MICHAEL L. MILLENSON
Say you want to know which baseball players provide the most value for the big dollars they’re being paid. A Google search quickly yields analytics. But suppose your primary care physician just diagnosed you with cancer. What will a search for a “high value” cancer doctor tell you?
Public concern over bloated and unintelligible medical bills has prompted pushback ranging from an exposé by a satirical TV show to a government edict that hospitals list their prices online. But despite widespread agreement about the importance of high-value care, information about the clinical outcomes of individual physicians, which can put cost into perspective, is scarce. Even when information about quality of care is available, it’s often unreliable, outdated, or limited in scope.
For those who are sick and scared, posting health care price tags isn’t good enough. The glaring information gap about the quality of care must be eliminated.
“When people are comparison shopping, knowing the price of something is not enough,” notes Eric Schneider, a primary care physician and senior vice president of policy and research at the Commonwealth Fund. “People want to know the quality of the goods and services they’re buying.”
While Medicare officials play up the need for transparency about prices, the information on Medicare’s Physician Compare website contains little more than professional credentials. Commercial websites have similar flaws, as does the information coming from state governments and nonprofit organizations.
Perhaps the most ambitious attempt to link the names of individual surgeons with hard data on their patients’ quality of care is the Surgeon Scorecard website hosted by the investigative journalism group ProPublica. Working with academic partners and using Medicare data available to researchers, ProPublica has published surgeon-specific complication rates for eight elective procedures, adjusted for how sick patients were to begin with. Unfortunately, the Surgeon Scorecard hasn’t been updated since 2015, although a new version is in the works.
ProPublica also showed how unreliable information can flourish when solid information is scarce. One of its reporters, a non-physician, was granted a Top Doctor award by a company whose profit model comes from selling plaques.
Since the mid-1990s, New York state has published risk-adjusted mortality rates of hospitals and individual physicians for a small number of cardiac procedures — one of the few states to do so. But those data are three to four years old and buried in reports whose bland titles, such as “Cardiac Surgery and PCI (Angioplasty) Outcomes Reports in New York State,” give no hint they contain names of individual doctors and hospitals.
The Society of Thoracic Surgeons offers both the best risk-adjustment and the most recent information (about seven months old). The group partners with Consumer Reports and has a public reporting website. But the information covers a limited number of procedures, and it comes only from medical groups that join the society’s national database and voluntarily choose to report their surgical outcomes to the public. The public-facing ratings cover only hospitals or surgical groups; even cardiologists can’t see outcomes for individual surgeons.
In cancer, the information contained in several registry programs is rich in detail. But it’s confidential, so patients can’t use the outcomes data to determine quality of care. That leaves cancer centers free to spend tens of millions of dollars on print and TV ads dangling the lure of “beat the odds” cures. Unfortunately, as with so many other advertisements, what consumers are being told is “deceptive,” according to a Truth In Advertising analysis.
The playwright Oscar Wilde once quipped, “A cynic is a man who knows the price of everything, and the value of nothing.” A good place to begin combating health care cynicism would be supporting the research needed to generate the detailed outcomes information patients urgently need for what can be life-and-death choices.
If you’re fortunate, your employer or health plan may have used its clout to get data for a “Center of Excellence” for some procedures, as Walmart and others have done.
Even though some believe that value ratings for individual doctors are a vain hope, a recently published University of Virginia study suggests a path toward developing them. Researchers crunched nine years of data from surgeons at their medical center, then assigned each surgeon a numerical score based on risk-adjusted death and complication rates in relationship to care costs. The quality of care and cost analysis was useful “for surgeons performing a certain volume of cases,” the study concluded, although greater detail on patient characteristics and the supporting hospital teams was needed “for more fairly attributing cost and quality to individual surgeons.”
Tellingly, while entrepreneurs promising price transparency are pulling in millions in funding, the Virginia researchers had to rely on mostly volunteer labor, lead investigator Dr. R. Scott Jones, a former senior official with the American College of Surgeons, said in an interview. The team is hoping for grants in order to continue.
Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, recently waxed enthusiastic about the potential of price transparency in an article on the website of a health care pricing startup. Verma praised the way American “shoppers” demand “value” and promised “to pull every lever in her power” to give patients the information they need.
There’s no greater value in health care than a human life. Responsible consumerism can’t cynically focus only on price. The government and providers themselves must make it at least an equal priority to give us the timely, reliable, and complete information about the quality of care upon which our lives depend.
Michael L. Millenson is president of Health Quality Advisors LLC and adjunct associate professor of medicine at Northwestern University Feinberg School of Medicine. This article originally appeared on STAT here.
Once again, robust and engaged Primary Physicians for each community’s citizens standout on the horizon of seeking quality. I notice that several states have begun mandating an increase in health spending on Primary Healthcare by their health insurance companies. Of all the commitments of Ewe Reinhardt that I admired, his emphasis on “charges” tended to obscure larger issues.
What I would like to better understand as a patient is how do doctors determine which specialists they themselves would want to go to or refer a family member or friend to if that expertise were needed. Maybe doctors just know high quality healthcare when they see it just as education experts and very involved parents know and recognize good teaching in schools when they see it even though it can’t be reduced to contract language or proven in court.
I rely on my primary care doctor, cardiologist and gastroenterologist to refer me to specialists who they would be willing to go to themselves if they needed them, especially when the specialists are surgeons. Hopefully, credentialing in the U.S. is strict enough so that most doctors are probably pretty good at least once they’ve accumulated ten years or so of experience. I’m somewhat skeptical of risk-adjustment because I just don’t think the state of the art is very good in healthcare and I wouldn’t want to see surgeons avoid the highest risk cases because it might hurt their quality scores.
If asked, I assume surgeons would tell patients how many times they perform a specific procedure per month or per year and how does that compare to the minimum number the specialty society says are necessary to perform in order to keep skills sharp. I also would be interested in knowing how many doctors and nurses a specialist has as patients and is that considered high, low or about average.
Maybe if doctors were the equivalent of bonds in the financial markets, some may be rated AAA, some double A, and some single A but all would be considered investment grade or, as a practical matter, good enough. Those rated below investment grade would be weeded out of the profession one way or another. Is that basically what we’re dealing with here?
Price transparency, by contrast, is a whole different matter. The more of that we can have the better for both patients and referring doctors.
Good docs 1. Worry about their patients. Discuss them at coffee and in meetings and with friends. Come to pathology and radiology to discuss their patients. Get autopsies. 2. Impress their office nurses and surgical nurses and aids and assistants.
The best way to gauge a specialist is by the content of the letter you receive as a result of a referral. Does it educate me about the diagnosis, what efforts were made to engage the patient regarding any changes in their over-all healthcare, how did these efforts support my role as the person’s Primary Physician, AND were they able to do all of this on one page?
When I started working in healthcare over 25 years ago, I was stunned by the fact that there was more information available when purchasing a dishwasher than in choosing a provider. Over those 25+ years, we have accumulated boatloads of evidence that a large portion of patients are either not getting the appropriate care or are getting non-value added care or in some cases, even getting care that is harmful. We have seen pockets of success where measurement, quality improvement methodologies and evidence-based proven care have been successfully employed to yield material improvements in patient outcomes. We have talked about pay for performance, population health, accountable care, high value networks, AI and analytics.
Yet, little has changed in terms of the scant objective information available when choosing a provider. The public continues to fly blind in selecting where and from whom to get their care. The industry continues to successfully avert accountability using the old standards about data quality, severity adjustments being inadequate, the need for MD autonomy, the public not being able to interpret the data and so on. We ought to do better.
Help us do a better job.
What are some professions (professions, not industries) that do a good job of measuring the performance of individuals and of sharing that information with the public?
Fair question. I don’t know of any other professions that have a model and methodology for public reporting that is worth studying. That said, I don’t think that obviates trying to come up with one in healthcare. The challenges, as you are no doubt aware, are real and substantial. Again, I wouldn’t agree that is a reason to avoid trying. Here is one specialty group’s thoughtful and thorough view on the issue of measurement:
Their point that the most important rationale for measurement relates to continuous improvement is worth noting.
So rather than stating “We ought to do better,” isn’t it more appropriate to ask “Can we do better? We don’t know – let’s find out.”
Nobody should object to open-minded trials of performance measurement where results are analyzed objectively and negative results aren’t brushed under the rug.
But what is so damaging is the application by fiat of unproven mandates designed to inflict financial pain on those who care for patients with the greatest needs.
The AAFP can put out some nice words, but their actions, in terms of policies that they promote, are truly despicable – all they’re interested in is getting on their knees and applying their mouths to the nether regions of low-level insurance and CMS bureaucrats.
Practically, to do this is a rough go. Because, if you really could rank physicians truthfully, we are going to have these particular practices swamped. Those docs would get all the work. Who would go to a doc not in the top three or four?
Besides, where else in the economy does this ranking actually happen? Lawyers? Dentists? Architects? Scientists? Mathematicians? Generals or Admirals? Politicians? These people can be as critically needed and important as any physician. Besides, skills and quality change as careers move along. Today’s high quality docs in, say robotic surgery for hernia repair, are not going to necessarily be tomorrow’s high quality doc…because people learn and improve and take courses,teach, and have learning experiences.
I think we are going to have to continue ranking professionals the same old way we always have: personal impressions, certificates on the walls of offices, word of mouth, stories in newspapers, rumors of lawsuits, rolling of eyes from friends…
Remember, the licensing boards in the various states claim to have done this. They continue to periodically look for crimes and misdemeanors and censorship and these results are posted on web sites in most states.
If we really dig in and do all the surveillance necessary to rank people we are going to have terrible consequences… I think: more docs quitting or going boutique; more doc suicides; bad access problems as manpower wanes; lawsuits against all rating agencies in sight; lawsuits against witnesses and testimonial sources. We don’t want a constantly surveilled, tattle-tale society anyway, do we?
Great comment. Thank you, Dr. Palmer.
Thanks thanks …
You wrote: ” If we really dig in and do all the surveillance necessary to rank people we are going to have terrible consequences… more docs quitting . . . more doc suicides.”
I really can’t reply.
Your comment says it all.
Remember Immanuel Kant’s ethical imperative?…which many ethicists extol? You shouldn’t use other people to get what you want. This means that one’s own actions can only be ethical if they can be applied to, and used, by everyone. You dont surveil physicians unless you are surveilling yourself and everyone. Otherwise you are using someone to get what you want. Viz. quality in health care by surveiling physicians.
These comments seem to be missing a key point. Unlike other professions, physicians have a direct impact on their patients’ health, longevity, and economic welfare. Shouldn’t the patient know which cancer center/specialist is more successful in terms of added quality life years for similar patients to themselves? In addition, shouldn’t they know what they will need to pay to be treated by this physician?