Thursday, June 21, 2007

Hospital Physician Relationships - Hospital Quality Ratings

Useful Tools or a Flawed Exercise in Futility?

Perhaps I’m a contrarian. Perhaps I’m overly pragmatic. Perhaps I’m cynical when I always consider the source. Or maybe, just maybe, based on my experience on the Medical Advisory Board of America’s Top Doctors, I trust doctors’ judgments on who are the best doctors more than mere data. Reputation, in other words, in my mind often trumps data.

I know these attitudes must sound naïve, but that’s how the mind of many of us non-managerial types work. Reputation, and related factors, word of mouth, personal knowledge, private referrals, and closeness to home are more powerful than often conflicting ratings and data emanating from the Internet, government, or media sources.

In any event, three articles, one in Medscape’s General Journal, one in the AMA News, and the other in the New York Times, prompt this blog.

•The Medscape piece, posted 6/1/07, appeared first in the Journal of Hospital Medicine. It bears the title “Conflicting Measures of Hospital Quality from ‘Hospital Compare Vs the U.S. News and World Report’s Best Hospitals.” The article notes that in April 2005 CMS launched “Hospital Compare,” the first government sponsored hospital quality score care. The authors compared government rankings vs. U.S. News and World Report’s Best Doctors. Here’s what the authors’ conclude.

The Best Hospitals lists and Hospital Compare core measure scores agree only a minority of the time on the best institutions for the care of cardiac and respiratory conditions in the United States. Prominent, publicly reported hospital quality scorecards that paint discordant pictures of institutional performance potentially present a conundrum for physicians, patients, and payers with growing incentives to compare institutional quality.

If the movement to improve health care quality is to succeed, the challenge will be to harness the growing professional and lay interest in quality measurement to create rating scales that reflect the best aspects of Hospital Compare and the Best Hospitals lists, with the broadest inclusion of institutions and scope of conditions. For example, it would be more helpful to the public if the Best Hospitals lists included available Hospital Compare measures. It would also benefit consumers if Hospital Compare included more metrics about preventive and elective procedures, domains in which consumers can maximally exercise their choice of health care institutions. Moreover, voluntary reporting may constrain the quality effort. Only with mandatory reporting on quality measures will consistent and sufficient institutional accountability be achieved.

• The second article, in the June 18, 2007 AMA News, has this title and subtitle, “Coping with Rankings: More Plans are Rating Physicians, but Patients Aren’t Keeping Score. Doctors Still Have Time to Pressure Insurers for Accurate Data or None at All.” The article says demand for publicly available performance measurements are up, and corporations are demanding this data more and more. In response, the AMA-led Physician Consortium for Performance Improvement and CMS has created 184 measurements it believes provide accurate evidence-based measures and outcome data. The trend is inevitable, so doctors are learning to shape new data based on physician negotiation with health plans. Harris Interactive Polling indicate less than 1% of patients use ratings to select their doctor. Most patients still rely on word of mouth. But health plans and corporations may think differently. They believe ratings are an effective tool for identifying the best doctors.

•And then there’s the New York Times June 14 revelation In Health Care, “Cost Isn’t Proof of High Quality.” Reed Abelson, the reporter, leads off with this commentary,

Stark evidence that high medical payments do not necessarily buy high-quality patient care is presented in a hospital study set for release today. In a Pennsylvania government survey of the state’s 60 hospitals that perform heart bypass surgery, the best-paid hospital received nearly $100,000, on average, for the operation while the least-paid got less than $20,000. At both, patients had comparable lengths of stay and death rates.

And among the 20 hospitals serving metropolitan Philadelphia, two of the highest paid actually had higher-than-expected death rates, the survey found.
Hospitals say there are numerous reasons for some of the high payments, including the fact that a single very expensive case can push up the averages.”
Still, the Pennsylvania findings support a growing national consensus that as consumers, insurers and employers pay more for care, they are not necessarily getting better care. Expensive medicine may, in fact, be poor medicine. “

The Times has been running a series of articles on medicine and money, and have reached the conclusions that doctors and hospitals vary in their pricing, that their results vary, that greed and fraud and bill padding must be involved, and that surely, if everyone including the public and payers, knew and understood the data, and the underlying costs, more homogeneous, more favorable, and lower pricing would logically follow.
he reporter concludes:

As eye-opening as the Pennsylvania report may be to the public, insurers have already been aware that their payment practices do not necessarily encourage hospitals to provide better care. Medicare, for example, pays essentially a flat fee, which varies depending on location and type of hospital, for the same surgery, regardless of outcome. Complications tend to simply mean additional payments.

The basic idea behind data-seekers, as I see it, is that we should pay more for better care and less for lesser care. That intuitively makes good sense. It may sound simple, but it is not, and the process can be distorted by a few cases with horrible outcomes and by hospitals’ locations and their varying constituencies and their expectations.

It is fashionable in government and managerial circles to say that anything that can measured can be managed. It is also fashionable, in conservative circles, to say that health care is so full on interactive permutations and combinations and personal considerations and choices that only the impersonal forces of the market can sort it all out. Finally, there are those who say hospital care is too “secretive,” and therefore only data and total “transparency” can identify the best, reveal the outliers, and smooth out cost and quality variabilities.

All of these critics may be right and yet all of them may be wrong. Unfortunately, variable costs, variable quality, and variable outcomes are a function of humanity, regional cultures and their constituencies. Independent variables are part of the human condition. Some of these variations may be beyond managerial control. Health costs are 30% higher in Boston, because the Boston public is enamored with the halo of quality surrounding academic medical centers. Health costs in Miami are higher because the seniors there may consider health care “free” because of Medicare and Medigap policies. In New York City, last illnesses are 40% higher at Columbia Presbyterian than at the Mayo Clinic because people have different cultural expectations, e.g. access to the best independent specialists. Variation in cost, quality, and outcomes is not always about greed or fraud or mismanagement. They may be about cultural expectations.

I remember Peter F. Drucker’s comment, “Large health care organizations may be the most complex organizations in human history.” It’s going to take a while to establish criteria to judge and sort out the good, the bad, and the ugly. Public disclosure of outcome data and performance data on the processes of care may help, but they are only part of a complicated human equation.


Unknown said...

Interesting take on scorecards. I think you're right in that Quality ratings can't be a top-down pronouncement that suddenly changes the payment structure. On the other hand, reputation only goes so far...the rest of the docs between "top doctors" and disciplined before licensing boards must be different in some way.

I think we'll see something similar to the restaurant industry--if we ever develop a true market in healthcare. Some people like editorial reviews, others like Zagat, others like the Michelin pricing isn't determined by any one "best" source...and neither should that be the case in healthcare.

Health is at its heart a business customized to local needs and relationships. Why not let the local community determine what they think is worthwhile?

Richard L. Reece, MD said...

Thank you Dr. Goel for your thoughtful and constructive thoughts. You're right that each doctor is "different," and maybe we ought not to try to categorize one as better than the other. Data may help show the differences, rather than being used to harp on quality. Local needs and relationships will always be more important than federal ponouncements.

Richard L. Reece, M.D.

Dr. Val said...

I really loved this post. I think you're right on the money, Dr. Reece. You are a true "Voice of Reason" in healthcare.

Richard L. Reece, MD said...

Wow! Thank you for calling me the "True Voice of Reason" in health care. It's a designation I so richly deserve but so seldom get. Keep this up, I'll be a legend in my own mind. On a more serious note, I invite readers to visit Dr. Val Jone's blog, the true voice on reason. You may view on

Richard L. Reece, D

Unknown said...

Dear Dr Goel,

A Patients Tale of Woe:

I was recently a patient at DePaul Hospital in St.Louis for a craniotomy. The surgery went well, but, problems ensued with poor health care starting in the ICU. My night nurse in ICU had put in a long shift and made some mistakes in my healthcare that almost proved catastrophic/fatal for me. During his tenure he gave me a glucose drip-unfortunately for me...I am diabetic and my blood sugar shot through the roof. Worse, when giving me shots, the nurse did not ensure that the IV was open by irrigating the site before injecting me. Apparently, I was given a heavy, as in syruppy, medication for anti-siesures...which hurt when he injected me. Subsequent, injections also hurt to the point that when I got to a floor right arm and forearm were swollen.
When the doctors came around the next day, I told them about my arm and hand...they thought that sort of thing happens and told me that my body would absorb the meds in three or four days. That did not happen.

My next visit to my neurosurgeon was the next week, I showed him my swollen right appendage. He prescribed antibiotics because he thought it was a result of an infection. I had an allergic reaction to the antibiotic and had to take a different one for ten days. When I went to my internist and showed her my arm, which was still swollen and hot to the touch. She recommended that I go to the emergency room and have it dopplered.
The doppler found that I had phlebitis AND several DVT's. I spend almost a week in the hospital taking blood thinners, my hand gradually stopped burning...but, the doctor prescribed a warm wrap around my arm...which the staff refused to do because the hospital policy precluded that type of treatment for fear of burning/scalding the patient.
Before admittance I had to pay $150.00 for going to the ER. I was told that when I was admitted if they kept me I would get a refund.
Here in begins the nightmare. I had been on short term disability due to being diagnosed with a brain tumor and siesures. In Florida your license is suspended for a year when that happens. Due to the healthcare I recieved, I have to be on blood thinners until the end of December and have protimes done at my expense,as well.
When I did not receive my refund of the ER payment at the end of July, I contacted DePaul and asked what was going on with my refund. They said that they were using it on my hospital stay. I said I wanted to talk to someone in Patient Care...whom I told that I thought that having me and my health insurance pay for sloppy nursing wasn't fair. While in the hospital for the second time, a Government report came out that Medicare and Medicaid are no longer going to pay for extended stays in the hospital for such reasons as I have noted. The AMA also came out with an evaluation of local St.Louis hospitals being below the national average in preventive procedures to minimize the amount of DVT's.
As I said I spoke with the hospital concerning this matter around the first of August. I did not get a written reply from the hospital until October 10th, 2007, though that letter took a week to get to me, 10/17/07.
From August to October it took DePaul to contact a surgeon on their staff, which they never directly spoke to, just his nursing staff. They made one phone call to my internist...who never saw me in the hospital, just a member of her staff. With the generalizing of how you can get DVT's but not mentioning the fact that poor nursing care could be the culprit...that same care that kills over 50k Americans every year.

The nurse had a bad night. Working them 10/12 hour shifts or even pulling doubles is DANGEROUS. My nurse on the floor discharged and admitted 14 patients on her shift, missing my insulin shots while my blood sugar was through the roof. I think she stopped in twice the entire day, forgoing my health care...a patient that had a craniotomy to check in/out patients. BTW, she was nurse of the month the previous month...probably because she got in and out...not really taking care of the one's she was supposed to care for.

When it came time for DePaul to address my concerns and issues it took them 2 1/2 months to come up with a sleazy generic blurb and sorry. [btw: I had been promised an answer on my concerns twice and never once did DePauls, Patient Affairs person ever reply on time or apologize for not having an answer or even call to let me know she didn't have one.
ONLY, after I called the Hospital President's office, a Mr. Johnson, did his secretary get PA started on answering my questions.
I am not a litigious person, but this hospital infuriated me to the point of soliciting an atty. All, told me that hospitals are protected by state laws against healthcare issues, unless of course I died...then they know they have a pretty good case.

DePaul Hospital needs to address their health care issues IMMEDIATELY. They also need to address their administration that cowers behind statutes that protect them from taking responsibility for their business decisions and Patient Safety. Tell me what other business would take TWO and ONE/HALF months to respond to an issue, if they were not confident they would not be held responsible for their health care issues. Furthermore, if the government isn't going to pay for these episodes like I had for those on Medicare and Medicaid, then who will pay it...the PATIENT.