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Thursday, July 06, 2006

Do Medical Report Cards Improve Surgical Outcomes?

Should measurements of physician quality be made available to the public?:

Grading Surgeons May Be Healthy Practice, by David Wessel, WSJ: In a society that champions consumer choice and market forces as the best ways to do nearly everything, medicine stands out as an exception. Most Americans know very little about choosing, say, a heart surgeon. They simply take their primary-care physician's advice or blindly pick a surgeon from those covered by their insurance plan.

For more than a decade, a handful of states ... have been issuing public report cards on individual surgeons that show the rates of death and complication of their heart-bypass patients. After all, practicing doctors and nurses know which surgeons are good, and which are to be avoided. Shouldn't the rest of us know, too?

But report cards remain surprisingly controversial... Daniel Kessler, a Stanford University economist, divides the debate into three camps. One says report cards boost the quality of health care. A second says they don't have much effect, good or bad, because ordinary patients ignore them.

And a third group, to which Mr. Kessler belongs, holds that report cards may have some beneficial effects, but those could be outweighed by unwelcome, unintended consequences -- such as encouraging doctors and hospitals to game the system by avoiding sicker patients, thereby reducing the overall quality of health care. [States attempt the tricky technical task of adjusting data so doctors who take tougher cases are compared meaningfully to those who take easier cases. Surgeons and other skeptics often criticize the precision of such adjustments.]

Now come a couple of Harvard School of Public Health physicians, firm adherents to the view that report cards do lead to better medicine, with an intriguing observation: Cardiac-bypass surgeons who get bad marks are more likely to give up practice than their peers. "These are cardiac surgeons, the best students in med school ... they've always been the stars. It's psychologically difficult to have spent 15 or 20 years training and practicing and then to be identified publicly as one of the worst in state," speculates Ashish Jha, one of the Harvard researchers.

More than 20% of the surgeons who scored in the bottom quarter of the New York state grades stopped practicing cardiac-bypass surgery in the state within two years after the report was issued... Only 5% of surgeons who scored in the top quarter, and fewer than 7% of those with middling grades, dropped out...

Other evidence reinforces the case that the report cards may have a big effect even if their consumers don't heed them. Another set of researchers compared the behavior of hospitals in the Madison, Wis., area -- where an employer group publicized report cards -- with other hospitals in the state that were given private report cards and still others that got none at all. ...

"What we found," says Judith Hibbard, a University of Oregon health-care-policy professor, "is that it's all about reputation. The hospitals were concerned about protecting their reputations or enhancing them. That's what motivated improvement..." Surveys found consumers in the Madison area were aware which hospitals got bad grades, and hospitals worried about the harm to their image -- even though their market share didn't flinch. Ms. Hibbard suggests that hospitals, nearly all nonprofits, may have worried about harm to their fund-raising efforts, even if the flow of patients wasn't affected. ...

Giving consumers information about quality and price is essential to any well-functioning market. Shopping wisely for health care is difficult for most of us, more difficult than acknowledged by those who advocate turning health care into a market like any other. But public report cards on individual doctors, if designed well, may still be valuable -- if they help push out poor-performing doctors.

It depends upon the precision of the quality measures. As the article notes, insiders have the best information. For example, there's a surgical nurse who lives next door. If I need surgery, I know who I'm talking to first. In general, I'd like to know where the families of doctors, nurses, and others with inside knowledge of quality go. Which doctors and dentists have the most visits from other medical professionals? Where do doctors and nurses send their kids, parents, and relatives when they need essential care? In internet language, count the number of inbound 'links' from other medical offices.

The point is that because insiders have the best information, they are in the best position to ferret out the weaker physicians. The trick for public policy is to create a strong incentive for them to do so.

    Posted by on Thursday, July 6, 2006 at 02:32 AM in Economics, Health Care | Permalink  TrackBack (0)  Comments (7)

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