Jury is still out on physician report cards

Experts debate pros and cons of making them public

Some call physician report cards just another marketing gimmick. Others question the fairness of releasing clinical and profiling data to an unsophisticated public. But those on the cutting edge of this new trend of making physician profiling reports public talk about the benefits: It will give consumers more information with which to make choices, and it will encourage physicians to improve customer satisfaction.

PacifiCare Health Systems of California in Cypress made national headlines this fall when it announced its new public Quality Index on medical group performance. The company will put a rating system for all of its contracting physician groups in membership directories. Consumers will be able to see how their own physicians did when compared with others, and if they like, they can switch over to the top-rated physician groups. These report cards will be updated twice a year, and PacifiCare officials say they do not expect the same group practices always will be in the top 10%.

Earlier, Minneapolis-based United HealthCare Corp. had touted a program that gives physicians clinical information that compares them to national best practices. United HealthCare will not release its reports to the public for at least two years, but that trend may be inevitable.

Physician’s Managed Care Report asked the chief medical officers of United HealthCare and PacifiCare to discuss their new programs. (See story on PacifiCare and United HealthCare, p. 190.) Also, PMCR asked integrated delivery system executives and other experts to analyze how these types of report cards or profiling might affect health systems and whether payers next will be issuing the same reports on hospitals. Their comments are as follows, along with a description of each expert:

• Henry Anderson, MD, FAAFP, is vice president of professional affairs and chief quality officer of Swedish American Health System in Rockford, IL. Swedish American Health System has 400 beds at the main hospital, nine outpatient clinics, private physician clinics, a home health agency, and an insurance company.

• Sharon R. Chamberlain is president of Madison, WI-based Chamberlain Research Consultants, a full-service marketing research firm that specializes in health care.

• Michael A. Cohen, MD, is a radiologist and medical director of Memorial Sloan-Kettering Guttman Diagnostic Center in New York City.

• Colleen Dowd, MHS, is vice president of Baptist*St. Thomas Health Associates in Nashville, TN. Baptist*St. Thomas is a managed care services organization that serves 10 hospitals, 400 physicians, and 25 ancillary companies.

• Joseph L. Francis is vice president of Cooper Research Inc., a health care marketing research firm in Cincinnati.

Here’s what they say about physician report cards:

PMCR: What are the pros and cons of physician report cards?

Anderson: We like to change behavior, and what most of us have seen is if I’m giving my own statistics and comparing this with others, that’s a powerful motivator.

But I guess to a certain degree I still believe that whatever we can do to try to get cooperation out of a physician is more useful than beating them over the head. As long as the statistics [used in the reports] are valid, that’s one thing. But sometimes we see statistics that are not so valid. For example, some of the best physicians are referred the worst patients, so their length of stay or cost per case may be higher. So if one can adjust for severity and patient mix, I think it’d be more fair.

Cohen: The problem is that statistics can be very misleading. If you put a lot of thought into it and if you have a good statistician, you could generate statistics that would look very favorable to you.

If you’re a provider and your population is aged 60 to 70 generally, as opposed to another provider who is handling a lot of younger people, your statistics will look different because old people get more diseases.

Dowd: If you look at one component of the care continuum rather than the continuum, you will make judgments that may not be 100% accurate. What if you make determinations based on pharmacy? If you say we’re going to do profiles on physicians based on pharmacy utilization, and if somebody had high pharmacy utilization, you would consider that bad, and if they didn’t it’d be good. But that doesn’t make sense because if you just look at pharmacy, the utilization may be higher because their acute care utilization is lower. A physician may be discharging patients from the hospital [earlier than other physicians] and using medications to keep patients stable.

Francis: I think you’re going to see a constant battle between providers and payers because one is never going to trust the other. When they make this information public, it becomes a very tenuous situation between the two parties.

PMCR: Will this become a trend among payers?

Chamberlain: We’re seeing [payers use] a lot of clinical report cards.

We’re hired on a regular basis to do patient satisfaction, and that kind of satisfaction is centered around meeting their expectations with spending time with doctors. Patients say, Let me know in advance if the doctor is running late.’ There was a day not too long ago when patients came into a clinic and did whatever they were told to do; now customers don’t want to wait 45 minutes to an hour for a doctor, and they expect to be called if the doctor is running late.

Payers are doing a lot of research with customers, including open-ended focus groups on what they think can be improved.

Francis: There might be a trend in this direction, but I don’t think it will have that great an impact on consumers of health care. The major purchasers are employers. This is probably just a better way to make public the fact that they’re indeed interested in the quality of their physicians.

PMCR: Could there be a backlash among physicians?

Dowd: That answer depends on the health plan’s approach. Do they use a lot of physician input into developing those programs? If physicians can have input into the methodology and approaches, then they’re very supportive of clinical data. And they’re not supportive of programs shoved down their throats. So if a health plan takes claims data and has one or two people analyzing it and creating judgments, I don’t think any provider will be comfortable with that.

Francis: What we think is going to happen is that physicians are going to turn around and release report cards on payers.

The problem is that many physicians aren’t banded together to do that kind of thing, so you will get a state medical association to do it. . . . What the payers are attempting to do is put pressure on physicians to increase their level of satisfaction with patients, and patients aren’t going to give bad scores to physicians unless there’s really something wrong. Where you’re going to see the low satisfaction scores is with payers. Payers receive such pitiful scores when it comes to customer service that as an industry they perform poorly over the years.

PMCR: Do you think payers will begin to require hospitals to make public their clinical profiling reports?

Cohen: It would be interesting to see if that ever gets off the ground. When you’re talking about quality and standards of practice, you can’t subpoena it as long as it’s done in closed doors and is done with the best of intentions. I don’t think a hospital will be ready to give that up to some big organization to use as a guideline. You’re going to get individual information on individual doctors, and I don’t think hospitals are going to give up that information to insurance companies.

Anderson: We’re starting to see payers ask for the reports. We have haven’t seen that a lot yet, but I think that’s coming down the pike here. As long as everybody provides the information on an equal basis, I think that’s fair. But to get data that compares apples to apples is very difficult.

They get data from several sources, marketing gives them something and so forth, and they get to a point where you don’t know which one to believe and which one is right. So they go back to the publicly available data, and most of it is not severity-adjusted.

Dowd: Providers have been collecting that information. But I wonder how much of that becomes confidential. So many hospitals run that information through medical staff structures that have some strict confidentiality, so breaking that information out from traditional medical staff structures politically is a challenge. But I don’t think it’s a bad idea.

However, I think hospitals should be worried if they see payers in their markets start initiating a lot of this [report card] communication activity to the public and the hospitals are very detached and uninvolved in the process. Because then they are forced to react. I would encourage hospitals to try to get ahead of the ball or get with payers on it, so they’re more involved with what’s going on rather than just reacting to it.