Consumer Reports' Heart-Surgery Scorecard: A Win for Consumers, a Dud for Docs
A Consumer Reports comparison of how well 220 cardiac surgery programs do open-heart surgery has been called a "watershed" in the evolution of report cards that grade doctor performance. But the CR initiative seems unlikely to alter most physicians' opposition to being publicly measured.
The report card on coronary artery bypass graft procedures uses risk-adjusted data for the past three years from a database amassed by the Society of Thoracic Surgeons (STS) over a 20-year period. The performance measures were applied to surgery groups or programs, not to individual surgeons, and participation in the report card was voluntary. Both of these provisions allayed the fears of the cardiothoracic surgeons who, up to now, have used the STS registry for performance feedback.
STS also used measurement methods that the society's members consider valid. Applying 11 performance measures endorsed by the National Quality Forum, the scorecard gives the cardiac surgery programs one, two or three stars. These stars indicate, with a high degree of probability, whether a program is below average, average, or above average. The report cards also provide star ratings and actual performance scores (on a scale from one to 100) in four subcategories. These include 30-day survival (e.g., patients have a 98 percent chance of surviving at least 30 days and being discharged from the hospital), complications, use of appropriate medications, and surgical technique.
Despite the scientific validity of the measures and the strength of the data, 80 percent of the 1,000 or so groups that submit data to the STS registry did not allow their performance to be publicly reported. And of the 220 programs that did, 50 received three stars and only five got a one-star rating. This strongly suggests that many of the programs that didn't participate in the Consumer Reports project would have received low scores if they had.
The authors of a recent article on the CR report card take a half-glass-full perspective on it. They laud the surgical groups that provided their data and predict that their courageous move will put pressure on other cardiac surgery programs to join in. "Physicians in other surgical specialties that are amendable to this type of approach, such as orthopedics or vascular surgery, may be expected to follow suit," they say. Down the road, when the Centers for Medicare and Medicaid Services (CMS) publicly reports some of the quality data it's now receiving from physicians in return for small Medicare bonuses, CMS might be able to do so in a way that will be supported by doctors, the authors suggest.
Permit me to be skeptical. First of all, CMS is asking doctors to report on only a handful of measures that they select from a list of about 180 metrics for all specialties. That indicates little about their overall quality of care. Even if CMS painted with a broader brush by mining Medicare claims data for report cards, as it proposed two years ago, physicians would not support the effort. In fact, when the latter initiative was revealed, the AMA and the American Academy of Family Physicians protested that the proposed report cards would be misleading and had the potential to harm both doctors and patients.
Physicians have not changed their minds about claims-based report cards, which are still the predominant type of scorecard. The California Medical Society recently filed a class-action lawsuit against Blue Shield of California, charging that the insurer's physician rating program could potentially harm doctors and their patients by spreading inaccurate information. The CMA alleges that the ratings are inaccurate because they rely on aggregated claims rather than the information in medical charts.
There are ways to fix these problems: Measure only groups, not individual doctors, so that there will be sufficient data to reach valid conclusions. Deploy a set of measures that's broad enough to ensure that the report cards present a balanced picture of a group. And use only data from electronic health records, not claims data. Unfortunately, those solutions won't be available until the healthcare system has undergone wrenching restructuring and everyone uses EHRs.
Image supplied courtesy of Flickr.
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