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A Midwest employers group thinks it has diagnosed a weakness in how workers choose their health plans: a lack of objective evidence on individual doctors' skills and performance.
An increasing number of employers and business coalitions are using comparative quality measurement to help employees pick managed care networks.
But while these so-called report cards are useful in helping workers negotiate a confusing maze of choices in managed health care, in general the report cards stop short of supplying physician-specific quality measures.
A few managed care companies have undertaken limited physician-level quality initiatives, such as the release of satisfaction surveys and background information. But such information generally does not pertain to patient outcomes-the type of data of most interest to employers and employees.
This month, however, the Chicago-based Midwest Business Group on Health unveiled a position statement calling for the measurement of the performance of individual practitioners. Its position drew mixed reactions from physicians experienced in quality measurements and a warning that meaningful statistics probably are at least a few years away.
MBGH, a coalition of more than 100 employers in 11 states, declared at its annual meeting in Rosemont, Ill., that employees and corporate buyers should have "easy and timely access" to doctors' qualifications, accessibility, financial arrangements and performance.
For performance measures, MBGH would include rating of practitioners' "caring attitude and communications skills"; morbidity and mortality rates; length of time patients take to return to work after treatment; Caesarean section rates; and past records of malpractice litigation.
Consumers must question doctors and shoulder more responsibility for selecting them critically, said Jim Mortimer, MBGH president. He said employers will be supportive.
"Employers realize the health care system varies a lot," he said. "They're after better and better panels of physicians."
MBGH has formed two committees to study how a system of physician ratings can be achieved. The business group has no specific plans to issue its own report cards or other forms of physician-level ratings but rather considers itself to be a "change agent" that will help others-such as health plans- unite to devise an area-wide system, said Larry Boress, MBGH vp.
MBGH's position statement did not address who might pay for such an initiative.
Physicians who are experts in health care quality measurement were cautious in their reactions to the coalition's proposal.
"I think it is a good idea," said Dr. Cary Sennett, vp for performance measurement of the Washington-based National Committee for Quality Assurance, which accredits and rates managed care companies. "It is a reflection of the idea that employees need good information if they are to make good decisions as consumers," he said. "I think physicians will recognize this information will be of great value to them. If I were a practicing physician, I'd want this to move ahead as soon as possible."
Nonetheless, MBGH faces imposing hurdles in realizing its vision, Dr. Sennett and other experts cautioned.
One question is whether patient populations will be large enough to have any statistical meaning, he said. For example, if a doctor has treated only a few cases of pneumonia in a year, it is doubtful that outcomes for that illness are significant. If a doctor contracts with many health plans, a way to aggregate data and avoid duplication must be found.
Risk adjustment also must be performed so that doctors who treat sicker patients are not penalized for seemingly worse outcomes-a difficult and expensive statistical challenge. And poorly developed information systems also may not be able to capture data effectively, Dr. Sennett said.
The health care community is several years away from being able to measure physician quality accurately, he said. "That isn't to say we can't begin," he said.
But many doctors may not like the MBGH position because physician-level measurements can stigmatize practitioners for outcomes out of their control, said Dr. Dennis O'Leary, president of the Oakbrook Terrace, Ill.-based Joint Commission on Accreditation of Healthcare Organizations.
Post-treatment functionality of the patient, for instance, is largely out of the hands of the physician, he said. Caesarean section rates may reveal more about a health plan's policies than a doctor's ability.
"Everyone needs to be understanding of the limitations of measurement data," Dr. O'Leary said. "This is one of those things that seem very attractive on the surface, and when you start digging down a bit, it gets more complicated."
And although some doctors wouldn't mind being rated, "others would be very nervous about this," he said.
Despite such reservations, reasonably reliable data from a single source would be superior to the paperwork jungle of internal evaluations health plans now generate, said Dr. William Jessee, vp of quality and managed care for the Chicago-based American Medical Assn.
An associate of Dr. Jessee, for example, recently received two letters from separate managed care plans, one noting that he performed very few Caesarean sections and the other questioning him for performing too many.
"You wind up in a situation where the physician doesn't believe the (report) and he tosses it in the trash," Dr. Jessee said. "For physicians, the current system is a huge hassle."
The AMA has its own long-range plan to roll out a voluntary accreditation program for physicians. It will include the evaluation of clinical performance and patient care outcomes. Even the AMA will find it difficult to gather scientifically reliable data, he said.
"Trying to figure out what to measure at what cost with what kind of data obviously is going to be a major challenge," he said.
The MBGH is not the first coalition looking at doctors. The San Francisco-based Pacific Business Group on Health in 1996 began a three-year, $1 million study of 48 physician groups in California and eight groups in the Pacific Northwest.
"We recognize that consumers choose doctors first and then health plans, so it would be helpful for consumers to have information on providers," said Cheryl Damberg, the coalition's director of research.
The group-level comparative information will be made available on the Internet and in printed form, and will be based on patient questionnaires. Data on individual doctors is not being collected because reliable performance measures are still elusive, she said.
An added unknown for MBGH is that even if physician quality measurement takes off, it is unclear whether employees will want to use the data or understand it.
According to a study last fall by the Kaiser Family Foundation and the Agency for Health Care Policy and Research, 76% of survey respondents said they would choose a surgeon who had successfully treated their family in the past, whereas only 20% would pick an unfamiliar surgeon who had better ratings.
Employees also might need help from employers or health plans to comprehend the data.
"A lot of this stuff is just really Greek to consumers," said Jim Pfeiffer, director of client services of the Boston-based Picker Institute, which studies patient attitudes toward hospital stays. "They need a guide or an interpreter."