Physician Report Cards and the Designated Driver

Posted on January 28, 2008
Filed Under General Rationing Issues |

A new study in the February 2008 issue of the American Heart Journal shows that cardiologists in New York State are less willing to aggressively treat patients with severe heart attacks than cardiologists in other states, and that the mortality of these patients is significantly higher in New York. The authors of the report attribute this reticence to treat to the existence of public report cards in New York, which publish doctors’ names alongside their procedure-related mortality figures.

The study compared the treatments and the outcomes in 220 New York patients with 325 patients from states without public reporting systems, who had shock (severe circulatory instability) caused by myocardial infarctions (heart attacks). They found that patients in New York were significantly less likely to receive either diagnostic cardiac catheterizations or stents. Both groups of patients were equally likely to receive coronary artery bypass surgery, but the surgery was significantly delayed in patients from New York. Among all patients, the risk of death in the hospital was 50% higher in New York than in other states. But among patients who actually received either stents or bypass surgery, there was no significant difference in mortality.

DrRich has pointed out earlier the advantages of physician report cards to a system based on covert rationing. Let us review the many benefits that accrue to the payers:

1) Fewer expensive procedures are being done
2) Fewer emergency procedures are being done (procedures like the ones being avoided in this study are often performed in the middle of the night and on weekends, entailing overtime payments and other excess overhead.)
3) More high-risk patients (destined to be chronically expensive) die expeditiously.
4) The docs who do persist in doing these high-risk procedures stand out even more in the public report cards.
5) Eventually, NOT doing these high risk procedures will become the new de facto standard of care, and outliers then can be dealt with directly (instead of relying on bad report cards to weed them out).
6) All the while, payers can stand upon the altar of altruism, proclaiming transparency and the patient’s right to know.

The inappropriately negative fallout experienced by physicians conducting potentially life-saving procedures on high risk patients, of course, could be easily overcome by appropriate risk-adjustment methodologies (to account, for instance, for the very high mortality predicted for any patient presenting with shock due to myocardial infarction). But doing so would wreck the whole notion of using public report cards to further the cause of covert rationing. (See items 1 - 6, above.)

But, as usual, DrRich has a solution.

It’s called the Designated Driver.

Imagine the distinguished Chief of Cardiology approaching a promising 31-year-old cardiology fellow, who is finally at the end of his long course of training and at last is ready to enter practice, and saying, “Son, you are going to have a brief but spectacular career. You are going to be our Designated Driver.”

For an extraordinary annual salary and immediate vesting in a generous pension plan, this young man is going to have the honor of being the one who gets all the high-risk cases for the group. He will agree to do this as long as it is feasible, that is, as long as he’s not run out of town because his report card is so abysmally bad. Given the inefficiencies of collecting and processing data for report cards (a process controlled by tangled bureaucracies of one flavor or another, and often, by several tangled bureaucracies that have to devise even more tangled processes for some semblance of cooperation), this is likely to take at least 5 years, and in many cases may take 10. With a sufficient number of more “routine” cardiac cases tossed his way by his sympathetic colleagues (to help him buffer his report card statistics), he may be able to survive 12 or even 15 years. But in any case, by the time he is in, say, his late 30s, he’ll be able to retire quite comfortably.

The Designated Driver scheme is a win-win for everybody (almost). Very sick patients can get the procedures they need (i.e., the ethics of medicine can be shored up for a bit). Your typical cardiologist can enjoy his/her long, relatively risk-free career. And your young, aggressive cardiologist will be presented with a glorious challenge not unlike those of the gladiators of antiquity (save that when it’s finally time to face the old “thumbs down,” they will be spirited to a much more agreeable retirement.)

This solution, as brilliant as it is, will attract critics. And those critics will eventually demand (Gekkonians) or pass (Wonkonians) laws, regulations, and guidelines to turn the Designated Driver into merely one more manifestation of the federal crime of healthcare fraud, punishable by the usual massive fines and jail time.

So when that time comes we’ll have to think of something else. But for now, given the alternatives, DrRich recommends the Designated Driver to cardiologists in the great State of New York.

Comments

8 Responses to “Physician Report Cards and the Designated Driver”

  1. alexa-blue on January 28th, 2008 3:23 pm

    I’m having trouble seeing why this is a bug and not a feature. The study cherry picks its patients to make the overall result look bad — of course P4P will increase mortality among the sickest, but even within that group in this study there’s a non-significant trend towards better performance when interventions are performed, and I wonder if overall mortality for patients presenting with chest pain, or elevated troponins, or whatever broader category you care to think of isn’t at least balance by this on the net. I wouldn’t be surprised if overall NY P4P keeps population-wide delivery of health care value stable for far fewer dollars; if that’s true you can tweak your risk adjustment strategies to improve overall care, but only at a tremendous cost/QALY.

    The relevant question, then, isn’t whether NY’s current scheme is worse than what an ideally designed transparent rationing scheme would provide, but whether it’s better than the current one, and that’s not answered by the present study.

  2. DrRich on January 28th, 2008 8:55 pm

    Alexa,

    Thanks for your comments.

    As nearly as I can tell we’re agreeing that the report cards are likely producing an overall benefit to society (over and above the advantage of transparency) - namely, a decrease in the overall cost of healthcare to society. (See Items 1 - 3 in the article.) Further, I agree that just because hospital mortality is worse in high-risk patients in whom doctors avoid invasive procedures, that doesn’t prove any real reduction in long-term mortality, and that more studies would have to be done to measure this. That is, the actual benefit of doing those invasive procedures is not measured in this study.

    To say it another way, even under a completely open and fair system of healthcare rationing, it’s entirely possible (perhaps likely) that if we knew all the data we would end up withholding such procedures in such patients.

    So, I think you’re asking, what’s the real harm here?

    It’s that covert rationing, inherently, is not based on what’s fair, efficient or effective. Instead, it’s arbitrary. It’s based on whatever you can get away with, however you can get away with it. To me, that’s what’s going on here. The existence of physician report cards is the “reason” that society saves money on sick heart attack patients in New York, that is, by coercing the behavior of physicians in such a way that money is saved, irrespective of outcomes.

    In this particular case, if we actually had all the data it might turn out that outcomes are actually not substantially harmed by withholding this therapy, as it now appears they are.

    The point is, we don’t know. The point is, under covert rationing, it does not matter that we don’t know. In fact, under covert rationing it’s better that we don’t know, since, if you’re already getting away with the rationing, why look to see if it’s the right thing?

    Rich

  3. Sp1ndoctor on April 18th, 2008 11:50 pm

    Love your blog - glad I was directed to it. I have always looked for the “covert rationing” in govt policy.

    I have been pondering the “Designated Procedurist” for a while since I read it, mainly because something seemed wrong. Then it struck me - it sounds no different than the tales of politicians sending other people’s kids off to war with promises of financial security in the future.

    Sounds good, but can that really be assured? And even if it could, what if the young gun didn’t aspire to financial security, but just wanted to be a good doctor for as long as he could until he retired?

    No, it makes more sense for the “designated procedurist” if there must be one, to be the seasoned veteran who has seen the best of his career, is the most skilled and experienced, but is also ready to retire, and is willing to go down in a blaze of glory, taking one for the team.

    This truly is a win-win-win -> the young-guns get to build their practice and reputation with the “easy” straightforward cases, padding their resume and the reputation of the group.

    The more experienced doctors gradually take on more difficult cases. When “bad outcomes” occur, they are, by design, diluted by their already impressive prior record.

    The patients are best served by having the most experienced doctors take on the most difficult cases with the best odds of success in a tough situation.

    And, when one of the veterans has taken too many hits and it is clear his ship is sure to sink, he heads straight out into the most difficult waters, taking on as many of the hardest cases that he can until he is obligated to retire.

  4. DrRich on April 19th, 2008 7:04 am

    Splndoctor,

    I have to admit your solution makes more sense than mine. It’s just that once I visualized the chief of cardiac surgery saying, “Son, you’re going to have a brief but spectacular career,” I just had to go with it.

    Rich

  5. HL Dorkin MD on April 20th, 2008 8:43 am

    I had just finished coming to the same conclusion as Spindoctor when I came to your site and found his/her comment. Surgery aside, I do fear that as my generation (the Boomers) ages, this concept will accelerate the already difficult issue of finding a primary care physician. The progressive “firing” of patients from primary care practices (as they become complex/noncompliant) to enhance report card findings will clog our ERs and hospital beds beyond anything we have seen to date.

  6. Sp1ndoctor on April 20th, 2008 1:30 pm

    Thanks for your kind relpy.

    Actually - none of makes a darn bit of sense, as I am sure HL Durkin is the most correct …

    Sad.

    When will we take back control of our profession and inject some sense into it?

    Your blog is a nice start. Others, like the “Open Letter” campaign at Sermo.com are also likely to be helpful …

  7. hoads on May 2nd, 2008 1:37 pm

    So glad to see somebody is exposing the dangers and deceit of P4P. You docs better get it together. You are the only ones that can save yourselves and the rest of us. Where’s the leadership?

  8. hoads on May 2nd, 2008 1:43 pm

    OK, I see I haven’t read your Grand Reunification for Healthcare Theory . I think you’re on to something Dr. Rich!

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