by Karen
Wolfe
USA Today
recently published a story about ProPublica, a non-profit news organization that
has developed a metric to score surgeons’ performance, comparing them to their
peers.[1] The study is intended as a
tool for consumers, however, it has generated debate and concern among surgeons
who feel they are being unfairly treated.
Rating is not new
What the article neglects to mention is that rating doctors and hospitals is not new in the general health world. Scoring medical providers has been a practice for decades. The Leapfrog Group[2] that scores hospitals has been in business well over twenty years. Doctor Scorecard[3] scores medical doctors and a Google search will offer more.
What is different about the ProPublica analysis is it is based entirely on data and singles out surgeons treating the Medicare population. It also uses an adjustment score for the difficulty of cases analyzed called an Adjusted Complication Rate.
Adjusted complication rate
The ProPublica study includes 17,000 doctors performing what are called low-risk, elective surgical procedures derived from Medicare data. The adjusted complication rate selects cases that are considered low risk, such as gall bladder removal or hip replacement. The study looks for complications such as infection or blood clots that require post-operative care, in this case re-hospitalization.
The cost of post-operative care requiring hospital readmission amounted to $645 million which was billed to taxpayers for 66,000 Medicare patients from 2009 to 2013. Logic says that if surgical complications requiring hospitalization are so costly for Medicare patients, the costs must translate to astounding rates in Workers’ Compensation, as well. However, the study does not directly apply to Workers’ Compensation.
Workers’ Compensation
The ProPublica study does not directly translate to Workers’ Compensation because the study examines Medicare patients only. While some injured workers qualify for Medicare, the majority are healthy, working adults under Medicare age.
What does translate from the study is that evaluating and rating medical doctor performance based on the data is do-able and important. However, it should not be limited to surgeons. The analysis of doctor performance must be comprehensive, accurate, and fair.
Case mix adjustments
Rather than using the limited measure of Adjusted Complication Rate following surgery, a broader view of the claim and claimant is appropriate for Workers’ Compensation. Analysis is not limited to those cases with complications. Instead, all claims are analyzed. Results are adjusted by the claimant’s age, general health (indicated by comorbidities), and also the type and severity of the injury itself. Administrative management analyses are also important in workers’ Compensation such as direct medical costs, indemnity costs, return to work, and case duration, among others.
Level playing field
Case complexity, sometimes presented as Case Mix Adjustment, is important to fairness in rating doctors in Workers’ Compensation. Also, analyzing a broad scope of data elements smooths the variability leading to more accuracy. Fortunately, in Workers’ Compensation, claims have a very wide range of revealing data elements that can be drawn from a payer's multiple data silos.
Provider angst
The ProPublica study has created push back from the physician community for several reasons. For one, gall bladder surgery is often performed in an outpatient setting, so re-hospitalization is a meaningless metric. The same is also true for others of the so-called low-risk surgery category. Moreover, the study names names.
Published ratings
Published provider ratings from a national survey caused much of the angst noted in the USA article. Names were even published in local papers, naming physicians well known in their communities. Doctors cried foul!
Expecting the general population of patients to understand what the ratings mean, regardless of their accuracy is naive. Ratings listed as 2.5 or 1.6 have obscure meanings to the uninitiated. Fortunately, Workers’ Compensation providers do not face that level of exposure. Doctor ratings in Workers’ Compensation are not published for the general public or made available for consumer interpretation
Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data and offers online apps that link analytics to operations, thereby making them actionable. MedMetrics analyzes data continuously and sends alerts as appropriate. MedMetrics also analyzes and scores medical provider performance. karenwolfe@medmetrics.org
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