Physician Report Cards: An Easy “A”

By Fred Tobis, MD

Many of us are upset about physician profiling. We mourn the loss of autonomy in policing ourselves. The increasing portion of health care dollars that are being earmarked for cumbersome bureaucracies concern us. We are suspicious of the motives of those who seek to control us and are frustrated by the incomplete data on which we are to be judged.

These concerns are legitimate. By focusing only on our concerns, however, we are ignoring the bigger picture. The introduction of physician profiling, like all changes, provokes fear and anxiety. Rather than let our fears cloud our vision, let’s look at the inherent opportunity for physicians to use profiling as a way to assume more control of healthcare quality and dollars.

Remember, physicians are very good at taking tests.

Objective physician profiling based on transparent metrics is a positive change. None of us went to medical school to evaluate the performance of our peers.

The current process of peer review is fraught with conflicts of interest and uncomfortable interactions with our colleagues. Let’s put away the sackcloth and ashes and open up the champagne. I agree with those who argue that profiling is “not fair.” But the inherent unfairness is to our advantage.

Profiling allows the students to make up the test! The metrics on which we are being evaluated are all metrics that we or our colleagues researched and published. Moreover, it’s an open book test! The guidelines are readily available on line. Slam dunk 4.0, no problem.

Health Care bureaucracy remains, but better accountability will limit its growth.

It is frustrating to see an increasing portion of health care dollars go into the pockets of bureaucrats. Let’s be honest: we only have ourselves to blame for this. Health care costs have consistently and significantly outpaced inflation for the past 10 years. A portion of this increase is the inevitable result of demographic pressure and technological breakthroughs.

Much of the rise in costs, however, is due to poor stewardship on our part. We have allowed pharmaceutical representatives to influence our prescribing habits; we wrote prescriptions for expensive newer agents when older agents were as good if not better. We gave antibiotics for viral infections. We rushed into new technologies before clear-cut benefit was demonstrated.

We haven’t focused enough on disease management. We resisted guidelines pejoratively labeling them “cookbook medicine,” while using “old” cookbooks from our training days. It will be a while before we can roll back the entrenched bureaucracies. Seizing the opportunity to document quality is a good first step in limiting further bureaucratic growth.

Everyone can win in profiling.

We are right to be suspicious of the motives of those who will be grading us. High-profile executives in handcuffs on the nightly news remind us that money is not only a motivator but a corruptor.

For some health plan and health system executives, saving money is probably more important than improving quality. Their underlying motivations for mandating guidelines may be inherently misguided. However, our willingness to implement clinical guidelines in our practices is neither wrong nor unethical. Following guidelines has been demonstrated to improve quality. Who among us can argue with that?

Call me radical, but I suggest it is not worth losing sleep over the fact that improving the care our patients receive will improve the profit margins of the insurance industry. The insurance companies are not the only winners here. Patients receive better care---and, unlike the insurance company’s short term monetary gains, these are long-term meaningful gains. Furthermore, once more of us actively engage ourselves in the process of both guideline creation and guideline adoption, we legitimately earn the right to sit at the table and ask for better reimbursement and payment from insurers and large employers.

Guidelines are a liberating technology for physicians.

Algorithms and guidelines need to be seen as liberating, not threatening. It’s reassuring to know that once a diagnosis of myocardial infarction is made, there are well-established and well-researched guidelines to follow to maximize the outcome for our patients.

Right now most of us use standing orders and templates for our “usual” personal algorithm. Moving to a standard algorithm is not introducing a new concept, but rather, it is introducing new data to our current concept. Being consistent not only makes life easier for us, it also makes things easier for our nursing colleagues when they don’t have to guess what we might want for a patient today.

Creating a set of standing orders and templates around these new report card guidelines is a cinch. We can spend more time with the patient and reduce wasted time spent recalling what the latest recommendations are for acute MI, pneumonia, etc. If that’s not enough to make us happy, maybe the A on our next report card will.

Fred Tobis, MD,is the principal of Tobis Healthcare Solutions, a consulting firm focused on improving health care delivery by building cooperative relationships. A former cardiologist, Tobis works with health plans, group practices, hospitals and medical technology companies to broker successful joint ventures and partnerships. He can be reached at fred@tobishealthcaresolutions.com or by phone at 206-853-3336.