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Nothing seems to make more sense than to compare notes and rate products. When I see a new book at Amazon.com one of the first things I do is see how it was reviewed by readers. It is no surprise that consumers will do the same to for doctors. Why wouldn’t you want to know your doctor’s record?
But it is not that simple. A person who is seriously sick, may need a doctor especially trained for his condition. In fact, he may be so sick that there is a higher than average chance that he will die in the doctor’s care. What this means is that doctors who are trained to deal with these serious problems are going to get a worse record than other doctors. But the difference is not that they are worse doctors. On the contrary, they may be much better doctors. The difference is that they are willing to treat riskier patients and thus see their record become “worse” than others.
Of course, if a doctor finds that his reputation is damaged most times he treats a seriously unhealthy patient, he might start displaying behavior aimed at avoiding such patients. But there is even a more sinister aspect to this. What if you were a health insurance company or a state agency that wanted to reduce “wasted” treatments on at-risk patients? If it were not politically viable to simply ration healthcare, then you could promote a reporting system so that doctors would avoid treating such patients.
This in fact seems to be what is happening in New York State,
One of my favorite healthcare policy blogs is Dr. Rich’s Covert Rationing. In his most recent post he discusses a research study linking New York State’s public report card system to increased heart patient death rates. Doctors’ names are published alongside their procedure-related mortality figures, so if a patient dies while undergoing a risky (though potentially life-saving) procedure, the doctor’s grade suffers.
It’s no surprise that doctors are more hesitant to operate on high risk patients if their professional reputation is on the line. The result is that patients with heart problems in New York State are less likely to receive life saving therapies.
Now here’s where my outrage increased exponentially – Dr. Rich argues that report cards are actively promoted by payers (health insurance companies and the government) under the guise of patient empowerment (they deserve transparency about their doctors’ performance record, right?) But the real truth is that the payers are benefiting financially from the report card system. Fewer procedures mean lower pay outs, and if high risk patients die sooner, then they save even more on care costs.
Dr. Rich summarizes the “benefits” of this system:
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.
While all of this is interesting in its own right, it also helps us understand how problematic unlimited medmal liability can be. High-risk specialties (like mammogram readers, for example) are tending to disappear due to the legal costs. Going after doctors who “cause” harm seems to simply target doctors willing to help in dire situations that are not easily fixed.
I’m not going to say much about these stories, but I thought readers might want to know about them. In all cases their tend to side with the plaintiffs.
First, there is this story about a Marine who died of a melanoma. You can read about it here at the website for news station KIRO. The main issue seems to be whether or not the Supreme Court’s “Feres Doctrine” should be upheld.
Secondly, the injury board posted a story about a wrongful death case involving a nine-year-old boy in a naval hospital. You can also read about it here. A court overturned a verdict by deciding that the standard for fault had to be “reckless disregard” rather than “negligence.”
I’d be interested in hearing opinions about the cases. For both of them, I notice that the issues don’t involve caps on damages, which is the most common form of reform that is advocated.
