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Another Complicated Mistake

Stanley Feld M.D.,FACP,MACE

Real price transparency, affordable healthcare costs and improved quality of care for chronic disease are essential goals in order to repair the healthcare system. Real price transparency by all the stakeholders, accurate criteria for evaluating quality of care, along with patients controlling their healthcare dollar and having access to the information have to occur simultaneously. Only then will stakeholders compete for the patients’ healthcare dollar. The result will be a decrease in the cost of healthcare.

At this moment neither quality health care nor real price transparency among stakeholders has been defined. When this occurs the marketplace will determine the price of healthcare. Neither artificial negotiation of prices nor price controls will result in a stable price environment.

Nevertheless a federal judge ordered the federal government to release the results of the raw medical claims data accumulated by Medicare. This data is supposed to be used to judge the quality of medical care and cost of that care delivered by thousands of physicians across the nation. This judgment would be fine if the data were a valid measurement of quality medical care. It is simply one of many tools that define cost of a disease.

Medical claims data can be used to evaluate the length of stay in a hospital for a hernia repair. If the average hospital length of stay is one post op day it would seem logical to say the physician releasing the patient in one day did a better job than the physician who released the patient in five days. If physician A’s patients were all released in one day and he did one thousand hernia repairs a year one could conclude the physician has many good hernia repair experiences.

The inaccuracy of medical claims data is easy to understand. Let us say physician A did hernia repairs on athletic patients under the age of 25. Physician B did hernia repairs on all patients. The majority of physician B’s patients have multiple diseases such as diabetes mellitus, hypertension and coronary artery disease. His patients were at greater risk of post operative complications and needed more post op hospital days. Technically, both surgeons were equal. However, physician A receives a higher score on his report card and a higher reimbursement for his performance (P4P) than physician B. Physician B would quickly figure this out. He would start selecting only healthy patients on whom to hernia repairs. His goal would be to match physician A’s performance and reimbursement. The result would be access to care for sicker patients would be restricted. The only way raw medical claims data could work is if the raw medical claims data would be refined to include accurate risk weighting of the patients.

Therein lies the weakness of medical claims data. Each piece of data has to be risk weighted. This simple example demonstrates only one defect in the use of claims data to determine quality care. On the surface medical claims data is intuitively sound but the details are complicated and the use of raw medical claims data to determine quality is invalid.

How could medical claims data judge a cognitive physician such as an internist, an endocrinologist or a non invasive cardiologist? Clinical endocrinologists take care of sicker diabetic than the generalist. They use the same billing codes. The generalist refers his most difficult cases to the clinical endocrinologist. This is as it should be. However, sick patients with chronic disease have worse clinical outcomes than patients who are less sick. These patients will cost more than less sick patients. Medical claims data will not measure the quality of care received by these sick patients as opposed to non sick patients. Raw medical claims data cannot and does not measure this nuance.

Emboldened employers and insurance companies could easily manipulate the medical claims data and steer employees to a lower quality of medical care using the inaccurate raw medical claims data definition of better-performing doctors.

Consumers Checkbook a consumer non profit company is developing web site to publish this medical claims data. They sued the government demanding the release of the medical claims data. Their business plan is to sell this potentially misleading information to patients for a fee in the name of consumer advocacy. Robert Krughoff the president of Consumers’ Checkbook says “This will make the efforts to rate doctors more reliable, more valid. The group will use the data to measure the quality and efficiency of doctors and plans to launch a Web site that tells consumers how much experience doctors have performing certain procedures”

Consumer experts believe the ruling, made by U.S. District Judge Emmet G. Sullivan in Washington, will not be appealed by the Bush administration. Last year, in an executive order, President Bush called for greater cost and quality transparency in the health care system.

“It honestly is a treasure trove,” says Francois de Brantes, the national coordinator for Bridges to Excellence, a program that rewards doctors for improving the quality of their medical care. “There is an unbelievable amount of analysis that can be done with the data that up until today just hasn’t been possible.”

Bridges of Excellence looks like a start up web site in search of a product. Rather than being a benefit to patients, it is interpretation of the raw medical claims data by laymen who have no concept of the complexity of medical treatment and can be harmful to patients.

“Consumer groups say the data has limitations but it nonetheless can be used to accurately rate physician quality.”

I think they truly believe what they are saying. They see a business opportunity. Physician organizations must define quality care and judge the quality of delivered care. Misleading, inaccurate and complicated raw medical claims data can only result in a decrease in quality and access to medical care. Healthcare system has just made another complicated mistake.

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