Now patients will rate you online

Short Take

Now patients will rate you online

A new Internet-based system will soon let them compare their care against the care other doctors provide. How will this affect your practice?

By Ken Terry
Managed Care Editor

You probably have patients coming to you clutching medical information they've picked up on the Internet. Or you may get new patients who chose you with the help of online physician directories that include data on your background, board certification, hospital affiliations, and even patient satisfaction.

If you find all this a tad disconcerting, take a deep breath—there's something else in the works. It's a clinical evaluation system that will allow patients to compare what you did for them with what other physicians did for their patients with similar conditions. The first elements of the system will start appearing on consumer health Web sites within the next several months. In the long run, this Internet program is expected to supply overall ratings of doctors' clinical performance.

What makes this new approach worth taking seriously is that it's coming from the Foundation For Accountability (FACCT), a Portland, OR-based, nonprofit coalition of large corporations, government agencies, and consumer groups. Together, these organizations represent about 80 million people.

When FACCT (www.facct.org) was formed in 1995, its founders believed that by giving employers and consumers reliable tools to compare health plans, they could create marketplace pressure to improve health care quality. But that vision hasn't panned out. Most purchasers have proved to be more interested in cost than quality; and by forcing managed care plans to broaden their provider networks, they've eliminated the ability to compare plans on the basis of participating doctors.

Moreover, consumers have largely ignored HMO report cards, even if they have a choice of plans. FACCT research shows that consumers perceive that the only way they can ensure quality health care is through their relationship with their individual provider.

So about a year ago, FACCT decided to design a new way to help patients evaluate and influence their own physicians. "The key is to enable consumers to understand the quality of care they're receiving and make decisions about their own care that are based on quality concerns," says David Lansky, president of FACCT. "We'll do that by giving people information about whether they're getting good care, using evidence-based standards and some subjective patient judgments. We'll also do it by compiling information that summarizes how other patients have rated the care they received, so that users can get an idea of how their care compares with other people's."

The patient-reported information—which, Lansky concedes, will afford only a partial picture of clinical quality—can be divided into four categories:

• Are key practice guidelines being followed?

• Are physicians involving patients in decisions about their care?

• How do patients rate their doctor's accessibility, communication skills, and trustworthiness?

• Are patients' symptoms well-managed, and is their quality of life as good as possible?

Lansky readily admits no one knows how much a doctor's care affects a patient's functional status. However, he says, "the health care system should be accountable for achieving improvement in some areas, such as managing asthma symptoms. Some physicians say they aren't responsible when patients don't get rid of environmental problems or don't take their medication. But FACCT believes health systems should be recognized and rewarded for achieving superior outcomes."

His emphasis on health care systems underlines FACCT's belief that doctors can be properly judged only within the context of their practice environment, their financial incentives, and the information available to them. But since consumers don't understand that, he says, "we need to talk to people about their relationship with their doctor as a way of beginning a conversation on quality."

As for the validity of rating physicians on their adherence to guidelines, Lansky stresses that the chosen protocols will be the most agreed-upon standards of care from specialty societies. "Let's take diabetes: A patient who's seen should have her feet, eyes, and blood sugar checked. We'll simply ask the patient, 'Have these things been done for you?' And in some cases, we'll give the patients some tips or feedback: 'Maybe you should ask your doctor next time to do this activity if it hasn't been done.' We're just enabling patients to ask the right questions and know what to expect when they interact with their doctors."

Drawing on the tools it developed for health plan report cards, FACCT will initially ask about several chronic conditions, such as asthma, diabetes, breast cancer, and coronary artery disease. It will also look at "life stages," such as early childhood care and end-of-life care.

When FACCT rolls out its clinical evaluation system, it will only be coaching patients on what to expect from doctors, says Lansky. Not until the methodology has been thoroughly tested and a large enough database built will FACCT enable patients to select and rate physicians on the basis of statistical performance data. Before that, however, the survey questions will help them evaluate their doctors.

The free service will keep patient health information strictly confidential, says Lansky. And while consumers will be asked to name their doctors, information on the physicians' practice and prescribing patterns will not be shared with FACCT's Web site partners. The value to them of hosting the service will come from its presumed ability to attract consumers to their sites.

Down the line, however, FACCT might profile physicians for provider groups, health plans, or employers. That would enable FACCT to get lists of individual doctors' patients so that it could assemble meaningful samples from them. In the short run, it will also work through employers and other entities to get surveys into the hands of patients who don't have Internet access.

Experts see problems, but laud FACCT's intent

A slew of health plans are profiling physicians, and UnitedHealthcare has suggested it might publish its clinical profiles in a couple of years. PacifiCare of California, Health Net, and the Pacific Business Group on Health have already put out report cards on group practices and IPAs, using either claims data or patient-reported information.(The AMA had planned to measure physician performance through its American Medical Accreditation Program, but the program has been discontinued. See "Your report card is about to go public," April 12, 1999.)

What makes FACCT's approach unique is that it will evaluate individual physicians on the basis of patient information. That dodges the problems inherent in claims-based profiling and in obtaining data from reluctant HMOs. "This cuts out the employer and the health plan. We're going directly to the consumer," notes internist David B. Nash, a FACCT board member.

The functional-status measures that FACCT will use are well-validated, Nash observes. "The tools have the sensitivity, specificity, validity, and reproducibility," he says, to make patient evaluation of doctors "worth listening to."

But other experts sound notes of caution. Internist John L. Wasson, professor of geriatrics and director of the Center For Aging at Dartmouth Medical School, supports the idea of coaching patients to obtain better care from physicians. His research shows, however, that while online respondents to functional-status surveys are demographically similar to those who fill out paper surveys, they tend to be much less satisfied with their care. Lansky says FACCT will check this out. If there is a bias, the organization will have to correct for it.

Internist Norbert I. Goldfield, medical director for 3M Health Information Systems, which analyzes health care for employers, raises other concerns. Goldfield, an expert in the field of performance measurement, notes that functional status is a very crude approximation of patient outcomes and that patients recall what was done for them with widely varying degrees of accuracy. What's needed to supplement patient reports, he says, is diagnostic and procedural information derived from claims and encounter data.

"Physician ratings will be more credible with the medical community if they include the other data," argues Goldfield, who still practices part time. "So that would ratchet up the value for patients—and for physicians. Also, there's a debate in the medical community about how to define the complexity and severity of illness of a patient, and how to get at that information. Do researchers get at it merely from patient-derived data, or do they need to know, for example, that a diabetic has cardiac and ophthalmic manifestations? I believe both approaches are worthwhile."

The Big Three auto makers and the UAW have begun incorporating both approaches in 3M-designed hospital report cards, he notes. FACCT could do the same at the physician level, he says, if it worked with large employers, including some that are on its board.

Doctors have mixed feelings about the proposed system

While practicing physicians are willing to be judged, they have reservations about any rating system based on patient reports.

"Medicine isn't completely scientific," notes family practitioner John R. Egerton of Friendswood, TX. "A doctor can do exactly the right things, and the patient can think, 'I don't really get on with this person. He doesn't seem to care about me.' "

Internist Catherine R. Landers of Skokie, IL, agrees that personality conflicts could skew the results. She also wonders how FACCT will take patient compliance into account. "Physicians are being blamed for everything," she says. "If I recommend that a patient come in for a physical, and he doesn't show up for three years, whose fault is that?"

FP Charles Davant III of Blowing Rock, NC, has had similar experiences. "A lot of patients come in episodically, even if they have a chronic disease like diabetes. The reason they don't get their feet or eyes checked is that they show up without an appointment. I say, 'You've got to make an appointment,' they schedule one, and they don't keep it. Then they show up three months later, having just run out of their pills, and I don't have time to do everything for them."

Physicians don't place much stock in profiles based on claims data, either. Egerton recalls that UnitedHealthcare sent him a list of patients who hadn't received Pap smears. "Those patients had all had hysterectomies."

Davant also worries that some guidelines used to evaluate physicians may be flawed or obsolete. FP Suzanne DeBremaecker of Beckley, WV, concurs, noting that many protocols are based on expert opinion rather than the best evidence. She also wonders how the clinical indicators will be chosen and whether they'll reflect the bias of health care purchasers.

On the other hand, ob/gyn James Mirabile of Overland Park, KS, says he won't mind if patients remind him of things he should have done but didn't. "There are certain things you need to do for pregnant women," he points out. "There are standards of care you should meet, according to the American College of Obstetricians and Gynecologists. If FACCT publishes data like that, fine. But if it's some off-the-wall thing, we'll have trouble with it.

"A rating system isn't going to hurt good physicians," he continues. "If anything, it might help—as long as people are looking at high-quality information. At the same time, it might weed out the incompetent doctors. If so, other practices might pick up some patients."

FP Scott R. Helmers of Sibley, IA, also sees potential advantages in FACCT's approach. "It may be a partial step in the right direction, just in the sense of getting patients' impressions of how well things were handled. That's at least as valid as the chart audits that are done now by insurance companies."

By involving the patient more in the process of care, he adds, the FACCT system "could make the patient more willing to have some things done. Otherwise, you sometimes have to argue with patients to get them to do things."

How would physician ratings affect patients' satisfaction with their care? That's a major question for Catherine Landers. "If they saw that I was doing well or poorly on a report card, it might influence their satisfaction with me," she says. "For example, if they knew my care was rated above average, their expectations might be greater. And if those expectations were not met, they might perceive their quality of care to be lower, regardless of the care I delivered."

Landers doesn't object to measuring performance against basic standards of competence. But ultimately, she says, "What makes a good or a bad doctor is a very individual thing."

 

Carol Pincus, ed. Ken Terry. Now patients will rate you online. Medical Economics 2000;8:42.