Evaluating Physician Quality

Most assessments of physician quality begin with the physician's training, experience, and professional certifications. The literature on the link between these factors and quality is limited. Nevertheless, these characteristics can serve as a starting point for evaluating a physician's level of knowledge and skills, which we might postulate would be related to the appropriateness and excellence of his or her practices. In addition, a review of physician credentials might reveal that small proportion of physicians for whom glaring quality-of-care problems have been identified. Characteristics to consider in this assessment include the following:

• Current unrestricted license to practice in your state.
• Current unrestricted license to dispense prescription drugs from the state and the Federal Drug Enforcement Administration.
• Certification by a specialty board recognized by the American Board of Medical Specialties.
• Current active, unrestricted hospital staff privileges.

The latter of these criteria may not apply to physicians who choose not to see patients in a hospital setting. It may be difficult, however, to determine if a physician's privileges were dropped as a result of his or her own choice or because of a quality-driven decision by the hospital. The advantages of using a physician with hospital privileges include having continuity of both inpatient and outpatient care and having the benefit of the hospital's QA and/or CQI program apply to your physician. This latter benefit includes hospital access to the National Practitioner Data Bank, a national database on physician quality problems that is not accessible to the public.

Conspicuously absent from the above list is malpractice experience. There are questions about the extent to which malpractice experience is a reflection of physician quality. On the other hand, research indicates that any history of malpractice claims, paid or unpaid, is associated with an increased likelihood of future claims. Therefore, it may be worth evaluating a physician's malpractice claim history, if only to reduce your risk of being involved in a future malpractice claim.

A physician's credentials can be evaluated directly by employees, by benefit managers, or by health plans. The following are some of the resources for employees and benefit managers to consider in conducting such an evaluation:

• American Board of Medical Specialties. www.abms.org
• American Medical Association, www.ama-assn.org
• HealthGrades, www.healthgrades.com
• Federation of State Medical Boards, www.docinfo.org

The state physician licensing board is a good place to look for answers to questions about the state licensing status of individual physicians. Most states have such information available on-line. A review of information available from state licensing boards has been assembled by Public Citizen Health Research Group and can be found at www.citizen. org/hrg. Some malpractice claim information on individual physicians may be available from the court clerk in the jurisdiction(s) where the physician has practiced.

The quality-related issues described above pertain to all physicians, regardless of their specialty. When assessing physician quality as it relates to specific diagnoses or conditions, additional factors should be considered. For example, physicians being evaluated for their quality in performing a particular surgical procedure should be asked such questions as these:

• What kind of advanced training and/or certification has the physician had in performing the procedure?
• What is the annual volume of the procedure performed by the physician?
• What is the complication/mortality rate for the procedure as performed by the physician?
• What is the success rate for the procedure as performed by the physician?
• What is the average length of hospital stay for the procedure?
• What is the average length of disability following the procedure?

The applicability of these and other questions will vary by specialty, condition, and procedure. Generally speaking, however, the quality of a physician's performance, as in the example of percutaneous transluminal coronary angioplasty described above, is related to the frequency with which he or she performs the procedure. For some conditions and procedures, there may be regional or national research centers or centers of excellence. Helpful resources in learning about such centers, and obtaining consumer information about various health issues include the following:

• National Cancer Institute, Cancer Information Service. Tel: 800-4-CANCER
• American Cancer Society local affiliates
• American Heart Association local affiliates 
• American Lung Association local affiliates
• National Institute of Mental Health. Tel: 800-421-4211

The National Committee for Quality Assurance, in collaboration with the American Heart Association, American Stroke Association and American Diabetes Association, has developed programs to recognize physicians demonstrating that they provide high quality care for patients with selected common chronic conditions, including diabetes mellitus, cardiac conditions, and stroke. Information about these programs and a database of recognized physicians is available at www.ncqa.org. These recognitions are being tied to rewards in four metropolitan areas through Bridges to Excellence—a coalition of employers, physicians, health plans and patients. Coalition members agree to financial incentives to be paid to physicians for providing high quality care as demonstrated through the physician recognition programs described above. These programs are part of a movement toward pay-for-performance in health care, that can be expected to grow in breadth and depth in the years to come. The Centers for Medicare & Medicaid Services, for example, is conducting the Physician Group Practice demonstration combining Medicare fee-for-service payments with a bonus pool to reward improvements in the management of care and services.

If your physician participates in any managed care programs, he or she may receive periodic performance report cards from the MCO and may be willing to share the results with you. Some of these results may be published. For example, the Pacific Business Group on Health has published performance data on medical groups that make up California health plans (though the data are not broken out by individual physician). The Pennsylvania Health Care Cost Containment Council published heart attack mortality data for physician groups. While "report cards" on physicians promise to be increasingly available, they should be interpreted with caution. A number of potential pitfalls with such reports have been identified. For example, multiple physicians may participate in a patient's care, making it difficult to assign primary responsibility for the patient's outcome to any one physician or medical group. In a study of physician report cards for diabetes care, Hofer and colleagues found that they were unable to reliably detect true practice differences among physicians at three practice sites. They also found that physicians could easily "game" the reporting system by avoiding or deselecting patients with high prior cost or with poor adherence or poor response to treatment.

Finally, there is a large body of research suggesting that physician– patient communication is related to the quality and outcome of care. Perhaps the best way to evaluate a physician's communication skills is to do so firsthand, scheduling an office visit to get to know a physician you may not already be familiar with. If you make such a visit, it may be helpful to prepare both general questions and questions particular to your circumstances in advance of your appointment.

Investigating even this minimum set of criteria for physician quality care requires a significant investment of time and resources. And such assessments should be repeated periodically to ensure that there has been no change in physician status. The extensive nature of this undertaking points to one advantage of purchasing medical care from a health plan that includes a network of providers. The various aspects of physician quality described above and others can be consistently and rigorously assessed by the plan on an ongoing basis, with associated economies of scale.

Is Quality Of Care Important?

Quality of health care is an important issue for employer and employee purchasers for a number of reasons. First, there are widespread documented errors in the delivery of health care services. Second, there is substantial evidence for extensive overuse and underuse of various health care services. Third, poor quality of care erodes the value of health care purchases. Fourth, failure to exercise due diligence in evaluating quality of care may impact an employer's liability for a bad outcome of care. And, finally, lack of attention to quality of care can have negative consequences for an employer in employee relations and relationships with providers and others in the local business community. 

Errors in the Delivery of Health Care Services

More than a decade ago, the Harvard Medical Practice Study found that injuries caused by medical management occurred in 3.7 percent of hospital admissions in New York State. Among these injuries were drug complications, wound infections, and technical complications. Fully 27.6 percent of these injuries were the result of negligence, and 13.6 percent of the injuries led to death. Extrapolating these results to all U.S. hospital admissions in 1997, as many as 98,000 Americans may have died because of errors during their hospitalization in a single year. Other studies have confirmed the order of magnitude of this estimate for injuries during hospital admissions. Yet, we must assume this is a gross understatement of the impact of medical errors, given that it does not include injuries because of outpatient care.

The Institute of Medicine focused attention on the impact of errors in medicine through the work of its Quality of Health Care in America Project. Its first published report—To Err is Human: Building a Safer Health System—notes: "More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516)." The group estimated that preventable adverse events resulted in total national costs of between $17 billion and $29 billion, over one-half of which are direct health care costs. More recently, a study of 20 percent of all Medicare hospital admissions in the year 2000 found that patient safety errors resulted in excess lengths of stay ranging from 1.34 days for accidental puncture or laceration to 10.89 days for post-operative sepsis. The excess charges associated with these errors were $8,271 and $57,727, respectively. Excess mortality was also associated with these patient safety errors, from 2.16 percent for accidental puncture or laceration to more than 21 percent for postoperative sepsis. Clearly, medical errors have a significant negative impact on employer health care costs, as well as employee health outcomes and productivity. These findings beg the question of what employers and individuals can do to help minimize the likelihood and the impact of medical errors in the health care services they purchase and receive a question to be taken up later

Overuse of Health Care Services

Investigators have long noted dramatic geographic variations in the use of health care services, without apparent differences in the health of the populations being served. For example, one study showed that Medicare hospitalization rates were 60 percent higher in Boston than in New Haven, yet Medicare mortality rates did not differ between the two cities. A recent study of Medicare end-of-life spending found that beneficiaries in higher spending regions of the United States received approximately 60 percent more care than beneficiaries in lower spending regions, without finding consistent differences between these groups in quality of care or access to care.

There is a large and growing body of research on the extent of medical care that is inappropriate or unnecessary. Studies of appropriateness of care have found that as much as 32 percent of selected procedures are inappropriate. An excellent example of research supporting this estimate is the series of studies commissioned by the State of New York Cardiac Advisory Committee on the appropriateness of various cardiac procedures in New York State. Evaluation of coronary angiographies (inserting a catheter into coronary arteries and injecting contrast material) found that 20 percent were of uncertain appropriateness and 4 percent were clearly inappropriate. When percutaneous transluminal coronary angioplasty (PTCA) (using a balloon catheter to open blood flow through a coronary artery) was evaluated, 38 percent were of uncertain appropriateness and 4 percent were clearly inappropriate. At some hospitals, as many as 57 percent of PTCAs were either inappropriate or of uncertain appropriateness. In a companion study, inappropriate and uncertain use of coronary artery bypass graft surgery was found to be 2.4 percent and 7 percent, respectively. Though these rates may appear relatively low, they have significant health implications, given that the average mortality rate for patients undergoing surgery in the study was 2 percent, and the complication rate was 17 percent.

These are but a few examples of research suggesting that inappropriate and unnecessary medical care has substantial negative consequences both for employee health and the cost of health care.

Underuse of Health Care Services

Another deficiency identified in health care quality is the failure to apply services known to be beneficial in improving health. In a study of patients hospitalized for acute myocardial infarction (heart attack), Marciniak and colleagues found that between 11 percent and 68 percent of patients nationwide did not receive particular standard treatments for this condition, despite being "ideal candidates" for therapies. An earlier study found that internists and family physicians were less knowledgeable about, and less inclined to practice, state-of-the-art advances in treatment of acute myocardial infarction than were cardiologists.

Similarly, a study of patients with diabetes treated in primary care offices found that between 55 percent and 84 percent of these patients did not receive optimal services recommended for their condition according to national guidelines in use. Optimal use of services varied by location of practice by as much as 238 percent. A recent study of 439 indicators of quality of care for 30 conditions and preventive care among a random sample of adults in 12 U.S. metropolitan areas found that only 54.9 percent received recommended care. Quality of care varied by medical condition, from a high of 78.7 percent of recommended care received for senile cataract to a low of 10.5 percent of recommended care for alcohol dependence.

Some studies suggest that physicians are more likely to underuse health care services when treating women, particularly black women. Research by Roger, et al. found that women with unstable angina (chest pain from blockages in arteries supplying blood to heart muscle) were 27 percent less likely to undergo non-invasive cardiac tests, and a startling 72 percent less likely to receive invasive cardiac procedures. Even within Medicare managed care health plans, black plan members were found to receive poorer quality of care than white plan members, specifically for eye examinations for patients with diabetes, for beta-blocker use after heart attack, and for follow up to hospitalization for mental illness.

There is also evidence to suggest that underuse varies by type of health plan. For example, a study found that Medicare patients with joint pain who were enrolled in HMOs reported less improvement in symptoms than similar fee-for-service Medicare beneficiaries. Yet, other research suggests no significant difference between quality of care in HMO and fee-for-service environments in such areas as hypertension and diabetes.

Failure to apply services known to be beneficial in improving health is a substantial and widespread problem. Clearly, this type of quality problem has negative implications for employee health and productivity. The implications for cost of care are more variable, because some of the underused services may result in a net increase in direct medical care costs, despite being effective in preventing negative and costly health outcomes. Nevertheless, in purchasing health care for ourselves or for employees, these are services we would want to receive as part of state-of-the-art quality in health care delivery. Whether one looks at quality from the perspective of individual providers, practices, or health plans, these landmark studies shed new light on deficiencies in quality of care, and suggest how appropriate to health care is the maxim: "Let the buyer beware."

Employer Liability

One reason employers should be concerned about health care quality is their potential liability for managed care programs they may purchase. The evidence for payer liability for managed care stems from two legal cases: Wickline v. State of California and Wilson v. Blue Cross of Southern California. In Wickline, the court concluded that a third-party payer can be legally liable for negligence in utilization review decisions. In Wilson the court determined that a third-party payer cannot escape liability for negligent utilization review based on the argument that the treating physician bears all legal responsibility for a hospital discharge decision.

In Fox v. Health Net, the estate of Nelene Fox was awarded damages from a managed care organization for its refusal to cover bone marrow transplantation and high-dose chemotherapy for advanced breast cancer. The total jury award was $89 million, $77 million of which was punitive damages. Some observers believed that the impact of this case on the liability of employers and MCOs was limited by the Employee Retirement Income Security Act (ERISA).

In the case of Goodrich v. Aetna U.S. Healthcare, a jury awarded the widow of David Goodrich $120 million for delays in approving coverage of high-dose chemotherapy and bone marrow transplantation for a form of stomach cancer. Although ERISA did not apply to this case because Goodrich was covered under a state-sponsored health plan, the size of the award and legislative action in 10 states to limit ERISA protection raised concerns about the exposure of MCOs and employer-sponsored health plans to litigation and resulting damage awards. More recent developments have mitigated these concerns. A 2003 study of the impact of state managed care liability statutes found that these statutes had produced no appreciable increase in liability exposure. In a 2004 ruling by the U.S. Supreme Court in Aetna v. Davila, the court essentially voided these statutes and found that employer-sponsored health plans cannot be held liable for damages for denial of coverage. While these developments represent a shift toward reduced liability of third-party payers for poor quality, negligent managed care processes, it nevertheless seems prudent for employers to address the issue of quality of care in their medical benefits plans as a matter of risk management.

Employee, Provider, and Community Relations

When medical benefits decisions are made without substantive consideration of quality of care, employees can take away the message that their health and well-being are not valued by their employer. This message can undermine one of the key objectives of offering medical benefits: to promote the recruitment and retention of employees. Incorporating quality assurance and continuous quality improvement (CQI) processes into medical benefits decisions, and effectively communicating these processes to employees, can help avoid the employee relations pitfall of employee dissatisfaction with their medical benefits.

Disillusioned providers also can undermine the extent to which employees value their medical benefits. Employee opinion may be influenced by negative assessments from physicians about the quality of an employer's health plan. In addition, physician performance may be adversely affected by a poor quality health plan, with consequences for employee health and productivity.

Failing to demonstrate a commitment to quality assurance and CQI in health care decisions can leave employers vulnerable to the charge of neglecting corporate social responsibility as well. This can have obvious negative implications for community relations.

Value of Medical Care Expenditures

The value of health care services can be defined as the health benefit per dollar spent. Chassin and the National Roundtable on Health Care Quality observed that errors in the delivery of health care services, as well as overuse of services, can reduce the value of health care services by both decreasing the numerator and increasing the denominator of this equation. Conversely, by reducing errors and overuse, the value of health care services can be increased. (The impact of underuse on value is more variable, as it tends to move the numerator and denominator in the same direction.) Most businesses would not view as prudent the practice of purchasing from suppliers based upon price alone. When viewing health plans and providers as you would view other suppliers to your business, considerations of quality and service, as well as cost, become essential components of the value equation.

Evaluating Managed Care Proposals: Quality Assurance

Traditional indemnity health plans do not actively monitor the quality of care being delivered. Members select the providers, and the providers are responsible for the quality of care. The growth of managed care has spawned increased interest in quality assurance. Because much of the cost savings from managed care comes from restricting the utilization of unnecessary services, MCOs must ensure that standardized UM controls and rules do not interfere with appropriate health care delivery. Thus, insurers and HMOs are investing in methods to measure quality and ensure that quality health care is being provided. In evaluating MCO proposals, quality assurance programs are a critical component. 

Assuming that the general network configuration matches well with employee locations, the plan sponsor must next understand how the managed care company selects its network providers and what types of quality assurance mechanisms are incorporated into network management. The provider is "front line" with plan members, and members' overall plan satisfaction level is often determined by their interaction with providers. This point cannot be overstated since the principal element in managed care plans is the deliberate alignment of contracted providers with membership. Not surprisingly, therefore, many quality assurance programs place considerable emphasis on the selection and credentialing process for providers.

Selection is primarily focused on ensuring that there are sufficient numbers of providers within a geographic area to ensure adequate availability of providers to patients. The plan also must ensure that there is a sufficient mix of PCPs and specialists to meet membership needs.

Credentialing helps ensure that providers meet acceptable levels of expertise and professionalism. While each managed care company has its own set of credentialing requirements, the following are representative of some of the standard areas considered:

Sample Physician Guidelines

1. Graduation from an accredited medical school.
2. Valid state license/Drug Enforcement Administration (DEA) registration.
3. Clinical privileges at a licensed participating hospital.
4. Current malpractice coverage/history.
5. Federation check of state licensure.
6. No mental/physical restriction on performing necessary services.
7. No prior disciplinary action/criminal conviction or indictment.
8. No prior involuntary termination of employment or contract.
9. No evidence of inappropriate utilization patterns.
10. Agreement to follow utilization programs, including periodic on-site review of procedures and adherence to contractual obligations.

Sample Hospital Credentialing Guidelines

1. Joint Commission on Accreditation of Hospitals (JCAHO) accreditation.
2. Contractual warranty of state license.
3. Agreement to participate in the various utilization control programs.

While credentialing does not guarantee the provision of quality medical care, it is an important indicator of the managed care company's commitment to provide high-quality levels of care for plan members. Several national independent organizations have evolved to monitor and establish criteria for health plan evaluation. The best known national organization is the National Committee on Quality Assurance (NCQA) which began accrediting HMOs in 1991. More than 70 percent of all HMO members are currently in NCQA-accredited plans across the country. NCQA also began accrediting PPO plans in 2000 and now also offers accreditation of Managed Behavioral Health Organizations (MBHOs).

NCQA accreditation is granted for a period of three years to new health plans that have in place sound organizational structures and processes to monitor and improve the quality of care and service provided to its members and meet NCQA's rigorous standards, which fall into five broad areas:

1. Access and Service: Do health plan members have access to the care and service they need? Does the health plan resolve grievances quickly and fairly?
2. Qualified Providers: Does the health plan thoroughly check the credentials of all of its providers?
3. Staying Healthy: Does the health plan help people maintain good health and avoid illness?
4. Getting Better: How well does the plan care for people when they become sick?
5. Living with Illness: How well does the plan help people manage chronic illnesses?

While NCQA accreditation is completely voluntary, most HMOs and other managed care plans actively seek accreditation. An increasing number of large employers now require managed care plans to either have received NCQA accreditation or have an established plan towards gaining accreditation in order to be offered to plan members. Thirty states now recognize NCQA accreditation as meeting regulatory and licensing requirements for health plan. NCQA accreditation has become a way for plan sponsors to measure the performance of a health plan and assess the value of their health care purchase.

Group Medical Expense Benefits, Managed Care Plans - Quality of Care

A difficult question to answer is whether persons covered by managed care plans receive the same quality of care as persons covered under traditional medical expense plans. If the sole objective of a managed care plan is to offer coverage at the lowest possible cost, there may be a decline in the quality of care. However, some type of quality assurance program is one aspect of any managed care plan. If properly administered, this type of program can weed out providers who give substandard and unnecessary care. In this regard, managed care plans may be more progressive than the medical field as a whole.

The results of numerous surveys and studies on the quality of medical care plans have been mixed. Some studies show that persons in managed care plans are less likely than persons in traditional medical expense plans to receive treatment for a serious medical condition from specialists, and they are also likely to have fewer diagnostic tests. There are those who argue that family physicians can treat a wide variety of illnesses and avoid unnecessary diagnostic tests and referrals to specialists. On the other hand, an opposing argument contends that the decline in the use of specialists and frequency of diagnostic tests is also a clear indication that there is a decline in the level of medical care. Other studies show that persons in managed care plans are much more likely than the rest of the population to receive preventive care and early diagnosis and treatment of potentially serious conditions such as high blood pressure and diabetes. In addition, managed care plans are viewed as having been successful in coordinating care when it is necessary for a person to see several different types of specialists. There is no doubt that there are some small provider networks with a limited choice of specialists, but most networks are relatively large or allow persons to select treatment outside the network. There are also many managed care plans that do refer patients to highly regarded physicians and hospitals or have these providers as part of their networks.

In evaluating the quality of medical care, it is also interesting to look at surveys of participants in the various types of medical expense plans. Most persons in traditional medical expense plans are convinced they receive better care because of their unlimited ability to choose providers of medical care as needed. While surveys of participants in managed care plans usually show a high degree of satisfaction with the medical care received, there are some concerns that have resulted in recent plan changes and legislative actions and interest.

Two recent developments relate to the quality of care provided by managed care organizations—an increased interest in accreditation and a consumer backlash against some aspects of managed care. This backlash has led to the introduction or passage of laws in many states aimed at solving consumer and provider concerns about access to care, quality of care, and choice.