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.
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
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.
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