Physician Quality Scores: What You Don’t Know — Can Hurt You.
Before choosing a doctor, we investigate. And before investigating, we usually begin with a premise. While the scientist may devise an elaborate experiment to test the premise, choosing a healthcare provider may only involve a superficial analysis. For example, one may simply ask their friends: “What do you know about this doctor?” Or perhaps the analysis may go deeper and employ a search on Google or Angie’s list.
Insurance companies try to assist by giving doctors in their network titles like “Preferred Providers,” or “Gold Choice Doctors,” or “Approved Quality Physicians.” But in the end those titles are generally garnered by any licensed physician in good standing willing to accept the insurance company’s fee schedule.
If the doctor has a web site, there may be pictures of the office and smiling staff, along with a list of degrees and awards. Hopefully the entire page will confirm a wise choice. But colorful web pages may be more of a testament to the web designer than the physician.
How then can we evaluate a service industry populated with so many different providers? A problem made worse if one needs a specialist from a medical field unknown to us. Are choices in healthcare dependent on personal taste only? Is it like finding a good restaurant? Unfortunately for a person struggling with a chronic illness, this choice is crucial.
Currently marketing companies, using metadata mining, can predict our buying habits even before we make a purchase. Where then can people go to gather the necessary information they seek? One likely source is government agencies created to protect the public health and identify problem doctors. Let’s explore what we can learn from these state medical boards.
State Medical Boards
Physicians in the United States are regulated by individual state medical boards. These boards license and oversee medical practices. Their authority evolves from either the state Department of Education or Department of Health. The Office of Professional Medical Conduct (OPMC) is a sub-agency that investigates doctors accused of poor conduct. Their findings are significant. Yet these agencies may be limited either by law or regulation as to what they share with the public.
It wasn’t until the late-1990’s that some states passed legislation that required state medical boards to use the world-wide web and share information about physician conduct. In 1996, Massachusetts became the first state to provide information about doctors online. By 2006, only twenty-two states had laws requiring state medical boards to provide basic physician profiles online. Unfortunately that information is still limited.
One organization proactive in driving transparency is Public Citizen. This nonprofit group with offices in Washington, D.C. and Austin, Texas monitors several public utilities, and also has a division focused on monitoring healthcare information available to the public. In 2006, they released an extensive report on the state medical boards from all fifty states. The medical boards of thirty-five states oversee both medical doctors (MD’s) and doctors of osteopathic medicine (DO’s). Fifteen states have separate boards for doctors of osteopathic medicine, bringing the total number of state boards in the U.S. to sixty-five.
The bare bones information about a doctor is called the physician profile. It contains only each doctor’s name, license number, and license status (active, inactive, retired, or suspended). In addition, there may be information on each doctor’s education, where the degree was obtained, and whether the doctor is board certified by the American Board of Medical Specialties. Some states include additional facts like which hospitals the doctor is affiliated with, whether there has been any disciplinary action by any state or federal agency, or the existence of civil and criminal court actions.
The Public Citizen report only gave one state, Maryland, an A grade for the information presented on its site and for its ease of use. Ten other states were rated as “best,” which were in ranking order the states of: New Jersey, Virginia, Massachusetts, New York, Vermont (medical only), Georgia, California (medical only), and Idaho, Florida (both medical and osteopathic medicine). Ten states were ranked as being the “worst” a title earned by only reporting the basic physician profile and board disciplinary action.
According to the Public Citizen report, there are six categories of information that should be available for public disclosure. Those categories and their explanations are as follows:
- Physician Identifying information – This would include the physician’s name, year of birth, address where the physician practices or resides, license number and license status as well as verification of specialty with board certification.
- State Board Disciplinary Action – This would include information that defined the offense committed, the action taken, the date of the action, the full board order, and a summary narrative of the offense.
- Hospital Disciplinary Action – This disciplinary action should include the committed offense, the date of the action, a summary of the hospital order, and the hospital order itself.
- Federal Government Disciplinary Action – This would include information on a physician disciplined by Medicare, FDA (U.S. Food and Drug Administration) or the DEA (Drug Enforcement Administration). Medicare actions are generally on fraudulent billing or overcharges, the FDA would be misuse of medical instruments, devices, and medications in non-approved manners, and the DEA would be unlawful prescribing of narcotic substances.
- Malpractice Information – This would include judgments and settlements against each physician, including the dollar amount within the past ten years.
- Conviction Information – This would include information on all felony and misdemeanor convictions or nolo contendere pleas in the past ten years.
I abbreviated the following tables published in the Public Citizen report. Although their report is over seven years old, I suspect, given current budget downturns in most states, the report’s information is still substantially the same. Their report underscores the variable range of information found on state web sites. Some state boards received a low score due to difficulty in use. They required viewers to log onto a different web site to retrieve information, or request a written mailed report.
The table displays what information is available for each state:
Disciplinary actions against medical doctors or osteopathic physicians.
|State||Report Offense||Action||Date of Action||Summary||Board Order|
|W. Va. Osteo|
|W. Va. Medical||YES||YES||YES|
For the total 65 boards:
- 58 report disciplinary actions taken against physicians
- 31 summarize the action taken
- 30 display the actual disciplinary order itself.
It’s noteworthy to consider that when state medical boards take an action against a doctor, it’s the result of an extensive investigation that may have taken several years. It’s not based on a single patient complaint. Usually it’s more than several cases which are then evaluated and distilled down to the most egregious cases. The voluminous data is collected and verified and the doctor is given an opportunity to refute the evidence.
By the time a board action leads to license revocation, the potential for ongoing risks to patients is real. As shown above, the lack of a summary report, or viewing the board order itself, forces people to speculate on what triggered the disciplinary action in the first place. At the time of this report, four states did not have a web based mechanism to report state disciplinary board actions to the public. Of interest are the fourteen states that distinguish between the types of material disclosed for medical doctors versus osteopathic physicians. Of those fourteen states, two states report disciplinary actions taken against medical doctors, but report nothing for osteopathic physicians.
The practice of medicine frequently involves care rendered in hospitals. If patients need hospital care, choosing quality providers is even more important. The table below, summarized from the 2006 Public Citizen report, illustrates the available information concerning hospital disciplinary actions found on state medical boards.
Hospital disciplinary actions against physicians:
A cursory view of this table illustrates the paucity of such data with only eleven states displaying any information of this type, and only four boards displaying a summary of the disciplinary action taken by the hospital.
Since there are more hospitals than states, and each hospital is governed by quality assurance boards, there is a wealth of information on physician quality and treatment outcomes. In addition, a hospital may decide to restrict a surgeon’s operating privileges due to many complications. Such factors place the hospital at risk as a co-defendant in malpractice. Even more alarming, in many states, when hospitals reduce a doctor’s privileges, they must notify the state medical board. Yet that same information may not appear on the public web site.
Reporting Medical Malpractice:
How frequently malpractice embroils a physician is something most people would like to know. The table below, also summarized from the Public Citizen report, reveals available information on malpractice made available on state medical board web sites.
Only eighteen states provide some information on their web sites. Of those states, only 5 report the dollar amounts of the settlement. Such information is also valuable because it speaks to the gravity of each specific case, and may distinguish between so-called nuisance suits. Interestingly, at the time of this report, only four states displayed all information regarding malpractice litigation.
An AMA Forum presented an interesting solution to enhancing transparency in this area.
Finally let’s explore how criminal activity by physicians is reported by state medical boards. In choosing any provider, be it doctor or baby-sitter, most people shun providers with a felony conviction. Yet it’s surprising how this is handled among various state medical boards.
Reporting Criminal Convictions in Physicians:
In this report, only 13 states report criminal convictions on their web sites. Eight of those states give details about the conviction and only four of those states report all of the conviction information.
Although personal privacy, forgiveness and compassion are important after someone commits a serious mistake, there is still a debate on how much information should be in the public domain. After “paying back their obligation to society” and amending their ways, many feel that doctors should be granted a new start. Yet the nature of the conviction alters how far the public forgiveness can be stretched. For example, people may be willing to forgive a DUI in a dermatologist nine years ago, but not a sexual offense in an obstetrician committed a year ago.
As we have seen thus far, it appears that healthcare prices are quite variable and unrelated to treatment outcome. In addition, it appears that selecting a medical provider based on a background check is dependent on where one lives. And most importantly, current information systems reveal nothing about the doctor’s skill for treatment results in patients with similar levels of illness. It remains one of the greatest challenges facing good public health at reasonable costs. It’s also what we will continue to explore in ongoing blogs. As a matter of fact, healthcare is one of the few service industries where payment is primarily based on delivery of service, not outcome.