WBB's Thought Leadership

The Fallacies Surrounding Physician Report Cards

August 8

The main goal of physician report cards is to show the effectiveness of the physicians and assess the quality of care administered to patients, ideally resulting in an overall healthier population.

The report cards gather data from checked boxes in the patients’ EHRs, which the providers are required to check. If a box is not checked, or resources are not available to provide the care immediately to the patients, that physician’s scores plummet.

Excerpt: “The Centers for Medicare & Medicaid Services benchmarks for top-tier organizations for most of the measures goes something like 100%, greater than 90%, greater than 92.95%, or less than 5.48% for some of those bad outcomes we don't want.”

“From the looks of it, none of us are providing much care at all. We're not documenting patients' medicines in the electronic record, we're not screening for fall risks, we're certainly not giving anyone any vaccines, not even trying to get them to quit smoking, or doing their mammograms, or making sure they get their colon cancer screening done, or getting their depression under control.

“In the parlance of these report cards, it's called ‘going green’ when your bar graph crosses the performance benchmark threshold and you make it safely into the zone where you pass that measure.

“Our head of information technology (IT), who knows about every click and check box in our electronic health record, didn't ‘go green’ except for a few automated items. The head of our ACO, who certainly knows what needs to be done for this, didn't do much better at all.

“Not surprisingly, senior leadership is now coming at us, trying to make sense of how this could possibly have happened, and looking for quick answers for a way to ensure that the next report card looks a whole lot ‘greener.’

“Unfortunately, their initial suggestions have included more education for the docs, improvements in the data collection from IT, and more ways to make pop-ups flash in our face to remind us to check these boxes.”

“If this is ever going to work, if we are ever going to truly have a system where not only do the report cards look good, but the patients look good, the healthcare system looks good, and the care we are providing is actually getting to our patients, then things have to change”


WBB Take: Various “report cards” and “star ratings” have been offered as indicators of hospital and physician quality, but face strong criticism from healthcare professionals (HCP) and quality management professionals.

HCP’s point out that in  many cases the “satisfaction” scores have little to do with patient outcomes, and that “quality scores” have low reliability and doubtful validity. The star ratings and scorecards typically aggregate many metrics, which makes comparison superficially easy, but hide the true complexity and may give patients no indication of whether the score reflects failures, or the nature of the conditions or patient populations served. Even when viewed individually, some of the frequently-used metrics are problematic for technical reasons. An example is the 30-day readmission score, which makes superficial sense, but which studies show is a poor indicator of quality. Many factors work together to cause a readmission, and although some certainly are the result of misdiagnosis, medical error, or missed opportunities, many more causal factors relate to the patient’s constitution, the nature of the condition, the patient’s environment, and the state of the art. Critics also point out that patients are often readmitted for an entirely different condition that may have no bearing on the quality or value of the previous episode of care even when the chief complaints are identical.

Quality management professionals have also criticized the “scorecard” approach, citing human factors that lead to gaming behavior and subterfuge when metrics are used along with extrinsic rewards and punishments. Gaming behavior results in a net reduction in quality even though the metrics may continue to show increased quality.

We very much need quality metrics in order to identify risks, issues, and opportunities, and to enable us to improve healthcare quality, safety, and value, but current scorecard and star rating systems have not shown themselves to be useful in this regard.

Cited by Shannen Irwin



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