Should We Fear Patient Ranking Systems?

How clean your bathroom is may now be with drives patience to you or away from you, that's in thought from a new rating system developed by a well known Zagat Survey.  Zagat is joined hands with low point insurance, so patients can now rate their doctors online.

Welcome to the Business of Medicine.  I am your host Dr. Larry Kaskel.  My guest today is Dr. Samuel Nussbaum, Executive Vice President, Clinical Health Quality and Chief Medical Officer for WellPoint Incorporated.

DR. LARRY KASKEL:

Dr. Nussbaum welcome to the show.

DR. SAMUEL NUSSBAUM:

I am delighted to be with you.

DR. LARRY KASKEL:

Sam, lot of doctors are pretty concerned about this and scared and hesitant and skeptical.  Should they be all those, why or why not?

DR. SAMUEL NUSSBAUM:

Larry, these are very legitimate concerns for physicians.  Physicians as you so well know, spend long years in training and each of us wants to be an absolutely exceptional practitioner of care.  So, when we look at rating systems, we fear that our patients that individuals may not understand fully the complexity of the decisions that we are making.  I think it is important to distinguish though between looking at the quality of care that a physician delivers versus the perception of care that takes place the quality of services that a physician's office provides.  This Zagat Survey worked that were doing at well point in partnership with Zagat's looks at the care experience through the eyes of the patient, and if we look at that care experience, I think the doctors and patients all of us have a lot to learn from what we can do better, how we can communicate better, how we can engage patients better to learn about and ask appropriate questions about their care, how we can better make them partners and share decision making and care and also how our office staffs treat our patients?  So, we have to very carefully distinguish between the quality of care if you are surgeon the technical quality of care, if you are an internist the drugs that we use, the effectiveness of the drugs, the effectiveness of the preventive health interventions and the care management and then balance that with what the experiences in the office.

DR. LARRY KASKEL:

Well, that's the issue, is that trying to quantify or qualify this experience they have in your office is enormously subjective?

DR. SAMUEL NUSSBAUM:

Absolutely, and we recognize that.  Larry and Zagat's recognizes that.  So we have done is we have to look at this from a much broader perspective and across the nation using clinical performance measurements developed by organizations like The National Quality Forum by organizations, professional organizations, such as The American College of Cardiology or The Society of Thoracic Surgeons that we will have very objective performance measures on the quality of care that a physician delivers.  Now that's not specifically what we're talking about because we have those measurements.  Those are becoming increasingly available through a series of online capability some through CMS, the Centers for Medicare and Medicaid Services, others through health plans, others through professional organizations.  What we are speaking about today is a specifically the elements that Zagat's has come up with and they are about trust, communication, availability?  What's the practice environment is and when you actually look at those categories, trust is so important, the confidence in your physician's approach to your care the recommendations that she or he is making to you?  Communication really refers to broadly what's a physician's bedside matter now.  Most often, we don't experience it at the bedside, we experience it in an Outpatient Ambulatory Office environment with his or her responsiveness to you, have they developed a rapport with you and then availability.  Think about in your own clinical practice, how important it is for patients to have access whether making appointments, whether it is a telephone responsiveness, whether we respect the commitment that patients make to get our office and the time that we spent with them directly and the environment is really about the physicians office staff.

DR. LARRY KASKEL:

You brought up bedside manner and trust.  I know that medical schools now are spending more time teaching students bedside manner, but if someone wants to tell me it is very hard for a 5 foot person to play professional basketball and MBA.  So there are many students that just don't have the inherent inborn skills necessary and they are going to be penalized now because they don't have the skill set.  Sometimes it can be learned.

DR. SAMUEL NUSSBAUM:

And we both agree that it's important as best we can in our medical training to at least understand why and how certain patients become more involved in their care and I agree with you that not all of us can master these skills or we master them to different levels of capability, but it is important that we all be familiar with those skills.  Now, in terms of, I agree with you in many ways that some may not be as talented as others, but I think that our patients are pretty understanding, and recognize that why they want someone with great empathy or they want someone who will take the time to explain issues well to them.  Doctors can compliment their office environment by having a very engaging nurse.  As we know in Diabetes Care, there is a lot of diabetes nurse educator play a very key roles.  I think it's not only the doctor, but his or her entire office environment and I would hope that patients continue to listen and learn from their primary care or principal care physicians and if the physician is making a referral for surgery, then that patient knows that the physician is referring the patient to a skilled surgeon and what those surgeons results may be and in that domain, it's probably much more important, or it is much more important for that patient who know that the surgeon has a very expert technical skills and has good surgical results, probably even more important than in engaging bedside manner.  What I find to be of concern if there is one in this broad area is the physician who is highly competent, highly dedicated, and yet because he or she does not have those specific attributes that they do not get graded highly, but it's our goal I think all of us to go beyond that.  So, this is a complement to the more objective ratings, for example cardiac surgeon, what his or her cardiac surgical mortalities, what their complication rate, what their infection rate is, what is their ability to do exceptional surgery?  That's the balance that we need to achieve.

DR. LARRY KASKEL:

My guest today is Dr. Samuel Nussbaum, Executive Vice President and Chief Medical Officer for WellPoint Inc. and we're discussing the new rating system for physicians that WellPoint has partnered up with Zagat Surveys with.

Sam, there's got to be a way to make this very objective and using different parameters besides just, oh, I really liked the physician.  He talked to me so well and his front office staff was great.  And what about some concrete data like how many years the doctors been in practice, his board certification, how many losses he has had, if he has had any medical staff actions against him?

DR. SAMUEL NUSSBAUM:

These seem more easily to objectify and those very objective measures exist for health plans today.  So, for example, if you were to go to the web site of a Health Plan Physician Directory, all of those very important issues are outlined, a board certifications act most of us.  Most health plans require board certification to be in network.  Continue with medical education and continuous learning, we know how vital that is and many of our organizations now look, for example at a physician's involvement for example in board re-certification, years in training, wherein a physician is trained, the quality of the team that she or he has surrounded.  All of those are objective measures and we absolutely must start with those as foundational elements.  As we get more and more data performance measurement, for example in Diabetes Care or in care for example, your area of expertise and lipid management, we actually can have objective measurements.  We can look and see how well people have intervened with preventive heart services or how well lipids are being management or the types of therapies that are being used.  Again, highly objective measures that there is absolute rigorous signs around.  When we get to this area of trust communication and office environment by its very nature, we are to clearing that these are subjective measures, but think about this Larry, in many ways if you or I which are move into our community or families were how would we ourselves choose a physician.  We would ask friends and neighbors what their care experience was, we wouldn't be asking what their surgical mortality was.  We wouldn't be asking how well the physician can manage the most detailed measures of blood sugar control for diabetes, what that individual physicians patient's complications rights are, so I think this is just trying to take input measurement around what we all do each day is to by word of mouth ask what the experiences been with a particular doctor.

DR. LARRY KASKEL:

I listen to you and it sounds great as you describe it, but I am still afraid that one person who have the power to spread more information because they are going to be angrier than a happy customer and they will go on and they will potentially sabotage my reputation and so where is the oversights?

DR. SAMUEL NUSSBAUM:

And that is, in fact, the potential risk of these types of models.  So let me share some of the oversights, but I think we want to be responsible here, we want to be responsibly want to provide a service to patients and also to physicians.  So let's look at the first way we go about this is that we are not even going to publish a physicians result until we have approximately 10 reviews because that creates we think again a more representative sequence of events.  We are not again going to encourage basically a blog where people can debate the merits of behavior or not, I think that's not respectful of the professionalism of medicine.  So, what we really are working to do is to try to use statistical probes to make this valid.  There is another point as you know our early results are that 88% of the reviews that we received are positive and recommend the physician, so I believe that you are seeing in those early results that patients want to use this tool to represent how effective their care has been and pinpoint some opportunities for improvement and we know that all is there in running in an office practice.

DR. LARRY KASKEL:

Can a doctor gain this system, can he have 10 patients go on and say glowing things about him if he asks some to do that.

DR. SAMUEL NUSSBAUM:

That could occur, with it would not be possible for the very same person to sign on his 10 patients, but what could happened is it so to be stacking of the court that could certainly happen what were asking the patient's to do is to represent choose Zagat's that in fact they have seen the doctor for a visit and that this is their honest response in terms of what the experience was like, but that could occur as I imagine that could occur in any rating system, correct with your rating restaurants, hotels or any thing that is a subjective rating.  In this situation, it is not done with that type of statistical approach.

DR. LARRY KASKEL:

Dr. Samuel Nussbaum, we are out of time, but thank you very much for talking with me today.

DR. SAMUEL NUSSBAUM:

Thank you.

DR. LARRY KASKEL:

I am Dr. Larry Kaskel.

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