PHYSICIAN PROFILING: Docs Don’t Cause Most Variations
Physician report cards, a highly touted component of managed care designed to decrease costs and boost quality of patient care, actually show very little variation in outcomes that are within physicians' control, potentially fostering an adverse patient environment. According to a study in this week's Journal of the American Medical Association of more than 3,600 diabetes patients at a West Coast HMO, a Midwestern urban university hospital and a New England private practice association, "relatively little of the variation in any of the resource utilization or glycemic control measures evaluated was due to individual physician practice style variation." The authors raise the concern that because doctors have so little control over patient outcomes or resource allocation, they may resort to dropping the sickest and most costly patients to achieve more favorable report cards, as these are often tied into physician financial incentives. They conclude that "[p]rofiling should be considered only if the physician-level variation is deemed important relative to other potential sources of variation," and that "profilers must consider that the application of profiles may foster an environment in which deselection of patients is the easiest way for physicians to avoid becoming deselected themselves" (Hofer et al., 6/9 issue).
Second That Emotion
In an accompanying JAMA editorial, Dr. Andrew Bindman of San Francisco General Hospital writes, "The finding that physicians only contribute a small amount toward inappropriate utilization should not be all that surprising." He argues that physician profiling may never reach the level of useful accuracy, as "the potential for gaming the system by avoiding the sickest patients remains a very real risk with unacceptable consequences for access to care." He notes that profiling is also expensive, and "may likely contribute to physicians' increasing dissatisfaction with the health care system." Bindman concludes, "[I]t is time that the health care community more carefully evaluates the contribution of physician practice to variation in service use" (6/9 issue).