The setting was the National Managed Health Care Congress' annual spring summit in Washington, D.C., a trade fair and talk show that's become gargantuan. This year it had seven "keynote" speakers and 13 educational tracks. Only one of the tracks was designed for doctors in general, but as these things go, it was pretty good. The topic was, loosely speaking, physician profiling.
At mid-morning on the conference's fourth day, Evelyn Eskin, president of Health Power Associates, a Philadelphia consulting firm whose clients include physicians, group practices, academic health centers, and hospitals, spoke to an audience of doctors about physician performance measurements. Eskin is energetic and animated, so it was hard not to pay attention. But in the middle of her spiel about patient surveying, I started to think about my Volvo.
My two-year-old station wagon is covered by managed care of sorts. Every time I pick it up from my authorized Volvo service center, my authorized Volvo service representative reviews the "treatment" the car has received, then escorts me to the cashier if I have to make a copayment. (Routine maintenance isn't covered under my plan, a.k.a., warranty.)
Before I leave with my car, the rep says someone from Volvo may call to get my opinion of the center's service. "Excellent" is the key word, my rep says suggestively.
I left the NMHCC conference, half-expecting that my internist will eventually make a similar announcement at the end of an office visit, something like, "Prudential may phone you at home to ask if you're satisfied with our service.... "
Has medicine sunk to parity with auto mechanics? Yes, in the strict business sense. With each passing day, corporate medicine holds doctors increasingly accountablevery much the same as Volvo keeps tabs on its grease monkeys. Performance assessment, of which consumer surveying is a part, and physician profiling are becoming de rigueur.
I don't know what my Volvo service rep thinks about profiling, but it's safe to say that most physicians loathe it. Too often, in their opinion, a physician profile shows only the ugly side. It's a tool-weapon some might say-that managed-care organizations employ to cut out doctors who don't play by the corporate rules. It's a ruse to force doctors to provide cheaper care and accept lower fees.
Wait a minute, say managed-care organizations. Doctors' paranoia is groundless. Physician profiling is as much a means of promoting and improving health-care quality as it is an effort to control corporate costs.
Doctors apparently aren't buying that argument. At the NMHCC conference, Scott Weingarten, the director of health-services research at Cedars-Sinai Medical Center in Los Angeles and an associate professor of medicine at the UCLA School of Medicine, said that his recent studies have found primary-care physicians growing more cynical toward practice guidelines, an element in physician profiling. "Fewer physicians think guidelines are used to improve quality," he said, "and more think they are used to cut costs." This in California, where you'd think managed care's ways would be widely accepted by now.
Overall, the speakers gave the impression that performance assessment is changing. Although one admitted that its purpose is still to ferret out bad apples, another insisted that usage is moving from the negative to the positive. Weingarten suggested cost and quality considerations will eventually blend. "The whole reason for accountability is to base competition on the value of care," he said. "All organizations will have to get below a certain threshold for cost, then we'll transition into a race based on quality."
Someday, maybe. But so far, performance assessment and profiling have been used almost exclusively as economic indicators. Perhaps that's because most performance assessment is still "rudimentary," according to David B. Nash, founding director of the Office of Health Policy and Clinical Outcomes at Philadelphia's Thomas Jefferson University Hospital. …