A Middle Ground on Public Accountability
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In an otherwise insightful review of the challenges of public accountability, Lee et al. (June 3 issue)1 fail to place the patient squarely at the center of the health care system. Patients and consumers are demanding — and deserve — information about how to choose the best doctor. One rarely hears patients ask for the "best medical group" when they are ill.
The majority of physicians practice in groups smaller than 10, the threshold that Lee et al. chose. With the use of their rule, more than half of Americans would not have the kind of information about doctors that they want. Furthermore, performance at a group level masks much of the interphysician variation of interest to patients. Performance data must be fair and accurate; programs such as Bridges to Excellence have overcome the methodologic challenges.2 The "battle lines" the authors describe should not be between payers and providers, but between what patients want and what stands in their way.
Robert S. Galvin, M.D.
General Electric
Fairfield, CT 06828
Suzanne Delbanco, Ph.D.
Leapfrog Group
Washington, DC 20006
Francois de Brantes, M.B.A.
Bridges to Excellence
Fairfield, CT 06828
References
Lee TH, Meyer GS, Brennan TA. A middle ground on public accountability. N Engl J Med 2004;350:2409-2412.
De Brantes FS, Galvin RS, Lee TH. Bridges to Excellence: building a business case for quality care. J Clin Outcomes Manage 2003;10:439-46.
To the Editor: Many of the principles regarding a middle ground on public accountability as cited by Lee et al. already exist in Pennsylvania under the nation's most progressive system of public reporting. Pennsylvania has a large-scale collaborative effort involving purchasers, providers, payers, and policymakers. Our analyses are based on robust clinical data, as well as claims data. In contrast to the findings of Schneider and Epstein's study1 more than six years ago, 12,000 people have downloaded the most recent report on coronary-artery bypass grafting (CABG) from the Pennsylvania Health Care Cost Containment Council, indicating a growing use of "report cards" by the general public. We also note that risk factors associated with CABG in the Pennsylvania population have remained consistent, suggesting that high-risk patients are getting the services they need while mortality rates continue to drop. As for cost inflation, it has increased less for CABG than procedures overall, perhaps because of public reporting. We share many of the authors' concerns but believe that the appropriate response to flawed methodology is the use of more rigorous approaches, rather than the quicksand of more middle ground offered up by the authors.
Marc P. Volavka
Christopher P. Gorton, M.D., M.H.S.A.
Pennsylvania Health Care Cost Containment Council
Harrisburg, PA 17101
mvolavka@phc4.org
References
Schneider EC, Epstein AM. Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998;279:1638-1642.
The authors reply: We agree with Galvin et al. that data on individual physicians can reveal important variability in practice patterns that may be masked by group-level data. In fact, we routinely use data on individual physicians in our organizations' efforts to improve quality and efficiency. However, the more widely data are disseminated, the greater the need for methodologic rigor. When data on individual physicians are reported publicly or are used to influence access in newer products and services offered by insurance plans, issues such as sample size and adjustment for the severity of illness and socioeconomic status become daunting. The issue of physician groups versus individual physicians as the unit of analysis is secondary to our concerns about the fairness and accuracy of publicly reported measures of quality. Given the quality of administrative data that are currently available, we agree that a good approach to these methodologic challenges is that of Bridges to Excellence, which emphasizes physician-level reporting on the availability of systems such as electronic records.
We are pleased with Volavka and Gorton's report of growing consumer interest in the Pennsylvania CABG report card. However, we continue to be concerned that there is not sufficient volume, data, and knowledge about risk adjustment to make analogous public reporting feasible for most other areas of medicine.
Thomas H. Lee, M.D.
Partners Healthcare System
Boston, MA 02199
thlee@partners.org
Gregg S. Meyer, M.D.
Massachusetts General Physicians Organization
Boston, MA 02114
Troyen A. Brennan, M.D., J.D., M.P.H.
Brigham and Women's Hospital
Boston, MA 02115
The majority of physicians practice in groups smaller than 10, the threshold that Lee et al. chose. With the use of their rule, more than half of Americans would not have the kind of information about doctors that they want. Furthermore, performance at a group level masks much of the interphysician variation of interest to patients. Performance data must be fair and accurate; programs such as Bridges to Excellence have overcome the methodologic challenges.2 The "battle lines" the authors describe should not be between payers and providers, but between what patients want and what stands in their way.
Robert S. Galvin, M.D.
General Electric
Fairfield, CT 06828
Suzanne Delbanco, Ph.D.
Leapfrog Group
Washington, DC 20006
Francois de Brantes, M.B.A.
Bridges to Excellence
Fairfield, CT 06828
References
Lee TH, Meyer GS, Brennan TA. A middle ground on public accountability. N Engl J Med 2004;350:2409-2412.
De Brantes FS, Galvin RS, Lee TH. Bridges to Excellence: building a business case for quality care. J Clin Outcomes Manage 2003;10:439-46.
To the Editor: Many of the principles regarding a middle ground on public accountability as cited by Lee et al. already exist in Pennsylvania under the nation's most progressive system of public reporting. Pennsylvania has a large-scale collaborative effort involving purchasers, providers, payers, and policymakers. Our analyses are based on robust clinical data, as well as claims data. In contrast to the findings of Schneider and Epstein's study1 more than six years ago, 12,000 people have downloaded the most recent report on coronary-artery bypass grafting (CABG) from the Pennsylvania Health Care Cost Containment Council, indicating a growing use of "report cards" by the general public. We also note that risk factors associated with CABG in the Pennsylvania population have remained consistent, suggesting that high-risk patients are getting the services they need while mortality rates continue to drop. As for cost inflation, it has increased less for CABG than procedures overall, perhaps because of public reporting. We share many of the authors' concerns but believe that the appropriate response to flawed methodology is the use of more rigorous approaches, rather than the quicksand of more middle ground offered up by the authors.
Marc P. Volavka
Christopher P. Gorton, M.D., M.H.S.A.
Pennsylvania Health Care Cost Containment Council
Harrisburg, PA 17101
mvolavka@phc4.org
References
Schneider EC, Epstein AM. Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998;279:1638-1642.
The authors reply: We agree with Galvin et al. that data on individual physicians can reveal important variability in practice patterns that may be masked by group-level data. In fact, we routinely use data on individual physicians in our organizations' efforts to improve quality and efficiency. However, the more widely data are disseminated, the greater the need for methodologic rigor. When data on individual physicians are reported publicly or are used to influence access in newer products and services offered by insurance plans, issues such as sample size and adjustment for the severity of illness and socioeconomic status become daunting. The issue of physician groups versus individual physicians as the unit of analysis is secondary to our concerns about the fairness and accuracy of publicly reported measures of quality. Given the quality of administrative data that are currently available, we agree that a good approach to these methodologic challenges is that of Bridges to Excellence, which emphasizes physician-level reporting on the availability of systems such as electronic records.
We are pleased with Volavka and Gorton's report of growing consumer interest in the Pennsylvania CABG report card. However, we continue to be concerned that there is not sufficient volume, data, and knowledge about risk adjustment to make analogous public reporting feasible for most other areas of medicine.
Thomas H. Lee, M.D.
Partners Healthcare System
Boston, MA 02199
thlee@partners.org
Gregg S. Meyer, M.D.
Massachusetts General Physicians Organization
Boston, MA 02114
Troyen A. Brennan, M.D., J.D., M.P.H.
Brigham and Women's Hospital
Boston, MA 02115