How residents can prepare for changes in physician measurement

The judging and measuring started on my first day as a urology sub-intern and hasn’t let up since. Two hours into a radical cystectomy, nervous about my suturing skills, and tired from feverishly reading the night before, the attending finally directed a question my way: “Alan, who performed the lead in this 1977 Broadway classic playing on the radio?”

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The notion of being measured and judged is as familiar to urology residents as coffee. Although that process continues beyond training where patients and colleagues form and spread opinions of a doctor’s aptitude, the world of physician measurement is rapidly evolving and residents need to understand the changing landscape.

Recently, a friend right out of training told me how devastated he was over his first negative Yelp review. The patient’s insurance didn’t cover the visit, and that brought down the doctor’s composite score to three of five stars. While online reviews of physician performance are not always that base and crude, they are becoming ubiquitous.

Last summer, ProPublica, a non-profit producer of investigative journalism, published its version of individual surgeon quality metrics using publicly available Medicare claims data. The “Surgeon Scorecard” incorporated case volume and complications to determine which surgeons were “best” at eight common procedures, including radical prostatectomy. ProPublica has come under scrutiny for its limited data scope (most prostatectomies are non-Medicare and thus not included), its non-validated method for risk-adjustment, and the inability to capture “clinically relevant” outcome metrics (such as functional status and quality of life).

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Despite the criticism, the Surgeon Scorecard publication attracted national attention on performance measurement and transparency, and the issue isn’t going away; ProPublica is currently working on version 2.0 of the Surgeon Scorecard. While ProPublica uses publicly available data, California-based tech startups are capitalizing on robust private claims data to refine those analyses further.

Next: Quality of data questioned

Quality of data questioned

The major criticism of these approaches, of course, is the quality of the quality data. Insurance claims are a) only as good as the coders/billers and b) limited in their ability to give us information about key components of the patient’s clinical outcomes. To focus performance data around “how do we improve” rather than “who is better,” the Michigan Urological Surgery Improvement Collaborative (MUSIC) links measurement with improvement initiatives. MUSIC, which is supported by Blue Cross Blue Shield of Michigan, is a physician-led consortium of over 40 urology practices designed to improve value in urologic care. The goal of participating practices is to identify actionable targets to improving care, and they have been successful in reducing post-prostate biopsy sepsis, among other endeavors.

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This type of high-level performance measurement strategy is an encouraging step in the right direction but is still geographically and topically limited. As trainees, it is essential that we prepare for a world in which our performance will come under intense scrutiny but perhaps without our input into the nuances of that inquiry.

Three steps to prepare

First, we must become informed about the metrics currently in use. Even our most technologically unsavvy faculty can understand Yelp, but what about the Pro Publica score? Being able to address questions like how data are acquired, how risk-adjustment is done, who does it and why, and what metrics are included into a scoring methodology allows us to better communicate with patients and colleagues that may ask about these tools.

Second, we need to get engaged in the measurement discussion. Join a quality improvement collaborative if one exists in your area, join the AUA Quality Registry (AQUA), or work with local and regional colleagues and payers to promote value that is driven by high-quality data.

Next: The importance of advocacy

Finally, advocate. Payers and policymakers are already driving health policy decisions based on quality and value data. As specialists, urologists have faced challenges getting the Centers for Medicare & Medicaid Services and others to adopt relevant metrics that make sense in our realm. Ensuring that policy decisions are based on metrics that represent relevant outcomes and are improvement oriented is of utmost concern to the young urologist.

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Someone recently told me, “The good old days of simply doing right by your patient and being good to your referring docs are gone.” While that may be true, I believe the horizon is bright. Novel data acquisition methods and analytics, information technology, and physician collaboratives based on improving quality open the potential for doing even more “right” by our patients and being even better to our referring docs.

So how do residents prepare for the inevitable changes in physician measurement? Embrace them.

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