Copyright © 2012, The Morning Call
Allentown, PA - November 26, 2012 - This month marks the 20-year anniversary of the first publication by the Pennsylvania Health Care Cost Containment Council, known as PHC4, on cardiac surgery outcomes in Pennsylvania. PHC4, an independent state agency, was established in 1986 to improve quality and restrain costs by publicly releasing data on both doctors‘ and hospitals‘ results.
PHC4 published “A Consumer Guide to Coronary Artery Bypass Graft Surgery” only a few months after I began my career at Lehigh Valley Hospital. The Morning Call‘s front-page headline of Nov. 20, 1992, was “Lehigh Valley Hospital gets minus in report on heart bypass surgery”; a related story was headlined “Individual surgeons reviewed.” The report caused shock waves not only at LVH but also throughout the state since this type of public reporting was extremely rare. We had entered a new world of public report cards for doctors and hospitals.
Surgeons viewed the report with skepticism, while hospitals statewide quickly began to look at their internal processes for credentialing surgeons, ensuring proper training and quality. Among other observations, this initial landmark report suggested that high-volume surgeons had better outcomes than low-volume surgeons. As a result, LVH and most other hospitals began to require a minimum yearly volume of heart procedures for surgeons to maintain their credentials.
The PHC4 report intended to measure quality and ensure accountability. PHC4 hoped to educate the public about our health care delivery system and in doing so encourage consumers to choose high-quality health care providers and hospitals. In return, it was anticipated that surgeons and hospitals would improve outcomes. Because better outcomes are typically associated with lower costs, PHC4 hoped that these public reports would indeed control health care costs as well.
There were some unintended results too. Though difficult to prove, it was widely believed surgeons were refusing to operate on high-risk patients to avoid bad outcomes. A 1996 study conducted by the Cleveland Clinic reported that it saw an increased number of high-risk patients from New York after that state published heart surgeons’ results. Further, in a 1999 survey in the Annals of Thoracic Surgery, 62 percent of New York heart surgeons admitted refusing to operate on at least one high-risk patient over the prior year.
These studies seemed to confirm my suspicion, originally written in commentary in The Morning Call on Nov. 29, 1992. At that time, I responded to the inaugural PHC4 report by stating my concern that some surgeons across our state may turn away high-risk patients to avoid unfavorable publicity.
But 20 years later—with nearly 6,000 cases performed and a lot more gray hair—I can say humbly that my concerns and skepticism about the public reporting of doctors‘ outcomes were largely wrong. The fact is that doctor report cards do change behavior, but mostly for the betterment of patients. In fact, Lehigh Valley Hospital responded to the initial PHC4 report with a comprehensive effort to assure patients of their safety by focusing on evidence-based clinical guidelines, creating minimal volume standards, and establishing a thorough peer review process to assess quality performance. For the ensuing 20 years, LVH has enjoyed some of the best outcomes for cardiac surgery in the state while continuing to care for the most complex, high-risk patients, using the most advanced technologies.
Simply stated we have never turned away high-risk patients and never will.
At the end of the day, it‘s all about value. Patients deserve the right care, at the right time, for the right reason and at a fair cost. More recent health care reform measures take doctor report cards even further by aligning hospitals‘ payment with quality. Medicare has established a value-based purchasing program that will reimburse hospitals based on their outcomes. Patients get to fill out surveys on the hospital staff‘s communication and responsiveness, as well as the hospital‘s cleanliness and quietness, all of which are reported on a Medicare website, http://www.hospitalcompare.hhs.gov.
Do report cards matter? You bet they do. The PHC4 reports may not be perfect, but as a result of this agency‘s effort, Pennsylvania remains well ahead of the curve when it comes to health care provider transparency and ensuring value for our patients. From critic to believer, let me be the first to wish a happy 20th anniversary to the Pennsylvania Health Care Cost Containment Council and thank it for its pioneering efforts to promote health care quality in our state.