Despite the proliferation of healthcare information available to consumers, Paul Ellwood, M.D., founder of the Jackson Hole Group, believes it's nearly impossible to know how to choose a physician wisely.
"You're going to see story after story (in the media) comparing doctors," Ellwood said. "They don't mean anything. We don't have the means to do it."
But the father of the HMO says data can help consumers sensibly pick a health plan.
Ellwood makes his living giving speeches and hosting conferences, but he doesn't like to write. So for the benefit of those who haven't had a chance to hear him speak or haven't been invited to attend a Jackson Hole Group meeting, Ellwood shared his insights on measuring healthcare quality with MODERN HEALTHCARE reporter J. Duncan Moore Jr.
Q. First of all, how much can we expect physicians to be the source of information on quality of patient care?
A. In the fee-for-service environment, the relationships between physicians are such that it is very difficult to find out who the bad doctors are because the whole system is built on referrals. If you go badmouthing some other doctor, then it jeopardizes the likelihood of your getting some referrals.
Furthermore, I don't think even doctors know much of the time who the good doctors are and who the less competent doctors are. They think they do, but because of the absence of objective comparisons of the results that doctors receive, there is really no objective way of making comparisons.
The lack of feedback and results that individuals get makes it impossible to discriminate. Take a place like the Mayo Clinic. They have a reputation for hiring very good doctors. But they take five years to look at them before hiring them. They've been residents. The supervision is quite close there. The average consumer doesn't have any of the necessary knowledge base or experience to arrive at those kinds of conclusions.
Q. What about managed-care plans?
A. If managed-care plans were to compare their results and outcomes, it would be possible to differentiate between them.
What we see now in the media, like in Barron's (March 4), are attempts at comparisons made with inadequate data because I certainly couldn't tell you the best five HMOs are in the United States, as far as quality is concerned.
I have my own biases. They're not backed up by objective information. The biases are based on the nature of leadership and commitment they have made to improving quality. The thing that worries me is we're going through a cycle, the first stage of which was HMO bashing, often based on misleading anecdotal information.
Q. Has the media been fair in its portrayal of the problems of HMOs, especially those that are revealed by quality measures?
A. They're having to rely on inadequate information. So we're having a second round of misleading information being given to consumers because there simply is not any adequate basis for comparing health plans other than opinions from people like myself.
Some of the purchasing organizations are keeping track of complaints and waiting times. But none of that is a measure of good health.
Under the old fee-for-service system, there isn't a very adequate means of separating good physicians from less capable ones. The same thing is true of managed-care organizations. Both types of healthcare have all sorts of mechanisms in place that supposedly are designed to eliminate poor sources of healthcare and to identify good sources. But nothing does that.
Now we see this very intense effort to rank healthcare organizations for consumers, things like the U.S. News and World Report report on hospitals. Or if you look at a typical regional magazine, they have an issue saying who are the best doctors in Atlanta. How do they know? They don't.
Q. What can HMOs bring to the table?
A. The opportunity that HMOs present, in my opinion, is an organizational arrangement where if we tried to find out the quality of care they provide, we could.
They take care of large populations of people. You have to do it epidemiologically.
In addition, they're responsible for the whole patient, everything that's covered by the benefits plan. And they have responsibility for people over an extended period of time.
The reason we haven't had quality control until now is we didn't have the technical capability or the computing power. And (there is) the natural reticence of any industry where objective, comparative information is made available to consumers.
If the competition is confined to price, then healthcare becomes a commodity, like buying milk. Nobody, particularly in healthcare, wants it to be in a commodity business.
Q. What effect will the availability of all this new quality information have on patients and the malpractice issue?
A. Patients have never had objective quality comparisons that talk about results, about what you can expect from medical care. People are going to be surprised when they get this information,about how much uncertainty there is in medical care and how many trade-offs there are.
We don't know how people will react to this information. People will have more insight regarding what medical professionals do, why they do it and the chances of success or failure involved. That may have a profound effect on medical malpractice over time.
