As public pressure increases to disclose individual-physician data, consumers are gaining access to a growing body of information, including malpractice history and hospital and medical board disciplinary actions. And increasingly, the dissemination vehicle is the Internet.
But whether that information actually is useful to consumers -- and the extent to which such information is a measure of a physician's competence -- has become a matter of contention.
Some physicians in California are complaining about the recent enactment of Assembly Bill 103, which requires the Medical Board of California to make available to the public information about any malpractice judgment, arbitration award or disciplinary action. They fear that providing such information without appropriate context may produce prejudicial outcomes.
Los Angeles anesthesiologist Marie Kuffner says she is among many California doctors who believe disseminating information about malpractice judgments, without an accompanying disclaimer or explanation, may do more harm than good.
"The problem with all of this is that there's no way to evaluate credible information," says Kuffner, who chairs the California Medical Association's Medical Board Liaison Committee. "It can be meaningless information, because there's little in the way of disclaimers. What we're fighting against is the opening up of information . . . to the public, with no way of clarifying that information."
Kuffner's point is this: Because some consumers do not understand that many physicians who practice in high-risk specialties such as cardiac surgery, neurosurgery and obstetrics face malpractice lawsuits during their careers, they might misinterpret such information to mean the doctor in question is incompetent.
Worse, she says, a patient who needs the expertise of a particular specialist "could end up not going to the doctor best qualified to treat him." She cites the example of a neurosurgeon who agrees to perform "last-hope" surgery on a patient, and later gets slapped with a $3 million malpractice judgment when the patient dies.
Kuffner also believes that physicians' fears that health plans would use the newly disclosed malpractice information to make decisions about provider panel inclusion have proved justified. "Managed care is driving this, and doctors are caught in the middle. They're penalized, and they're running scared because they know that if the health plan gets the information, they'll be cut from the panel," Kuffner says, adding that she knows of several cases in which this has happened.
Concerns about the context of malpractice information prompted Massachusetts physicians to lobby hard in 1996, following a proposal in the state Legislature by the state teachers association of a broad disclosure bill. To fight the bill, which would have required Internet posting of uninvestigated patient complaints to the Massachusetts Board of Registration in Medicine, the Massachusetts Medical Society crafted its own bill.
Although that bill also called for disclosure of malpractice judgments and hospital and medical board disciplinary data, it required an accompanying disclaimer, which reads in part: "Settlement of a claim may occur for a variety of reasons which do not necessarily reflect negatively on the professional competence or conduct of the physician. A payment . . . should not be construed as creating a presumption that malpractice has occurred."
In the case of physicians with malpractice judgments, information on the number of physicians in the same specialty who paid awards -- and whether those payments were above or below average -- also is included. Since the Massachusetts Physician Profiles went on-line in May 1997, the board's Web site has received 1.6 million "hits," says Wayne Mastin, coordinator of the project. What Mastin doesn't know is how consumers are using that information.
"It's too soon to tell what this means, to assess this activity with hard data," he says. However, during the first year the profiles were made available, complaints against doctors decreased 25%. "We just don't know why," Mastin says.
The Massachusetts State Medical Board is one of 14 state panels participating in the on-line Administrators in Medicine DocFinder program (www.docboard.org), sponsored by the Association of State Medical Board Executive Directors. Four additional state medical boards are expected to join in before the end of the year. Of the participating states, only Massachusetts provides detailed information about malpractice awards. California lists whether malpractice judgments have occurred, but directs visitors to the site to call the board for details. All of the states list license status, and whether disciplinary actions have taken place.
As consumers, healthcare purchasers and legislators continue to push for broad disclosure of physician quality information, some organizations are taking a proactive stance. The American Medical Association is moving forward with its American Medical Accreditation Program, a comprehensive assessment program intended to serve as a single source for physician-quality information.
The AMA program is coordinated through state medical societies, and is designed to comply with requirements of the Joint Commission on Accreditation of Healthcare Organizations, which accredits hospitals, the National Committee for Quality Assurance, which accredits HMOs, and other accrediting bodies.
In an effort to eventually create more uniform measures of medical quality, the AMA, JCAHO and NCQA have announced an effort to coordinate their evaluation efforts. But a coordinating council established by the three watchdog organizations is not expected to begin to produce recommendations before next year at the earliest.
In the meantime, AMAP will attempt to measure and evaluate individual physicians in five key areas: credentials, personal qualifications (ethical behavior and continuing medical education, among others), patient-care results and environment of care. The latter assessment is based on an office visit.
Physicians apply voluntarily to receive AMAP accreditation, and those with a history of disciplinary actions or criminal convictions are automatically disqualified.
By design, the AMAP does not include malpractice information, says Randolph Smoak, M.D., the project's director, because, without any interpretation, it's not a useful measure of physician performance. "It won't be weighed in until the program has a track record," Smoak says.
Eventually, the AMA plans to add patient satisfaction and outcomes measures as components but not until "a broad enough sampling" can be conducted, Smoak says. Consumers do not have access to the evaluation results -- just whether a physician has earned AMAP accreditation.
In New Jersey, the first state to participate in AMAP, application requests from physicians are increasing steadily. To date, more than 2,000 of the state's 13,000 physicians have applied, and one health plan, NYLCare, is making AMAP accreditation a requirement for physicians on its panel.
The District of Columbia recently joined the program -- which is still in its pilot phase -- and the AMA expects to have four more states signed on by fall.
Smoak says the program is not just an attempt to stay ahead of legislative efforts to disclose physician-quality information. "We're answering what we believe is a responsibility of the medical profession. Physicians inherently want to offer their best to patients, and this gives them (patients) a yardstick (with which they can) measure," he says.
In California, the Pacific Business Group on Health, a not-for-profit business coalition representing more than 3 million employees and their dependents, is attempting to provide physician-quality information through its newly released Physician Value Check Survey. While the patient survey -- which covers 58 groups in California, Oregon and Washington -- doesn't profile individual physicians, PBGH's information improvement director David Hopkins says it constitutes a measurement of quality of physician groups.
"We think it's a bona fide, legitimate way to get quality information. We're using it to gauge the performance of groups, and to turn that information into a record," Hopkins says, adding that a second survey covering an additional 50 groups is under way.
The PGBH has no plans to pursue individual physician profiling, Hopkins says, because the process would be "too expensive and too complicated." Likewise, the NCQA, which recently began certifying physician groups, has decided to opt out of individual physician accreditation. "We think it's a good idea, but it's not what we do," says NCQA spokesman Brian Schilling. "Measuring performance at the individual level gives a small sample size and it's hard to adjust for risk."
Bonnie Darves is a freelance writer and editor based in Lake Oswego, Ore.