Rating Hospitals and Doctors

The November/December 2008 issue of the highly respected journal Health Affairs published a study comparing how nine 250-plus-bed general hospitals in the Boston area fared among five leading hospital quality reporting services. Led by Michael B. Rothberg, MD, MPH, at Tufts University School of Medicine, the researchers found wide variation for many of the hospitals. For example, two hospitals that were top-ranked for coronary artery bypass graft (CABG) surgery from one service were ranked fourth and last, respectively, by another service. Hospitals that scored strongly in hip replacement surgery received a mediocre rating by the same service on quality measurements in treating patients with pneumonia. Dr. Rothberg was quoted as remarking, "I don't think these ratings are at the point where doctors or patients can really use them. The inconsistency in these systems does a disservice to patients....."

Earlier in the year, a survey of 3,000 consumers conducted by Deloitte Center for Health Solutions for the Department of Health & Human Services (DHHS) was published online and revealed that consumers perceive significant quality differences among doctors, hospitals, and health plans. Consumers see the greatest variation in quality among doctors. Over half (57%) of respondents rated doctor variation at 80 on a scale of 1 - 100, with 100 representing "great differences in care." Comparable figures for hospitals and plans were 55% and 53%, respectively. Barely one in ten (12%) believe quality among doctors does not vary. Comparable figures for hospitals and plans were 10% and 9%, respectively.

Meanwhile, findings from a survey of 1,517 consumers by the Kaiser Family Foundation were released publicly in October 2008, reporting that only three in ten patients reported seeing quality information of any kind on health plans, hospitals, or physicians. This is down 17% from 2006 and has dropped 23% since 1996 when Kaiser first surveyed consumers on the same subject. The proportion of patients who used the quality reports to make decisions is even reportedly lower.

Still, in 2003 the RAND Journal of Economics published research examining the importance of quality differentiation in hospital care markets, in which quality and distance are important determinants of hospital choice. The tradeoff between quality and distance, as well as the valuation of different aspects of quality, varies with patient characteristics. Younger consumers, for example, view judgments about hospital distance differently than older consumers.

What are we to make of these confusing and even somewhat contradictory studies?
My take is that a consumer needs input from multiple sources in order to make smart choices and needs to understand the basis for a performance rating from any source. Different organizations will be rated differently by different services. In addition, different people have different preferences. And different diagnoses and circumstances may dictate different decisions. One size does not fit all. Nor should we even aspire to a single overall quality rating for a hospital offering 30 or more diverse clinical services. It wouldn't be terribly meaningful even if we had one, homogenized number to rely upon. Most importantly, we should never underestimate the ability of an educated, informed consumer to make the best choices in healthcare to meet his needs.