Today, it seems clear that this prophecy has come true. Many surgeons, simply put, began gaming the system immediately and continue to do so today. “We still have people at this hospital who will not treat a high-risk patient,” says David Brown, an angioplasty cardiologist at SUNY–Stony Brook, with evident frustration. “I see a case on Monday morning with an acute myocardial infarction”—a heart attack—“that wasn’t treated. They come in and assess the patient, they think the patient’s at risk of dying no matter what they do, so they do nothing. And people admit to it.”
This isn’t just about high-risk patients. It’s about doctors playing games with practically any patient to get better scores. Some surgeons look for ways to make their easy cases seem harder. Others make their hard cases appear so difficult that they place out of the state reporting system. When it comes to the sickest patients, some surgeons simply turn them away, asserting that they’re better off getting drug treatments, or waiting in the ICU. “The cardiac surgeons refer their patients to the cardiologists, and the cardiologists refer them to the intensive-care unit,” says Joshua Burack, a SUNY–Downstate surgeon in Brooklyn who in 1999 released a study revealing that nearly two-thirds of all heart-bypass surgeons in the state anonymously admitted to refusing at least one patient for fear of tainting their mortality rates. “Everyone’s going to pass along the hot potato to the person who’s not vulnerable to reporting.”
In the past five years, no fewer than five studies have been published in reputable journals raising the possibility that New York heart surgeons are not operating on certain cases for fear of spoiling their mortality rates. The clincher came in January, when, in an anonymous survey sent out to every doctor who does angioplasty in the state, an astonishing 79 percent of the responders agreed that the public mortality statistics have discouraged them from taking on a risky patient. If you’re a hard case, in other words, four out of five doctors would think twice before operating on you.
And consider this: Research shows that New Yorkers are more prone to dying from heart attacks than people in any other state, and the death rate from heart disease in the New York metropolitan area remains disproportionately high. There could be something wrong with our diets. It could be the stress of living here. But it’s also possible that another factor plays a part: Just as more people than ever are dying of heart disease in New York, the very system designed to make heart surgery safer here may be convincing surgeons to turn patients away.
Choosing a heart surgeon has long been more of an art than a science. Aside from word of mouth, there was once no verifiable way of even guessing at who was the best. Surgeons perceived to be at the top of their field were the ones who had the most patients sent to them by cardiologists—and, in a crazy loop, those high referral numbers further fueled the doctors’ reputations. That began to change in the seventies. At that time, state health officials would examine the mortality rates of hospitals every five years or so, and when they did were startled to find wild disparities—11 percent in some places, nearly zero percent in others. As alarming as that seemed, there was no real way to compare hospitals, because each compiled its own mortality statistics in different ways and included different procedures.
The first steps toward standardization took place under David Axelrod, the hard-nosed commissioner of health under New York governors Hugh Carey and Mario Cuomo. Hospitals offered any number of procedures, from transplants to valve replacements, but Axelrod settled on coronary-bypass surgery as the common denominator—the standard by which all hospitals would be judged. Bypass was both the most important lifesaving procedure and among the most standardized of techniques (measuring valve replacements and angioplasty came later). The decision to share these mortality figures didn’t come naturally to a profession that prides itself on discretion. When Axelrod tried to make the scores public in 1989, the state initially balked. Newsday then sued to make them public and won. The state finally released its first set of coronary-bypass numbers in late 1991.
To preempt accusations of unfairness from the medical community, Axelrod had commissioned his director of the state bureau of health care and research, Ed Hannan, to come up with a way to risk-adjust the data so the ratings would be more equitable. Widely credited as the godfather of the current system, Hannan created score adjustments for a number of risk factors that made heart surgery tougher—a prior heart attack, for example, or unstable angina, or weak pumping capacity of the heart, and, of course, age, gender, and weight. Today, depending on the year of the survey, there are about 45 potential risk factors that can bring a surgeon’s mortality rate down. (For the purposes of the report card, any operation performed in conjunction with a second operation is dropped from the statistical sample.)