The new statistical glasnost did bring about a general improvement in surgical technique. Some of the underperforming heart programs began to adopt the practices of the best ones: Certain hospitals, for example, began stabilizing a patient before operating, the way the top ones do. Recorded mortalities plummeted. In the first year of the program, the death rate for bypass surgery dropped from 3.52 to 3.14 percent—a decrease of 11 percent. The rate for 2003, the most recent year available, is 1.6 percent. In time, so many doctors have become so good that the minute differences between them are virtually moot. “If one hospital has the lowest risk-adjusted mortality rate, that doesn’t mean that they’re statistically better than the third lowest or the second or the fourth or the fifth,” Ed Hannan says.
If you’re a hard case, a recent study found, four out of five doctors in New York would think twice before operating on you.
Some analysts, however, couldn’t help but wonder if the scorecards had nothing to do with the drop—noting nationwide improvements in technology and surgical techniques. Others suspected that too many risk adjustments simply watered down the data to the point that it was almost meaningless. “It’s kind of like teaching to the test,” says David Dranove, a health-industry management professor at Northwestern who analyzes the impact of health report cards. “The doctors are going to treat patients who are sick on the dimensions the report card mentions. But they’re not going to operate on patients with illnesses the report card doesn’t mention, because they won’t get credit for it.”
A new word entered the surgeon’s lexicon: upcoding. To make a patient look riskier than he might actually be—and therefore lower the impact his death might have on a mortality score—some surgeons coded them with related conditions they didn’t actually have. When intravenous nitroglycerin became a risk factor for the data, there were reports of a greater number of patients getting intravenous nitroglycerin before operating. “Some of that was gaming the system,” says Zoltan Turi, director of the Cooper Vascular Center in New Jersey, “but not all dishonest. It was human, natural. But if chronic lung disease suddenly goes from 10 to 50 percent, it’s hard to believe that there was a sudden epidemic of chronic lung disease.”
Surgeons became quite creative in finding ways to keep their patients out of the data sample. David Brown of SUNY–Stony Brook remembers a patient from 1999, a man in his early fifties who was athletic, a bicyclist, whom he referred to surgery for a bypass. On paper, the man was a low-risk patient—young, healthy, with just one vessel that needed repair. For some reason, however, the man went into cardiac arrest while being put under anesthesia. If he had died, the Department of Health would have scored the death with a very high mortality and no risk adjustment. But the man survived, and a week later Brown glanced at the report and noticed that the surgeon had performed an additional procedure while the patient was on the table. “He did a mitral annuloplasty, which is putting a little ring around the mitral valve,” Brown says. Because of this surgery, this patient no longer could be considered for the state data; he was knocked out of the sample. If the patient died, it wouldn’t affect that surgeon’s mortality rate. “I called him, and he sort of hemmed and hawed about it,” Brown remembers. “I was going to report it, because I thought it was assault. Certainly it was done strictly to manipulate the data.”
Another operation that’s occasionally added is closure of the patent foramen ovale, an opening between the right and left atrium of the heart. “Twenty percent of the population has it,” says Brown. “But doctors close it to take the patient off the list.” Non-heart-related disorders like AIDS or leukemia are not recognized risk factors in the data, but they make it less likely that a patient will get out of the hospital alive. Some doctors inevitably pass those patients along.
The gaming problem isn’t just about hospitals’ and doctors’ reputations; it’s also about money. Heart procedures typically contribute up to a third of a hospital’s total revenue. Heart surgery—because it requires relatively short hospital stays and attracts an older, more affluent patient pool—is one of the few things hospitals do that turn a consistent profit. Competing for market share in treating heart disease, hospitals have begun using the state report cards as marketing tools, advertising their doctors as “low mortality” surgeons. Many also target and recruit low-scoring doctors from rival hospitals. Any double-asterisk doctor often fields offers from several medical centers; Sharma, for example, was heavily courted recently by Lenox Hill after Columbia poached Lenox Hill’s entire angioplasty program, but Mount Sinai paid handsomely to retain him. Faced with a lucrative new game to play, hospitals and doctors are playing to win.