The first significant study to suggest that all was not right with the new system arrived in 1996, when researchers at the Cleveland Clinic suggested that some of the sickest New York heart patients were being shipped out of state. In the first few years after the report-card program began, the Cleveland Clinic received 31 percent more referrals from New York hospitals than they had previously received—and the study verified that the New York patients were sicker than those who were referred from other states. A few years later, a study closer to home looked at the same issue from the physician’s point of view: An anonymous 1999 survey of bypass surgeons revealed that 62 percent of cardiac surgeons refused to treat at least one patient in the preceding year who was perceived to be high risk. “The state health officials were invited to a number of local forums to discuss it,” says co-author Joshua Burack of SUNY. “They didn’t come.”
Eventually, the state’s proudest achievement—the low mortality rates—also came into question. David Dranove of Northwestern released a study in 2003 suggesting that the patients being selected for surgery in New York were simply healthier than elsewhere. Dranove’s data revealed that of those patients in New York who came in for heart attacks, the sicker ones got operated on less often, and the healthier patients got operated on more often. The failure of New York doctors to operate on some sicker patients, Dranove’s study concluded, has led to poorer patient care overall. “Everybody was worse off,” he says. “Costs went up for all, and outcomes were a little bit worse.”
Those seeking further confirmation that New York doctors were passing off sick patients found it in January of this year, when Craig Narins, a cardiologist who performs angioplasty at Strong Memorial Hospital in Rochester, published in the Archives of Internal Medicine the results of a survey he conducted that found that four out of five cardiologists are cowed by the report cards. The response rate was 65 percent, outstanding for a blind mail-in study, and 79 percent of the respondents agreed or strongly agreed that the report cards have in certain instances affected their decisions whether to perform angioplasty on patients. “I was pretty struck by that,” Narins says. “While I knew these feelings existed, I never would have thought it would be this large.”
Perhaps the most disturbing news of all arrived in June, when a group of Michigan researchers and one from SUNY–Stony Brook suggested that heart doctors in New York were more hesitant to operate than perhaps anyone had realized. Their study compared New York with Michigan, which does not have surgeon report cards, taking great care to ensure a fair comparison by collecting data straight from hospitals, not Medicare. They concluded that not only do Michigan angioplasty doctors take on harder cases than the doctors in New York, but that they were far more likely to perform angioplasty on a patient having a severe heart attack. The difference wasn’t even close. “If you come into the hospital in shock having a heart attack, you’re four times as likely to have the cardiologist open up your coronary artery in Michigan than if you were in New York,” says Zoltan Turi, who wrote about the findings in a companion article. “There’s nothing subtle about that number. If there was a small chance to help someone, and you were afraid to do it because of the data, that would be a tragedy.”
In some cases, of course, doctors may be turning away patients for defensible reasons. “There’s a more complicated argument, which is the futility argument,” says Craig Smith of Columbia, the bypass surgeon who operated on Bill Clinton. “Let’s accept for the sake of argument that they’re doing more high-risk cases in Michigan. Are the patients they are doing as salvageable? Should they have been treated with angioplasty or not?”
Which brings us back to Dr. Sharma. The top cardiologist, who often finds himself defending the system that has elevated him, would never say he picks easy cases to help his numbers. On the contrary, he says that he earns consistently low scores because he accepts the tougher cases that the state scores higher in its risk adjustments. Yet over the years, Sharma has frequently been asked how he does it, often by the heads of thoracic-surgery departments of hospitals that have recently experienced an alarming uptick in mortalities. He always has the same answer: His rate is so low, at least in part, because he’s smart enough not to operate on people who—in his words—are “already dead.”
Consider, for instance, a case that would fall into more of a gray area than that of the 60-year-old TV executive. Let’s say, instead, it’s a much older man, one who comes into the hospital with a massive heart attack, and on top of that he’s in cardiogenic shock, meaning that his blood pressure is dangerously low. If you do nothing, there’s perhaps a 95 percent chance he’ll die; if you give him an angioplasty, the chance of death still lingers at 55 percent. As a cardiologist, do you make a hopeless case only slightly less hopeless, put the patient and family through a dangerous and expensive ordeal, and risk ruining your own mortality rate? Or do you walk away?