For Sharma, walking away is sometimes just good medicine. “Ethics are very important, your morality,” he says. “But you need to use your judgment also. If it’s beyond repair, angioplasty is not a solution for every patient. The key is that you need to make a medical decision.”
Heart surgery is one of the few things hospitals do that turn a consistent profit. Faced with a lucrative new game to play, hospitals and doctors are playing to win.
The problem with decisions is that not every doctor makes wise ones—and “futility” is a matter of opinion. David Adams, who came from the Brigham and Women’s Hospital at Harvard a few years ago to chair the heart-surgery program at Mount Sinai, remembers a young woman who came to his office late last spring. Her age and her overall health made her seem like a low risk on paper, but before she’d come to see him she’d had an infection in her heart valve that caused a leak that in turn sent her spiraling into gross heart failure. To take on her case, doctors essentially would have had to rebuild the whole top of her heart. Several surgeons turned her down; whether it was because of the risk of public exposure or the practice of good medicine is an open question.
But in Adams’s office, he has a card from the woman. “How grateful I am,” she writes, “that you said yes . . . when other doctors didn’t want to take the risk.”
Ed Hannan continues to be a part of the counterefforts to keep surgeons from gaming the system, overseeing the risk-adjustment formulas as a department chair at the SUNY–Albany School of Public Health. The report cards, he concedes, are still a work in progress, and he has some thoughts on how they might change. “Some of the cardiologists say that shock patients”—the ones that are four times as likely to get angioplasty in Michigan than in New York—“should be omitted from public scrutiny for angioplasty,” he says. “I think that’s worthy of continued examination.”
Even Samin Sharma, the darling of public reporting, would like to remove patients in shock from the reporting sample. He’d also like to include non-heart-related ailments like cancer as risk adjustments, to remove the temptation to pass such patients along. But the state committee of heart surgeons that vets the data won’t have it. One chief problem appears to be that it would make more work for the committee. “The people voting on this,” Hannan acknowledges, “would be the ones sent these cases to vet them.”
In recent years, Hannan’s report cards have become a model for the increasingly popular “pay for performance” system of health care, in which private health insurers keep track of medical outcomes and direct their patients (and coverage) to hospitals and surgeons that excel. If New York’s experience is any indication, that could mean improvements in every field from cancer care to obstetrics. For all the potential flaws of public reporting, Hannan insists, “states that have public report cards have lower mortality rates.”
It’s just as likely, of course, that a new era of public reporting could also bring a wave of widespread gaming. “I’ve been speaking to hospitals and health-care companies about this,” says David Dranove. “It’s on everybody’s lips. Everybody thinks this is important. You can’t measure success based on the risk-adjusters that are being used for the report cards. If you do, you’ll think you’re doing better than you are.”