On a Tuesday morning not long ago, Samin Sharma strolled into his operating room on the fifth floor of Mount Sinai Medical Center in Manhattan and stood over his patient. The doctor’s assistants had already inserted a thin plastic catheter into a blood vessel in the man’s leg, threaded it into his badly clogged left coronary artery, slid a metal wire tipped with a tiny balloonlike device through the catheter, and scrubbed the offending artery clean. Now, squinting at a television monitor showing a real-time X-ray of the patient’s struggling heart, Sharma began manipulating a second wire to insert a stent, a tiny metal device resembling the springy coil of a ballpoint pen, to keep the offending artery open.
It was at about that time that the patient, a 60-year-old television executive, spoke up. He had been anesthetized locally, affording him the unique privilege of watching Sharma save his life.
“When can I go back to work, Doctor?”
Sharma fiddled with the second wire. “You can go back Monday.”
“How about Sunday?”
“You can go back Sunday also.”
Sharma is a 48-year-old cardiologist who specializes in angioplasty, the increasingly popular minimally invasive procedure he was in the middle of performing. If he finished the job correctly—if the stent he chose fit properly and he installed it without a rupture—blood would again rush through the artery unfettered, helping the man’s heart pump at something like normal capacity. The slightest misstep, however, could burst the vessel, causing a heart attack and, perhaps, even death.
Sharma spoke again. “Okay, my friend. I want you to take a deep breath now.” He needed the patient to keep perfectly still.
With the flick of a finger, Sharma delicately placed the stent. Another flick, and the balloon was withdrawn. On the monitor, the clogged artery opened and the stent held; blood flushed easily past where the blockage used to be.
“Breathe normally now. Very good.”
Sharma gave a nod, left the man to be stitched up by the others, and headed back to his office for a Frappucino. He’d been at the table all of ten minutes.
This was Sharma’s third patient of the day, and he was scheduled for fourteen more. Each week he does about 40; each year, at least 1,100. No one in the state even comes close to doing as many; the runner-up, in Buffalo, does something like 800. Not only is Sharma one of the most popular doctors for angioplasty in New York; as a matter of statistical fact, he has the state’s single-lowest mortality rate. And in New York, where everyone is watching, that now matters quite a lot. In 1989, New York became the first state in the nation to make public the mortality rates of its heart surgeons. Report cards for two different procedures, coronary bypass and angioplasty, were chosen as the standards by which the entire profession would be judged—a sort of litmus test for the skill of a given surgeon or hospital. The mortality numbers, risk-adjusted by age and other factors, are released every year or so on the Internet and reprinted in newspapers for all to see, hospital by hospital and doctor by doctor. Ending years of private, clubby surgeon culture, the public report cards were intended to shine a light on poor surgeons and encourage a kind of best-practices ethic across the state. If the system worked, mortality rates would fall everywhere from Oswego to NYU.
At first glance, the system seems to have made an enormous difference. Although there’s no satisfying way to compare our risk-adjusted death rates with those of other states (most of which only have data from Medicare patients, who tend to be sicker and therefore skew the sample), the most recent data suggest that in the past fifteen years, New York’s coronary-bypass surgeons have improved their mortality rates to the point that they are, on average, just one-third of what they were. Sharma’s risk-adjusted mortality rate in the latest angioplasty report is an astonishing 0.1 percent, the state’s lowest. In eleven years, he has been the only doctor to have consistently earned the state’s coveted double asterisk, which designates a surgeon with numbers far below the norm. These days, plenty of his colleagues have low numbers, too; everyone has drifted downward together. Like the children of Lake Wobegon, the surgeons of New York are all, apparently, above average.
But the statisticians who devised the report cards have been tormented by a persistent, intractable glitch in the system: It involves human beings. From the start, it was clear that surgeons’ careers were on the line as well as patients’ lives, and even before the first set of data was released, leaders in the heart-surgery community warned with an air of eerie certainty that the threat of public exposure would create a chilling effect—influencing surgeons to turn their backs on the sickest patients in order to prop up their personal success records.
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.)
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.
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?
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.”