How To Rate A Doctor? It's Open To Manipulation From Documentation.

How do you rate doc?  That, my friend is a loaded question, and very open to manipulation.  You are only as good as you document. Let me explain.

For the hospital the simple explanation is DRG. Diagnosis Related Group. If you get admitted to the hospital for, lets say congestive heart failure (CHF), your hospital plugs the code for CHF into the medicare system, and viola, out pops a dollar value. For argument sake, lets say $10,000. Your hospital will get paid $10,000 whether you are admitted for 2 days or 2 weeks. It is a fixed payment based the diagnosis. It is not related to the number of days you spend. It is in the hospitals best interest to get you exited from their walls as quick as medically able, to free up that bed for another  paying customer.

There is a whole crew working behind the scenes at a hospital near you called the "utilization review" folks. They carry around big books of criteria that determine if continued hospital stay is medically necessary, based on resource utilization, ie based on what your doctor is ordering and documenting. Whether your doc thinks you need to stay doesn't really matter. If you get the pink slip, that is the hospital saying you are free to stay, but your third part insurance won't pay for it, and expect a bill from us. I tend to agree with this stance. If you are taking up a bed that is not medically necessary, based on physician documentation and resource utilization then why should your insurance pay for it? If you are Medicare/Medicaid, why should I pay for it? It then becomes your choice to stay. It becomes really expensive rent for you, the patient. The decision to stay or go is ultimately yours, as far as the cost to you. But it's up to your doctor and your insurance as far as getting it payed for. The doctor through experience, the insurance by controlling the money, which you agreed to sign up for.

Back to the DRG.

What if you have two people with CHF. One is 85 years old with lots of chronic medical problems and the other is 85 years old with lots of medical problems. One 85 yo is in the hospital for 2 weeks and the other 85 yo is there for two weeks. Does your hospital get payed the same $10,000? Well, yes, and no, and maybe. It is all based on documentation by your physician. A DRG payment also carries with it a sort of severity of illness component. The sicker you are, the more a hospital can get payed for. So if you're physician documents well, involves other major complicating conditions (MCC) and complicating conditions (CC)  in the decision making, the hospital will get extra money, because your illness is more severe. You can see the importance of documentation on payment to the hospital. The more the doc documents, the more the hospital gets payed.

But what does this have to do with rating a doctor? A lot. And that's why it's open to manipulation, in a big way. I heard a lecture by a consultant who made very clear to me how the documentation of Doctor A can manipulate his/her own "quality" rating by learning what and how to document, not how good a doctor they are. Read on.

Severity of illness is associated with expected mortality. The sicker you are, the more likely you are to die. There are four levels of severity of illness,simply enough: 1,2,3 and 4. If your severity of illness is 1, then your expected mortality is <1%.

If you are the proud owner of a level 4 severity of illness, our expected mortaliy is 25%.

These numbers aren't exact but the gist of the argument is the same.

So how is a doctor rated? By their outcomes. What is their ACTUAL mortality, when compared with the EXPECTED mortality, in the community for which they work. The expected mortality is in part defined by the severity of illness. So how is this manipulable?

Severity of illness determinations are made based on the documentation in the chart. In other words, how to rate is doctor is determined by how well your doc describes the medical conditions and problems and complications.

Let me give you an example. If a doctor writes in your chart "CHF", and nothing else, that is considered a level one severity of illness. It is as if you have CHF at home and don't need to be in the hospital. Your expected mortality is <1%.

If you write "Acute CHF", you get to a level 2 severity of illness. Indicating acuteness of you illness makes you more sick.

If you write" Acute CHF with hypoxemia", you get to a level 3 severity of illness. Indicating proximal complications of your acute medical problem indicates you are more likely to die.

And If you write "Acute CHF with hypoxemia and hypotension causes renal failure, confusion" you have a level 4 severity (indicating distal complications) of illness and your chances of death are >25%. You are 1/4th your way to the underground.

Now Doc A may be the smartest doctor in the world but writes very little in the chart. You, the patient may be on a respiratory ventilator, special medications intravenously and in the intensive care unit, but if all your doctor writes in your chart is "CHF", you are considered healthy with a <1% chance of death.

Doc B may be less in tune with the latest therapies but knows how to write essays in the chart. He may be able to describe to a tee the intricate details of your medical problems, but less knowledgeable on how to fix them. He could "document" his way to an expected mortality of >25% for you the patient, and if you live, he will look great.

You can see how statistics lie. Doc B may be an "inferior" doc, but knows how to play the system. Doc A maybe a doctor's doctor but won't play the documentation game, just practices good solid medicine. His published actual vs expected mortality data will pop up as an outlier for a doctor to avoid, when in fact, he could be the one that you need to save your life.

Welcome to medicine's attempt the compare. Do you care more about the doctors mind, or the doctors writing skills.

And what's the public to do?