Becker's Hospital Review

52 CARE DELIVERY How to Combat the Most Common Excuse in Healthcare By Emily Rappleye I t's a line any hospital executive has heard before: "My patients are sicker." "is data isn't statistically meaningful." "ere's more to the story." ey likely came from physicians who received less-than-sat- isfactory performance results — whether it's surgical complica- tion rates, cost and utilization rates, or patient outcomes. As a healthcare leader, these words seem like a knee-jerk reaction to shi blame elsewhere. Mark Wagar, president of Northridge, Calif.-based Heritage Medical Systems, has heard a similar line or two before. "Physicians are scientists at heart," Mr. Wagar says. "ey are preselected for scientific acumen." is scientific frame of mind, powered by a healthy dose of competition, explains the root cause of these excuses. "When a physician is presented with performance data and compared to their peers, their natural instinct is to look for what the drivers or differences are," says Igor Belokrinitsky, a healthcare strategist and partner at Strategy&. Train physicians to see the forest, not the trees It may be frustrating to see living, breathing patients repre- sented by dots on a graph. is is especially true for physicians today, who now not only face internal performance scores, but ex- ternal ones like Yelp, ProPublica's Surgeon Scorecard, and Medi- care's Physician Compare. Part of the frustration stems from concerns about the metrics used to track performance. Physicians know each of their data points personally, as patients. ey know patients' vitals and other clinical measures, as well as their stories, setbacks and triumphs. is can make it difficult to see how a patient with significantly improved medication adherence, for example, still misses other quality benchmarks. ere is great variability in terms of patient complexity. Pa- tients with multiple chronic illnesses, behavioral health issues or socioeconomic difficulties may have poor nutrition, lack access to resources or not comprehend their medication schedule. "It can have a dramatic impact," says Mr. Belokrinitsky. "We don't always have a good way of capturing those complexities." However, it is highly unlikely complex patients will gravitate to the same physician rather than multiple within the same facility or organization, Mr. Belokrinitsky notes. If every physician at an organization draws from the same pool of patients, they will likely treat similar portions of complex patients, with multiple chronic diseases or other difficulties. Considering two important factors — risk adjustment and physician variability — the "My patients are sicker" excuse becomes plain unconvincing. e first of these factors is risk adjustment. Data should be adjusted for case mix and outliers that could significantly skew data — a physician with low procedure volume at a specific facili- ty, for example — should be thrown out. While it's not out of the realm of possibility to have flawed data, any issue raised by physicians should be met with data clari- fication and actionable information. "e 'My patients are sicker' explanation is not plausible es- pecially when we are able to compare the practitioner with peers using the case mix index — which tells us how sick the patient is — and other risk adjustment methodologies for length of stay and mortality through vendors," says Anil Gopinath, MD, region- al CMO of Presence Health Fox River Valley in Aurora, Ill. Second, the 'My patients are sicker' explanation is improbable due to the undeniable "physician-factor" in patient care. Variabil- ity in physician skill and performance significantly impacts out- comes, as many studies have shown. One such study, published in e New England Journal of Medicine links unnecessary testing directly to individual ophthal- mologists. e likelihood patients in the study would undergo preoperative testing — which is shown to have no effect on out- comes — hinged on provider preference. In fact, the 36 percent of ophthalmologists responsible for most of the testing administered it to 74 percent of their patients. Even beyond basic practice patterns, medicine involves a lev- el of skill that varies among medical staff. is is aptly demon- strated by ProPublica's online Surgeon Scorecard database. While the scorecard has met some skepticism from the medical commu- nity, it clearly indicates a great deal of variation in surgical per- formance. More than 750 surgeons, for example, had no recorded surgical complications, while 25 percent of complications could be attributed to 11 percent of surgeons. e idea that quality metrics are not effective is "completely outrageous," says Mr. Belokrinitsky. When case loads are adjusted for severity and outliers, it is doubtful one physician is a magnet for the sickest patients, and even more so considering physician variability. Consequently, any physician who cries foul should raise a red flag for hospital leadership. "For the most part, when there's smoke, there's fire," says Mr. Wagar about physicians who claim their patients are dispropor- tionately complex when faced with poor performance results. Open the conversation anonymously Telling someone they are wrong isn't easy. It's especially challenging if that person is trained to think and act like an expert. e key to addressing physicians' most com- mon excuse, according to Mr. Belokrinitsky, lies in framing the conversation as collaborative, not confrontational. Data should be anonymously presented to physicians, Mr. Belokrinitsky says, to keep meetings from becoming personal

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