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Misguided Transparency?

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A court ruling would allow consumers to see physician data from the Medicare claims database, but some say the risks outweigh the benefits.

Everybody in healthcare is all for transparency--until the window-washers pull into the driveway. That's when transparency about healthcare quality becomes a complicated conundrum, in some cases prompting its advocates to argue against it.

"Being transparent is the right thing to do, but doing the right thing in the wrong way undercuts its value," says Martin P. Wasserman, MD, executive director of MedChi, the Maryland State Medical Society. "Then it doesn't become the right thing anymore."

His concern explains why physicians, with the American Medical Association at the helm, are fighting to keep the Medicare claims database, which reveals some details about physician practices, behind closed curtains.

"The AMA is concerned that the indiscriminate release of raw Medicare claims data has the potential to put patient privacy at risk and will paint an inaccurate and incomplete picture of the quality of physician care, misleading patients," AMA Chairman Edward Langston, MD, said in a prepared statement. "The risks and harm associated with the release of this information far outweigh any potential benefits."

At issue is a court ruling last summer that ordered the Department of Health & Human Services to release certain information about physicians from the Medicare claims database under a Freedom of Information Act lawsuit filed by Consumers' Checkbook/Center for the Study of Services. The consumer group wants to use the information on its Web site so patients could learn, for example, the number of knee replacement surgeries for Medicare patients a given physician has performed.

One year before--in August 2006--President Bush showed his support for healthcare transparency when he signed an executive order that, among other things, "directs federal agencies to share with beneficiaries information on the quality of services provided by doctors, hospitals and other healthcare providers."

Nonetheless, in October 2007, HHS filed notice that it will appeal the court ruling to release physician data. HHS officials declined to discuss their argument. The AMA--which encouraged the appeal--cited a concern about patient privacy, despite the fact that the court ruling only authorized the release of Medicare claims data that would not make possible the identification of patients.

Beyond that, however, AMA's concern about "an inaccurate and incomplete picture of the quality of physician care" is one every healthcare provider can relate to. Like transparency, healthcare quality measurement is a topic most easily enjoyed at the theoretical level. In pressing for the Medicare claims data, Checkbook pointed to research that has shown better outcomes, in some cases, are associated with the number of procedures a physician has performed. Thus, Checkbook sees the number of procedures as a proxy for healthcare quality.

Physicians agree with that only up to a certain point. Wasserman says a physician who has performed a certain procedure 300 times should not automatically be chosen over another physician with less experience.

"Those [procedures] may not have been for patients with the kinds of underlying conditions another patient has," he says. Indeed, a physician who has performed a procedure on 200 patients--of whom 100 are elderly diabetics--might be the best choice for an elderly diabetic. For that reason, he considers Medicare claims data about physicians to be worthless or even misleading.

"I'm not sure patients are going to get the kind of information that they can really go to the bank with and end up saying, 'This is the doctor of preference for me,'" he says.

At an even more basic level, Wasserman and many colleagues worry about the accuracy of the Medicare claims data and advocate that the best quality indicators will come from physicians, rather than the government. "It is the future of our profession to have increasing amounts of information available to patients so they can make better decisions, so we need to support that," he says.

-Lola Butcher

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