Study of Minnesota clinics shows some are twice as expensive as others.
Article by: JEREMY OLSON, Star Tribune
Updated: December 18, 2014 – 9:00 AM
Spending on medical care varies dramatically depending on the clinics that Minnesotans choose — from $269 to $826 per patient per month — according to a first-of-its-kind analysis designed to make patients wiser shoppers and doctors more accountable for the cost of care.
The average patient cost $425 per month, but fully one in five of Minnesota’s clinics was substantially cheaper or more expensive than average, according to the analysis by MN Community Measurement (MNCM), a nonprofit agency formed a decade ago to compare clinics by the cost and quality of care.
Even after weighting the data for clinics that treat sicker or more problematic patients, the analysis found huge variations in cost.
“What’s striking is the difference,” said Jim Chase, MNCM’s president.
At Fargo-based 7-Day Clinic, a walk-in provider of basic services such as strep tests and vaccinations, regular patients cost only $269 per month, and at Hudson Physicians patients cost $344. On the other end of the scale, patients receiving most of their primary care from University of Minnesota Physicians cost $567 and patients with Mayo Clinic cost $826 per month.
The “total cost of care” report, released Thursday, was billed as a major advance in the consumer health care movement — and one that would soon be mimicked by other states and federal agencies seeking to place more cost and quality data in consumers’ hands.
Clinics have been ranked in the past on their costs for individual procedures such as colonoscopies. But the expensive clinics argued they were ultimately more efficient because they had fewer medical errors or could deliver quality care with fewer procedures.
Examining overall patient costs addresses that argument.
“It opens up dialogue about why Provider A is more expensive than Provider B,” said Paul Berrisford, chief operating officer of Entira, an East Metro clinic group where the average monthly cost per patient was $398. “That drives consumerism and internal competition.”
MN Community Measurement already has a track record of spawning change by publishing clinic data. Since 2004, for example, it has graded clinics in Minnesota and just across its borders on meeting care benchmarks for patients with diabetes. Since 2008, the share of diabetics at optimal health has increased from 17 percent to 39 percent.
The new report includes services that patients received away from their main clinic — such as imaging scans at radiology centers or surgeries at hospitals. But in the current era of health care reform, a primary care clinic is often considered the “medical home” for patients and bears responsibility for all medical services they receive.
Chase said the new cost ranking should motivate clinics to re-examine tests they order and reconsider referrals to higher-cost specialists.
Northwest Family Physicians, based in Crystal, ranked favorably, with a monthly cost per patient of $360. In a separate study this fall, it was ranked by a Stanford University think tank as one of the most efficient clinics in the nation — partly because its doctors were trained to provide procedures such as allergy tests rather than refer patients to specialists.
Rewards from insurers or other organizations for measurably efficient care are shared by the entire staff, giving everyone motivation, said Dr. James Welters, Northwest’s president and chief medical officer. “Everybody gets it or nobody gets it.”
MNCM worked with doctors and other specialists over three years to figure out how to fairly evaluate clinics, and also to decide which patients were assigned to which clinics. They used data for all patients privately insured by Minnesota’s four largest health plans and assigned patients to family medicine, pediatric, internal medicine or OB-GYN clinics based on which ones they used most in 2013.
“The reason nobody has done it before is because nobody could get agreement” on how to set it up, said Erin Ghere, a spokeswoman for MNCM. “For the majority of people, it probably stands up that the provider they see the most is their primary care doctor.”
Small clinic groups with fewer than 600 claims for service were excluded. Researchers then adjusted the dollar figures, using a nationally accepted method developed at Johns Hopkins, to adjust for differences in the health of patients at different clinics. All providers reviewed their data in advance of Thursday’s public release.
Overall, the project amassed data on $8 billion in medical services received by 1.5 million patients last year, and reviewed 115 medical groups.
Students low, Mayo high
Mayo had appealed the cost results for its Rochester clinic group, which were 98 percent above average. Clinics aligned with the Mayo Clinic Health System in southeast Minnesota also posted high costs — $524 per patient, or 20 percent above the state average. But Mayo officials particularly disagreed with the Rochester data.
While MNCM removed some of the highest-cost patients who distorted clinic results, Mayo officials said 5 percent of their patients made up 50 percent of their clinic costs. Remove these patients, which included a heart transplant recipient, and Mayo is average for costs, said Dr. John Wald, Mayo’s medical director for public affairs.
While all clinic groups in the state could have high-cost patients, such as those suffering unexpected cancers, Wald said no clinic group in Minnesota has a patient population as challenging as Mayo’s. “Not everyone can make that claim,” he said. “Certainly not everyone can claim the number of complex patients that we see.”
Some results were predictable — such as low average costs for the student health services at the University of St. Thomas, at one end, and higher costs at Mayo and the University of Minnesota, which are renowned for treating complex patients at another.
Chase said that doesn’t change the reality that some clinics spend more than others, even if they have responsibilities such as medical education and research that others don’t.
The analysis also found stark regional patterns. In addition to Mayo, the Gundersen and Olmsted clinic groups serving southeast Minnesota were among the most expensive.
West Side Community Health Services of St. Paul had a high cost — $535 per patient per month — despite being a community clinic focused on low-income, adolescent and minority populations. A clinic executive said the numbers were inflated by West Side’s substantial population of costly HIV patients.
Chase said the data can influence health care in several ways:
For patients, he said, the goal isn’t necessarily to pick doctors on the cheap. But knowing the costs could help in an era of limited insurance networks and increased deductibles.
For clinics, the goal is to become cheaper, not the cheapest, he said; nobody expects equivalency between Mayo and 7-Day Clinic. But if all clinics cut spending by $12 per patient per month, Minnesota patients and insurers would save $750 million in health care costs each year, he said.
Most states fail when it comes to providing publicly available information on the quality of their physicians, according to a new report.
The Health Care Incentives Improvement Institute gave 40 states and the District of Columbia a failing grade of “F” while four other states received a “D,” which is also considered failing. Thus, a majority of Americans – more than four in five – are making uninformed choices when it comes to choosing a physician, authors of the report say.
States were graded on the availability of quality information on physicians as well as how accessible it was to the public. The findings are disappointing given the push by employers, insurance companies and health policymakers for more transparency in health care at a time millions more Americans have medical care coverage under the Affordable Care Act.
“Consumers are flying blind when it comes to selecting hospitals and physicians, and the overall quality and affordability of American health care won’t be improved until we find a way to solve this problem,” Francois de Brantes, executive director of the Institute, known as “HCI3” in the industry, said in a statement accompanying the report.
Just six states passed with a “C” or higher. Minnesota and Washington each earned an “A” while California and Maine received “B” grades. Wisconsin and Massachusetts were each awarded a “C.”
In a state like Minnesota, which earned a rare “A” for its quality reporting, doctor practices are compared on several performance measures as well as the patient’s experience in the doctor’s office. Measures and comparisons of practices are available on conditions like asthma care and colon cancer screenings on the Minnesota HealthScores web site.
Though insurance companies like UnitedHealth Group UNH -0.21% (UNH), Cigna CI +0.12% (CI), Aetna AET -0.1% (AET) and Humana (HUM) have their own ratings for doctors, health plan information isn’t part of the Institute’s report. Consumers often don’t trust insurer ratings, industry analysts say, so advocates for transparency are pushing states to disclose more doctor quality information to the public. The information from those states earning high grades generally comes directly from the doctor practice or hospital system.
“The goal of this report is to not only highlight efforts that are doing well, but also to grab the attention of lawmakers in states lacking this vital information for their residents,” de Brantes said. “If your state isn’t receiving an A or B, it can and should.”
Providing high quality care at the lowest cost is a tough double play for doctors to turn.
Yet a small Twin Cities practice is getting national notice for the feat, even while going up against competitors with, well, bigger payrolls.
A Stanford Medicine think tank recently examined 15,000 primary care groups across the country, stripping away clinics that didn’t finish in the top 25 percent for quality, and also in the top 25 percent for low cost.
About 750 were left. Researchers with the Peterson Center on Healthcare then looked for the best of the best and came up with 11 “most valuable” groups.
One was Northwest Family Physicians, a primary care group in Crystal, Plymouth and Rogers.
Defying stereotypes that only large groups can provide affordable care in modern medicine, the 16-doctor practice made the cut for a variety of innovations, including “up-skilling” their doctors so they can provide procedures such as colonoscopies and allergy tests in-house.
“The cost is significantly lower than doing these things in a hospital,” said Dr. James Welters, Northwest’s president and chief medical officer.
Good fortune allowed the practice to stay independent. Others have found new requirements such as electronic medical records so expensive that they have had little choice but to merge or get bought out.
Northwest invested in e-records a decade ago, when the cost was more manageable. Now, e-records are integral to the clinic strategy of keeping patients caught up with care.
“A cold is never just a cold in our office,” Welters said.
Not that Northwest is perfect. MN Community Measurement ranks Northwest highly for diabetes and depression care, but ho-hum for asthma management and cancer screenings. Welters said that is one limit of being small: the practice can’t improve in all areas at once. But the recognition is still worth celebrating while his group keeps working at improvement.
“It’s not just for us,” he said. “It’s for people like us — smaller, independent primary care clinics. Unfortunately, the health care system is stacked against us.”
The stakes are high for the world-class hospital, which must transform itself amid a new era of reform.
Story by Jeremy Olson
Angie Carlson faced a tough choice when buying health insurance for her employees at DataIQ in Eden Prairie last year: Keep her existing coverage, which allowed employees to use the vaunted Mayo Clinic, or exclude Mayo and instantly save 5 percent on premiums.She knew her workers would appreciate the savings. But how would they feel about losing access to one of the best known health systems in the world? None of them had ever traveled to Rochester for medical care, but one had an eye condition that might suddenly require sophisticated treatment.“What if that worsens?” she wondered.Carlson stuck with Mayo this year, and will do so again next year. But her debate underscores the challenges facing Minnesota’s premier medical institution as economic, demographic and political forces combine to transform the way health care is delivered and paid for in the United States.Mayo has been lauded by President Obama and influential health economists as an example of superb care and medical efficiency. Yet Mayo also has a reputation in Minnesota — confirmed by publicly available health data — for high prices.
How Mayo resolves that paradox will determine the future of a clinic that has become a signature Minnesota brand. Mayo draws patients from all 50 states and more than 130 countries each year. With nearly 41,000 Minnesota employees, it is the state’s largest private employer and, as of this year, a partner with taxpayers in a $327 million venture to elevate the state as a global medical destination.
“If Mayo Clinic were perceived as being too expensive and not worth it, it would be a huge risk to the organization,” said Mayo CEO Dr. John Noseworthy.
As Mayo celebrates 150 years of history, it’s adapting aggressively to meet the coming wave of reforms. It is extending its brand nationally through exclusive affiliation agreements with smaller hospitals around the country. It’s investing more money in a lab that develops and exports cost-saving medical techniques. And it’s formed an unusual alliance with the nation’s biggest health insurer, UnitedHealth Group, to use “Big Data” to prove and improve the value of Mayo’s services.
Premium care, prices
The financial squeeze facing hospitals and clinics has been building for years; total U.S. health spending has slowed sharply since 2008 and last year grew at the slowest pace on record.
But the scale of Mayo’s challenge became clear last year with the debut of Minnesota’s MNsure insurance exchange, which allows consumers to compare health plans by price and coverage. The only plan in Rochester to include Mayo Clinic as an “in-network” provider cost two to three times more than comparable insurance plans in the Twin Cities. Eventually, state regulators persuaded a second insurer, Medica, to offer a plan on the exchange for Rochester-area residents. But even its network did not include Mayo’s primary care clinics in the city of Rochester itself.
Mayo’s leaders argue that the cost figures are misleading. They say data comparing Minnesota hospitals fail to reflect the fact that Mayo treats sicker patients and more complicated diseases — some of which have been mistreated or misdiagnosed elsewhere.
But a Star Tribune analysis of 2012 hospital and insurance data found that Mayo charges more than its Minnesota competitors for even the most common procedures. A colonoscopy at Mayo cost $1,311, compared to just $573 at Allina specialty clinics and $449 at Fairview clinics in the Twin Cities, according to Minnesota Community Measurement, a state-sponsored nonprofit that tracks cost and quality data. A knee X-ray cost private insurers $92 at Mayo, $69 at Allina and $51 at Fairview.
Those disparities make little sense to business executives such as Angie Carlson. “Even if they bought … top of the line equipment for colonoscopies,” she said, “there still is only one way to do a colonoscopy.”
Mayo’s higher fees partly reflect its market dominance in southeast Minnesota, where it has the clout to command higher payments from insurers. Twin Cities hospitals, for example, discount their rates by 40 to 50 percent in order to be included in the networks of large private insurers, according to data from the Minnesota Hospital Association. Mayo’s hospitals — St. Marys and Methodist — by contrast, discount their rates to private insurers by roughly 20 percent, the data show.
So even when Mayo’s prices are comparable — it charges $10,562 for a knee arthroscopy and Abbott Northwestern Hospital charges $10,424, according to hospital association data — it is possible that Mayo is discounting less and getting more of its sticker price back from insurers.
And that may be taking a toll. Insurance brokers say more customers are willing to sacrifice the cachet of having Mayo in their plan, especially this year, as employers cope with rising premiums taking hold under federal health reform. Individuals and small businesses can now find limited-network plans that exclude Mayo and other higher-cost providers.
“You see fewer people signing up for [plans with] Mayo when they realize what the additional cost is,’’ said Paul Howard, a broker with the DCI agency in Chanhassen, which helps individuals and small businesses select benefits.
Mayo officials say they aren’t seeing the consequences in terms of fewer patients. Mayo treated 1.2 million patients from 135 countries last year, an increase from 2012. They also point to a partnership with Wal-Mart, the world’s largest retailer, which said this fall that it will cover 100 percent of employees’ treatment and travel costs for breast, lung and colorectal cancers if they went to Mayo. And, for 2015, Medica added a plan on MNsure for Rochester-area residents that only covers services provided by Mayo doctors and facilities.
Still, patient choices could shift as consumers make greater use of websites, such as MNsure, that make hospital charges more visible, said Garrett Black, a vice president at Blue Cross and Blue Shield of Minnesota.
“With the level of transparency and consumer choice that is emerging … people are going to choose with their wallets,” he said.
Insurers such as Blue Cross have been trying to steer patients to less expensive hospitals and clinics through “tiered” benefits, which offer financial incentives such as lower coinsurance payments. In Blue Cross’ Distinction program, for example, Mayo shows up as a high-quality provider for cardiac care, knee and hip replacements, and spine surgeries. But it doesn’t receive the “Plus” designation that the insurer awards to hospitals with a combination of high quality and low cost in those specialties.
Similarly, the ranking system used for Minnesota state employees’ health insurance ranks Mayo’s primary care clinics in Rochester among the most expensive, and gives workers financial incentives to choose others.
Costs vs. outcomes
Mayo officials don’t argue with the cost figures. But they say sticker price is a crude measure by which to judge a hospital or clinic.
“Despite the reputation of high cost that some people would try to pin on us, we think we can do pretty well and we are constantly working to do better,” said Dr. Douglas Wood, medical director at Mayo’s center for innovation.
Mayo’s tradition of paying physicians a salary, rather than fees for each procedure, encourages doctors to collaborate, while eliminating the incentive faced by many American doctors to bill for more and more procedures. As a result, Mayo doctors say it’s more likely to make an accurate diagnosis the first time, sparing patients the expense of repeat tests and unnecessary procedures.
Mayo’s neurology department, for example, has developed particular expertise in the diagnosis of multiple sclerosis. In some cases, Mayo doctors found that patients did not have the condition after they had already undergone expensive tests and thousands of dollars in treatments at other hospitals, said Dr. Charles Rosen, a Mayo transplant surgeon.
Organ transplants are another example. Even if Mayo charges more for the initial surgery, its patients suffer fewer deaths and fewer follow-up transplants due to complications, Rosen said.
“If you avoid that [second] one, you save a bunch of money,” he said.
Even the higher price for a standard colonoscopy may be justifiable, according to Dr. Vijay Shah, chairman of Mayo’s gastroenterology department. Mayo doctors conduct more thorough searches and remove dangerous polyps in the first procedure, while other doctors wait until a second procedure, he said. The hospital achieves high success rates, and reduces complications such as perforations of the colon, by funding extensive training for its gastroenterologists before they can fly solo, he added.
“A blood draw, that’s a pretty standard procedure,” Shah said. “But to have a long tube stuck all the way up through your back side? That’s an invasive procedure that requires competence and excellence.”
And where Mayo does charge more per procedure, there is evidence that it simply uses fewer of them.
In a 2008 study, the Dartmouth Atlas of Health Care estimated the United States could save $50 billion annually in spending on end-of-life care if all hospitals operated as efficiently as Mayo, largely because it had found ways to excise waste and unnecessary care. Mayo is now working with other hospitals through Dartmouth to identify savings in nine areas of notoriously wasteful medicine.
“What’s really important about Mayo is that they have shown they can do integrated, high quality care that doesn’t involve a huge quantity of care,” said Jon Skinner, a health economist for the Dartmouth Atlas, which is based at the Dartmouth University medical school in Hanover, N.H. “It doesn’t involve … lots of surgery and lots of procedures and lots of hospital admissions that other hospitals are doing and claiming they need to do.”
Later this year, Minnesota Community Measurement will, for the first time, rank hospitals by the total cost of caring for each patient — rather than the amount charged per procedure. This would theoretically favor a hospital that performs one colonoscopy instead of two, or makes a correct diagnosis the first time.
But Mayo’s CEO, Noseworthy, is warning that this first round of data will end up looking bad for Mayo, because it won’t adequately adjust for the fact that Mayo treats sicker patients.
Innovating for efficiency
When compared to other “destination” medical centers around the country, Mayo does appear more cost efficient. Noseworthy said that, in part, reflects Mayo’s investments in research that makes medical care more efficient.
“Mayo is very strong right now, and we’re in a very strong position to lead going forward,” Noseworthy said, “but to lead one has to innovate.”
A streamlined patient-tracking system in its ICU, for example, has been credited with reducing hospital errors and reduced lengths of stay; it is being tested at five U.S. hospitals and will produce an estimated $80 million in savings over three years.
A tissue-freezing technique in Mayo’s pathology lab produces faster test results, giving surgeons the ability to treat patients in a single procedure rather than wait for lab results and schedule follow-up operations. Improved preparation of patients for orthopedic surgeries has allowed Mayo to reduce the use of intravenous narcotics in recovery, reducing drug costs as well as patients’ hospital stays. A Medicare demonstration project subsequently found Mayo with the lowest costs for hip and knee replacements out of 19 major U.S. medical centers.
“You do things up front that allow the patients really to heal in a natural manner,” said Dr. Robert Cima, a surgeon and chairman of Mayo’s Surgical Quality Subcommittee. “That allows them to feel and act as if they are able to leave” the hospital.
Even large insurers that monitor Mayo’s costs acknowledge these efficiencies. Blue Cross, for one, is exploring the creation of an insurance plan that would include Mayo in specialties where it is clearly superior, such as the diagnosis and care of multiple sclerosis. “The more complex the care is,” Black said, “the more cost effective Mayo becomes.”
What is the best way for providers to get objective and actionable information on whether they are delivering patient-centered care? Ask the patients.
Patient experience surveys, particularly those that use validated questions such as the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Surveys (CG-CAHPS®), give providers feedback on patients’ office visits. Practices can then take specific steps to improve the care experience.
A new suite of materials from the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) initiative includes an issue brief, and related resources, exploring key lessons on how patient experience surveys help providers better understand and deliver patient-centered care and help consumers find the best care for themselves and their families.
By Lola Butcher Hospitals and Health Networks 6.10.14
Purchaser and Provider Collaboratives Bring Increased Transparency
MN (Minnesota) Community Measurement is the oldest and most influential of several regional collaboratives that bring a wide range of stakeholders together to increase transparency into health care quality, patient experience and financial information.
The nonprofit organization, currently chaired by Penny Wheeler, M.D., chief clinical officer of Allina Hospitals & Clinics, introduced MNHealthScores.org in 2009 to allow patients to check out the quality of care delivered at clinics or by medical groups. After the Minnesota Hospital Association joined as a sponsor organization, the website grew to include comparative data on hospital quality, including both process and outcome measures, and patient experience.
“We know that consumers are looking at the information, and we also know that providers are looking at the information and using it to improve the quality of care within their own organizations,” says Tina Frontera, chief operating officer of MN Community Measurement. “One advantage of transparency is that it does help spur improvement efforts.”
MNHealthScores.org collects payments from the state’s insurers and publishes a blended average payment rate for basic services — office visits, imaging services and a few procedures — for each clinic system.
Because it is a blended average, that information is not particularly useful to patients, but it allows payers and purchasers to compare their options — and McCoy, the Fairview Health Services executive, finds it very helpful.
“Our preference is to be at market or below market in our pricing, so that is certainly something that we look at,” he says. “And if there’s an issue with a price being out of line, we want to make sure we address that with the payers.”
Next up: MNHealthScores.org later this year will debut a total cost of care measure — the average total, including hospital, physician, pharmacy and all ancillary providers, for an individual for a year. This will allow a comparison of the total cost of care among provider systems throughout the state — information that purchasers and payers will love to have.
Minnesota health care leaders are building on quality measurement and improvement efforts—including reductions in avoidable hospital readmissions that led to $70 million in savings—to tackle the important, but tough, task of measuring how much an individual health care episode costs. These efforts are led by MN Community Measurement, one of RWJF’s Aligning Forces for Quality communities, which has convened disparate health care stakeholders over the years to measure everything from the management of diabetes to the patient experience.
This program is a part of a larger effort by Aligning Forces for Quality to boost the overall quality of health care in communities across the country and provide models for national reform.
When Americans go to the doctor, it’s essentially a coin toss as to whether they’ll receive the care medical experts recommend for their conditions. Measuring the quality of care is a critical starting point to close these gaps. After all, we cannot improve what we do not measure. Publicly reporting about the performance of physician practices allows patients to make informed choices about their care, helps health care professionals see where they can improve, and allows purchasers to know the value of the care they are buying.
This issue brief examines lessons from RWJF Aligning Forces for Quality alliances that have made information about the quality of care local physicians provide publicly available to everyone who gets, gives, or pays for care.
MN Community Measurement, an Aligning Forces for Quality alliance, measures and publicly reports provider performance data. State practices and hospitals, including Entira Family Clinics, are using these data to inform efforts to improve care and patient outcomes for conditions including depression and diabetes.
Aligning Forces for Quality (AF4Q) collaborates with Consumer Reports to help consumers make informed health care choices
Are you receiving quality care? How would you know? With a grant from RWJF and in collaboration with AF4Q communities, Consumer Reports published information comparing the quality of doctors in three states.
Patients generally don’t practice medicine, so it can be hard for them to know just what constitutes high-quality care. In the absence of easy to understand, objective information, health care consumers might never know how well their physicians measure up.
Aligning Forces for Quality (AF4Q) alliances have been leaders in measuring and publicly reporting the performance of physician practices. The challenge has been ensuring that patients have access to and use this data to make better care decisions.
This case study highlights how three AF4Q communities—Greater Boston, Minnesota, and Wisconsin—partnered with Consumers Union to publish special inserts in its magazine, Consumer Reports, to provide consumers with access to performance data for local medical practices.
These reports help physicians and hospitals identify areas for improvement; guide consumers’ decisions in choosing high-quality providers; and offer employers and insurers objective information on the quality of care being delivered.
Ratings on nearly 500 adult and child primary care practices based on patient experience.
Ratings on 552 medical practices based on their success at helping patients achieve key targets in managing cardiovascular disease and diabetes.
Ratings on 19 medical groups (when combined, these serve nearly half of the state’s patients) based on their success at providing patients with any of seven medical services.
By John Lundy, Duluth News Tribune McClatchy-Tribune Information Services June 19, 2014
The annual Minnesota Rural Health Conference will take place Monday and Tuesday at the Duluth Entertainment Convention Center.
More than 500 health care professionals, educators, state health workers, policymakers and students are expected to attend, according to a news release from the National Rural Health Resource Center. It sponsors the event, along with the Minnesota Department of Health’s Office of Rural Health and Primary Care and the Minnesota Rural Health Association.
The screening gap Minnesotans with public health insurance are much less likely to be screened for colorectal cancer than those on private plans.
That’s the conclusion of the seventh annual Health Care Disparities Report conducted by MN Community Measurement and sponsored by the Minnesota Department of Human Services.
In 2013, 51.8 percent of Minnesota Medicaid-covered adults ages 50 to 75 were screened for colon cancer, compared with 71.8 percent of those covered by other types of insurance, the American Cancer Society said in a news release.
That’s the largest disparity among the 13 measures tracked by the report.
Colon cancer is the third-leading cause of cancer-related deaths in the United States.
“The latest Health Care Disparities Report should be a call to action for the health care community to ensure all Minnesotans receive the health care they need. While we are heartened to see improvement in some areas for public program enrollees, there is much more work to do to close these gaps. Providers need to be held accountable for gaps in care that affect public program enrollees and people of color, and we will work with the health plans we contract with to address these disparities with providers. We are turning to the Cultural and Ethnic Communities Leadership Council to help keep us all focused on these issues and to identify solutions.”
Every year, metro magazines around the country publish lists touting the “top” and “best” doctors in town. The issues are money-makers for the magazines and PR fodder for hospitals and health systems. But doctors themselves appear to be wildly ambivalent — and highly skeptical — about the lists.
Who Says Those Are the “Best” Doctors?
Nationwide there are a lot of variations on the top-doctor theme. There are “best” doctors and “most influential” doctors, and selection criteria vary.
While most doctors are quick to recognize and dismiss lists that are simply paid advertisements, their reaction to the peer-nominated “top” and “best” doctor lists frequently published in city and consumer magazines is more complex.
For example, many city and consumer magazines partner with New York-based Castle Connolly Medical Ltd. to compile their lists. Physicians are asked to nominate doctors who, in their judgment, are the best in their field. The firm’s research team then vets nominees to check board certifications, licensing, and disciplinary histories. Physicians cannot nominate themselves and do not pay to be on the list, but they may pay to advertise in the magazine publishing it or for plaques showcasing the recognition.
Physicians are generally happy to make such lists. “Physicians are proud of what they do,” says Kenneth T. Hertz, a principal with MGMA Health Care Consulting Group. “They’re proud of their education and skills.”
But what about the doctors who don’t make the list? A lot depends on the doctor, says Amanda Kanaan, President of WhiteCoat Designs, a Raleigh, North Carolina-based medical marketing firm. Some may have bruised egos. Others may express disdain for the list, while secretly wishing they’d made it. Still others simply don’t care.
Is It a Blow to Your Ego?
Whether the lists have value for physicians beyond bragging rights is open to debate. Hospitals and health systems are quick to issue press releases touting their “top” doctors. Some physicians practicing in competitive markets say making a list can be a huge career booster, attracting new patients and media attention. Others who already have busy practices say they don’t need to have their name on a list to attract patients.
“There are good arguments on both sides,” says Kanaan. “From a marketing perspective, a doctor’s reputation is all that he or she has. They can provide amazing care, but if they don’t have the reputation, patients aren’t going to walk through their door.”
When physicians ask her opinion about whether they should purchase an advertisement in the magazine or a plaque for the waiting room, Kanaan says it’s important to consider their individual circumstances. Do they need help with reputation management? Have patients been slamming them in online reviews? How credible is the list in question and how much do they intend to spend?
“These things can get expensive, and sometimes doctors don’t realize how expensive they are,” she says. “The biggest cost is usually advertising in the magazine, but in some cases, participating is buying into a PR opportunity that entitles you to use the ranking organization’s logo on print and marketing materials.”
Too often, she says, physicians participate not because they want to but because they feel obliged to do so. They participate because the competitor down the street is a “best” doctor or because their partner has a plaque hanging in the waiting room and they don’t want patients to perceive them as inferior. Likewise, if they buy a plaque one year, they feel compelled to do so the next, lest patients think they didn’t make the list a second or third or fourth time.
“For many doctors, it becomes one of their yearly marketing expenses,” Kanaan says. “They realize that if they don’t do it, then there could be repercussions.” In that regard, she says, the lists “somewhat have doctors on their knees: If they don’t participate, they’re going to send the wrong message.”
Specialists, particularly those in highly competitive fields or whose services aren’t covered by insurance, seem to feel the greatest pressure, she says. While patients often choose primary care physicians based on convenient locations, they are willing to travel much further to find a specialist, making it more important for specialists to differentiate themselves.
“I see the value of these as a marketing tool,” Kanaan says. “But this is just one very, very small part of what it takes to market a practice, and it’s not even a necessary part. If I had a limited marketing budget, this would not be my first priority. Not by a long shot.”
What About “Paid” Lists?
Wanda Filer, MD, who practices family medicine in York, Pennsylvania, and earns top marks from patients on Healthgrades and Vitals, says she frequently receives congratulatory letters in the mail that she’s made one list or another. She doesn’t bother to open them.
“I don’t put much credence in the lists. I get notifications fairly often, and to me it always looks like they’re trying to sell a plaque. I’d rather let my work speak for itself.”
Dr. Filer says she thinks other doctors feel the same way. As a board member for the American Academy of Family Physicians, she often introduces speakers at conferences. In preparation for that, “I look at a lot of CVs for physicians from around the country,” she says. “Rarely do I see ‘top doctor’ recognition listed among their accomplishments.”
While a lay audience might put stock in a list of doctors recognized by other doctors, Dr. Filer says physicians themselves know the choice of specialists should be patient specific.
“I just saw a patient who needs knee surgery and asked for a referral,” she says. “I considered two practices. They’re both excellent, but one is more interconnected with an EMR than the other, which is important because he’s an older patient with other health issues. The other group does a great job with knees, but they may not have access to his cardiology record and my records. Nowadays we know that coordination of care is more important than ever, and it’s helpful for me to think through the systems issues when selecting a doctor.”
Another reason Dr. Filer says she doesn’t concern herself with “top” doctor lists: She’s a busy primary care physician. “We’re always trying to find a place to put patients. We’re not out there actively recruiting. A specialist who has more head-to-head competition might feel differently.”
Just a Popularity Contest?
Betsy Tuttle-Newhall, MD, Division Chief of Transplant Surgery at St. Louis University, who likewise earns top marks from patients on Healthgrades, has a different take on the lists. She hasn’t been nominated for one, she says. A relative newcomer to St. Louis, she regards the local top doctors list as “a popularity contest” rather than affirmation of clinical skills.
“CMS tracks my performance. They know my mortalities and my length of stays,” she says. “I know I’m above standard of care, but I never make this list in town.”
Jim Chase, President of Minnesota Community Measurement (MNCM), a nonprofit organization that collects performance data on physicians in the state, says the lists may be revenue generators for the magazines and PR opportunities for the showcased doctors, “but they’re not very important to the quality side or to directing people to the right care providers.”
He says that about eight years ago, MNCM approached Minnesota Monthly about incorporating their patient satisfaction data into its “best doctors” issue.
“They weren’t interested,” Chase says. “They didn’t want to alienate the doctors. They were worried that if the physicians didn’t like the kind of data we were publishing — because we publish both the good and the bad — they wouldn’t advertise with them.”
But What Does the Patient Think?
While doctors may have mixed feelings about the lists, consumer reaction is even harder to gauge.
It’s unclear how much stock the public puts in the lists, which emphasize doctors’ opinions. It would be hard to make a case that they have no value to the public. However, there is solid evidence that patients value the insights of their fellow patients when selecting a doctor and that they do consult doctor-rating Websites.
In a survey of more than 2100 Internet users, 59% say Internet ratings on sites such as Yelp, Healthgrades, and RateMDs are at least “somewhat important” in choosing a doctor, according to a report published in the February 19 issue of JAMA. Of those, 19% say Internet reviews are “very important.”
Patient review sites may be imperfect, but Chase notes that they discuss not only the doctor but also the staff, wait times, follow-up, and other issues that are critical to the patient experience.
“Patient behavior has changed,” Kanaan says. “There are a gazillion doctors out there and patients are confused. They go online just as they would go searching for something to buy. I don’t see these ‘best’ lists competing in the online space.”