The modern health care system, with its abundance of medical providers, insurance plans, and networks of hospitals and clinics, offers a dizzying array of choices for the consumer. Making informed, smart decisions about which doctor and hospital to choose is more difficult than ever.
How can consumers gauge the quality of one provider and/or hospital and make comparisons? What are the tools available to help them judge the accuracy of information on the Internet about medical providers?
In this episode of Kentucky Health, host Dr. Wayne Tuckson speaks with a renowned surgeon and professor in Louisville to find out the answers to these questions, and to learn more about the best ways for patients to find the doctor and clinic/hospital that best suits their medical needs.
Dr. J. David Richardson, MD, FACS, is a professor and vice chair of surgery at the University of Louisville School of Medicine, and is the immediate past president of the American College of Surgeons (ACS). He has spent his entire professional career at U of L, starting in 1976.
Richardson says that when he started, the health care system in the United States was structured in a way that gave priority to doctors’ concerns and demands. In subsequent decades, he says that the model has shifted toward one in which health care administrators have more authority in decision making. In Richardson’s opinion, the most effective medical care systems are ones in which there is a give and take between doctors and administrators, with the patients’ needs always at the core of the overall mission.
“I think that team care is important, and team care has become the watchword of the day, and clearly for hospitalized patients we need good nurses as well as a whole variety of doctors,” he says. “I think it’s important to remember that there are different levels of expertise and that there’s different levels of experience. And the key to me about having a good health care network or a good health care system, or certainly a good hospital, is a partnership between the administration and the physicians involved. … If the model is purely a business, then I think we’ve lost our way.”
The Insurance System and Patient Choice
During his recent tenure as president of ACS, Richardson says he spent a lot of time in Washington, DC, working with government officials, staff, and various policy groups and lobbyists. He believes that there is a lack of understanding among policy makers about the day-to-day challenges of providing health care in America, and that is reflected in the confusing, overly bureaucratic, and often inefficient medical care system that is currently in place.
“Some of the thoughts about quality of care really have little basis in reality,” he says. “They’re broad-based conceptual things from a 30,000-foot view, and not at a ground level.”
Richardson says the insurance-financed health care system is constrained by its profit-driven structure and focus on controlling costs. An emphasis on cost-cutting may be understandable given the rising percentage of U.S. gross domestic product spent on health care (almost 18 percent in 2015), but Richardson believes that any model that groups medical providers together in a network organized by an insurance plan by definition limits patient choice.
Personally, Richardson says that he will always make the best recommendation of a doctor or hospital to a patient regardless of whether the provider is in or out of the patient’s network. He realizes, however, that the insurance network or HMO (health maintenance organization) model is the dominant paradigm, and says that it may become even more widely used in the future.
Richardson envisions our health care system evolving into one where a particular insurance company and an individual hospital or affiliated group of hospitals partner on all aspects of patient care – from nurses, to anesthesiologists, to surgeons, to recovery counselors, and so on. Such partnerships are already in place to a certain degree among insurers and HMOs, but Richardson believes they will become even more common and restrictive.
“My view is that choice will become more limited over time – that would be my bet, if I were betting,” he says. “I think that what you’re going to see, based on different payment models, is what’s referred to as bundled care. … I think that’s the way you’ll see things moving, as a way to try to control costs, and then there will be discussions within that entity. But, that very act of consolidation, if it comes to be – and it’s already starting in many areas – will by necessity limit choice somewhat.”
Medical Ratings: Are They Accurate?
Americans are awash in a glut of information available at an instant via the Internet and mobile technology, and the popularity of online ratings for any number of services (restaurants, hotels, movies, etc.) shows no sign of abating. Medical ratings are also easily accessible online, and are also published by trade groups and nonprofits after surveys are conducted. These ratings reports may get a lot of attention, but what criteria are they based on?
“I’m very skeptical of all the health reporting systems we have now,” Richardson says. “None are risk-adjusted, most have very small data points on which to judge, and most of the factors on which they judge are really not necessarily what patients are interested in.”
Since most organizations who release medical ratings do not adjust for risk, Richardson says, their conclusions are inaccurate. He discusses a recent ratings report on hospitals in Louisville conducted by the Washington, DC-based nonprofit The Leapfrog Group, which was reported on the front page of the Louisville Courier-Journal. That report gave average and low grades to several area hospitals, including Richardson’s longtime employer, the University of Louisville Hospital.
Richardson says he is the first to admit that University Hospital has problems that need to be fixed, but that the report’s “D” grade fails to adjust for the high number of trauma patients the hospital serves. He says that of the 4,000 to 5,000 patients he operated on in his career for elective procedures, only one died during surgery. On the other hand, Richardson says that he had dozens of inter-operative deaths during his career among trauma patients. These patients came in with grievous gunshot wounds or after suffering a major accident, he said, and “were more dead than alive when they came in.”
“Louisville hospitals interestingly rate much lower than almost all rural hospitals in Kentucky,” he continues. “The reason, I think, is because we take care of sick people. And sick people, by their nature, probably aren’t as happy with their care as well people. And certainly your results aren’t going to be as good. You’re going to have more complications operating on sick patients than patients that are fundamentally well, and are having strictly an elective operation.”
Regarding patient satisfaction surveys, which are used to calculate some of the ratings systems found online, Richardson says they are often based on superficial criteria that is irrelevant to the quality of medical care.
“In surveys that have been done to determine what leads to patient satisfaction, the two things that people talk about more than anything else – assuming of course there’s not a major complication or problem that’s an issue – are really parking and food service.”
Ultimately, Richardson believes that a patient who seeks out opinions from friends, relatives, peers, and primary care physicians will have more success in finding a good doctor or other medical care provider and establishing a health-beneficial relationship.
“I think that networking probably helps you – to me, that’s a much better way to do it, frankly,” he says. “Even though that’s very arbitrary, and seems old-fashioned, I think that’s better than getting on a computer and trying to look up things.
“Within our city, we’re fortunate that we have very good hospitals, and good surgeons and doctors. … But, I also believe at times that some of it’s based on faith, and nothing more than that. Even if a doctor is credentialed by a hospital, that means that you’ve got to have faith that that hospital did a proper vetting process of that surgeon before they’re allowed to operate.”
