Keeping score: scorecards, profiles and report cards rapidly expanding to track physician performance

Physician Executive, Nov-Dec, 2005 by Maureen Glabman

About five years ago, physicians and executives at three central New Jersey hospitals that encompass Meridian Health were concerned that scorecards developed by health plans and others might portray its doctors unfairly.

"We wanted to know the data better than an outside agency so we could challenge it if it was wrong," says Jeffrey Borell, Meridian's manager of outcomes measurement.

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"Data has been available to insurance companies for years. Doctors needed to know what the companies had on them," adds Douglas Bechard, MD, Meridian's senior vice president for clinical effectiveness. So Borell and members of Meridian's teaching hospital staff at Jersey Shore University Medical Center, created their own scorecard from scratch. "We looked at what data we already had and started to formulate something," Borell says.

Benchmarks to compare physicians came from 3M's APR-DRG software, the New Jersey Department of Health, JCAHO, and the CMS Web site. Once executives created the scorecard, they stacked it up against physician profiles at other facilities, and then tweaked it more. "It's a work in progress, a good foundation. There will be changes in the future," Borell says.

Meridian's scorecard has endured several revisions following distribution and physician complaints. In the current incarnation, doctors are rated in three areas:

1. Quality, such as giving prophylactic antibiotics prior to surgery

2. Clinical effectiveness, like mortality and length of stay

3. Financial issues, such as percentage of managed care days denied.

Cardiologists, for example, receive grades on 10 quality measures, four clinical effective measures and three financial measures.

The scorecards compare physician performance to members of his or her own group, members of the same specialty who work at their hospital, and to other doctors who treat similar conditions at their hospital.

For readability and ease of use, Borell and his team limited color-coded scorecards to one page. (See Figure 1)

"We felt if it was a booklet, doctors wouldn't read it," Borell says. To assure doctors didn't discard it, Meridian sent it to physician homes with a sticker emblazoned with bold red type: "This is some of the most important information you will receive this year."

Meridian judges 600 of its 1,750 physicians twice annually. Only the largest admitters, those with more than 10 inpatient discharges per six months, qualify for the program since the data are not deemed statistically significant otherwise. Internists as a group receive the most scorecards, followed by cardiologists, pediatricians and surgical subspecialists.

It costs the system about $40,000 annually in manpower to produce the scorecards, excluding technology and mailing. Though Meridian has installed CPOE, it is not yet helpful in data collection. Information manually accumulated from nearly every chart is fed online to QuadraMed, a Reston, Virginia, information management company. QuadraMed then spits it back with results.

For its investment, Borell estimates at least 10 percent of doctors improve their performance each time scorecards are issued. One male cardiologist, for example, received quality scores of 75-96 percent in 2004.

"In the first six months of this year, the most recent period for which we have data, he has all 100 percent," Borell says.

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"After presenting him with 2004 data, he immediately changed his practice," Bechard adds. "Physicians are under pressure. They don't want to be left behind." Bechard and Borell do not attribute improvement solely to Meridian's scorecards. "Physicians today are bombarded with quality information," Borell says. Less frequently, doctors score lower than their previous profiles.

Meridian has had an overall reduction in length of stay and noticeable quality gains, a result that pleases the system's board of directors. "The board of Meridian realizes improved quality from the profiles has an economic benefit even though there is a cost to doing it," Borell says. "We believe we are saving money."

Hospital accountants call the savings "funny money" because when doctors avoid a $15,000 expense by discharging a patient sooner, it's not cash in your pocket," he adds. Bechard is reticent to mention cost benefits. "We don't want physicians to believe this is a financial tool masquerading as a quality report," he says. "Sometimes quality saves money by preventing infections and lowering readmission, but not always. Quality can also cost more."

Meridian physicians are neither rewarded for high scores nor penalized for low ones. "We don't play 'gotcha,'" says the manager. And profiles are not tied to recredentialing. However, when scores are persistently low, doctors are summoned to meetings with their department chairs. Bechard sits in if necessary.

About 10 percent of the 600 who receive the cards, or 60 doctors, are called in twice a year. "We have conversations with individuals who do not do well. The department chair says, 'I've sent you your profile. Are there areas you are concerned with? We don't say 'your mortality rate is 20 percent higher than the group,'" Bechard says.