NEW YORK: GOVERNMENT MEDDLING KILLS OFF THE VERY ILL

In 1989, New York became the first state in the nation to make public the mortality rates of its heart surgeons. Report cards for two different procedures, coronary bypass and angioplasty, were chosen as the standards by which the entire profession would be judged—a sort of litmus test for the skill of a given surgeon or hospital. The mortality numbers, risk-adjusted by age and other factors, are released every year or so on the Internet and reprinted in newspapers for all to see, hospital by hospital and doctor by doctor. Ending years of private, clubby surgeon culture, the public report cards were intended to shine a light on poor surgeons and encourage a kind of best-practices ethic across the state. If the system worked, mortality rates would fall everywhere from Oswego to NYU.

At first glance, the system seems to have made an enormous difference. Although there’s no satisfying way to compare our risk-adjusted death rates with those of other states (most of which only have data from Medicare patients, who tend to be sicker and therefore skew the sample), the most recent data suggest that in the past fifteen years, New York’s coronary-bypass surgeons have improved their mortality rates to the point that they are, on average, just one-third of what they were. Sharma’s risk-adjusted mortality rate in the latest angioplasty report is an astonishing 0.1 percent, the state’s lowest. In eleven years, he has been the only doctor to have consistently earned the state’s coveted double asterisk, which designates a surgeon with numbers far below the norm. These days, plenty of his colleagues have low numbers, too; everyone has drifted downward together. Like the children of Lake Wobegon, the surgeons of New York are all, apparently, above average.

But the statisticians who devised the report cards have been tormented by a persistent, intractable glitch in the system: It involves human beings. From the start, it was clear that surgeons’ careers were on the line as well as patients’ lives, and even before the first set of data was released, leaders in the heart-surgery community warned with an air of eerie certainty that the threat of public exposure would create a chilling effect—influencing surgeons to turn their backs on the sickest patients in order to prop up their personal success records.

Today, it seems clear that this prophecy has come true. Many surgeons, simply put, began gaming the system immediately and continue to do so today. “We still have people at this hospital who will not treat a high-risk patient,” says David Brown, an angioplasty cardiologist at SUNY–Stony Brook, with evident frustration. “I see a case on Monday morning with an acute myocardial infarction”—a heart attack—“that wasn’t treated. They come in and assess the patient, they think the patient’s at risk of dying no matter what they do, so they do nothing. And people admit to it.”

This isn’t just about high-risk patients. It’s about doctors playing games with practically any patient to get better scores. Some surgeons look for ways to make their easy cases seem harder. Others make their hard cases appear so difficult that they place out of the state reporting system. When it comes to the sickest patients, some surgeons simply turn them away, asserting that they’re better off getting drug treatments, or waiting in the ICU. “The cardiac surgeons refer their patients to the cardiologists, and the cardiologists refer them to the intensive-care unit,” says Joshua Burack, a SUNY–Downstate surgeon in Brooklyn who in 1999 released a study revealing that nearly two-thirds of all heart-bypass surgeons in the state anonymously admitted to refusing at least one patient for fear of tainting their mortality rates. “Everyone’s going to pass along the hot potato to the person who’s not vulnerable to reporting.”

In the past five years, no fewer than five studies have been published in reputable journals raising the possibility that New York heart surgeons are not operating on certain cases for fear of spoiling their mortality rates. The clincher came in January, when, in an anonymous survey sent out to every doctor who does angioplasty in the state, an astonishing 79 percent of the responders agreed that the public mortality statistics have discouraged them from taking on a risky patient. If you’re a hard case, in other words, four out of five doctors would think twice before operating on you.

And consider this: Research shows that New Yorkers are more prone to dying from heart attacks than people in any other state, and the death rate from heart disease in the New York metropolitan area remains disproportionately high. There could be something wrong with our diets. It could be the stress of living here. But it’s also possible that another factor plays a part: Just as more people than ever are dying of heart disease in New York, the very system designed to make heart surgery safer here may be convincing surgeons to turn patients away.

Much more here

***************************

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.

***************************