Report cards won't improve health care
Proposals would apply some of the mistakes made under No Child Left Behind to hospitals and doctors.
By KIP SULLlIVAN
Minneapolis StarTribune
January 7, 2008 - 6:03 PM
If you liked the school report cards required by President Bush’s No Child Left Behind law, you’re just going to love the doctor and hospital report cards that will almost certainly be recommended by the two state health care commissions — the Health Care Access Commission and the grandly named Minnesota Health Care Transformation Task Force — due to report in the next few weeks.
The supreme irony is that these calls for medical report cards will come in the midst of a tremendous backlash against the school report cards required by the 2001 No Child Left Behind (NCLB) Act. Teachers, parents and leaders of both political parties are fed up with NCLB school report cards. Those report cards have not been shown to improve the quality of education for all children, but they have driven up education costs, induced teachers to “teach to the tests,” punished schools that serve an above-average number of disadvantaged children, induced some schools to get rid of troubled kids and triggered lawsuits by states and school districts against the federal government.
We can expect similar mayhem from widespread implementation of No Patient Left Behind report cards.
The best-documented example of a medical report card harming patients is the New York state report card on heart surgeons. A 2003 study said the report card led to “major adverse health consequences for sicker patients.” At least three other studies reached similar conclusions about New York’s heart surgery report card.
This illustrates a serious problem with most of the studies on medical and school report cards: They tell you only about what the report cards measure; they tell you nothing about the unintended consequences, including the decline in quality of services rendered to patients and students whose care or education was unmeasured.
The most serious indictment of medical report cards is identical to the most serious indictment of school report cards: Even though they fail to take into account factors outside of the doctor’s or teacher’s control, the report cards are nevertheless used to punish and reward doctors and teachers. To put this another way, even though we don’t know why School A or Clinic A scored poorly on a report card, we’re going to pretend the low grades were the teacher’s or doctor’s fault and punish them financially and with embarrassing publicity. Report cards used in this fashion are a prescription for disaster — for inducing good doctors and teachers to leave their profession, for punishing disadvantaged patients and students, and for wasting precious resources on “solutions” that may even make the problem worse.
My criticism of report cards should not be construed to mean I think our education and health care systems are problem-free. To the contrary, I believe both systems suffer serious problems. But what is the cause of these problems?
Report-card buffs assume defects in doctors and teachers, or clinics and schools, are the main problem. But they have no evidence for this claim. Advocates of medical report cards often state that doctors follow guidelines only half the time, but that claim is simply not supported by scientific evidence. It’s true the research indicates patients do not get the care they need half the time. But the research does not tell us why. The causes of that problem are more likely to be high rates of uninsured people, a serious nurse shortage, crowded emergency rooms, sky-high drug prices, managed care and other factors far beyond the control of clinics and hospitals.
Let’s study the reasons American patients get half the care they need, and let’s continue to do research on report cards. If by some chance it turns out report cards do more good than harm, and if it turns out spending money on them will accomplish more than spending money on other quality-improvement projects, then let’s proceed with widespread implementation of medical report cards. But until then, let’s ignore calls to endorse No Patient Left Behind.
Kip Sullivan is the health systems analyst of the Greater Minnesota Health Care Coalition and the author of “The Health Care Mess: How We Got Into It and How We’ll Get Out of It.”