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INSURING YOUR HEALTH Michelle Andrews


As more doctors get rated, star systems raise doubts


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or most people, picking a doctor is hardly a scientific process. They ask friends or family members to pass along names of doctors they like and trust, or rely on another doctor’s referral. Increasingly, health plans and independent groups are making physician information available online to help consumers make these choices more methodically. But experts caution that most doctor- rating systems are still rudimentary, and a four-star rating or other high- performance designation may not reliably reflect a doctor’s abilities. While ratings can provide helpful information, consumers still need to dig a little to find the best doctors for their needs. The systems provided by some health plans to rate doctors are typically based on two factors: cost and quality. Data that measure the quality of care — whether a diabetic gets regular blood-sugar tests or foot exams, for example — are not as easy to translate to the level of individual doctors but cost is, so cost tends to be the bigger factor. “Often insurers will do a


two-step process,” says Ha Tu, a senior health researcher at the Center for Studying Health System Change, a nonpartisan research and policy organization based in Washington. First, they “make sure doctors meet a quality threshold, but not a very high one. Then they’ll weed them out further based on cost.”


Complicating the situation for consumers is the fact that every insurer measures these variables differently, and there are no agreed-upon standards for which combination of attributes makes a top-notch doctor. In fact, a physician who receives a top rating from one insurer may receive a middling or even low score from another, says Elizabeth McGlynn, associate director at Rand Health, a division of Rand, a think tank based in Santa Monica, Calif. It’s no surprise then that


doctors are resistant to many insurer efforts to rate physicians. In a recent letter to 47 health plans, the American Medical Association and 46 state medical societies asked the plans to improve the accuracy, reliability and transparency of physician ratings. To support this call for change, the letter pointed to research by Rand that examined physician cost profiles and found that health-plan ratings were inaccurate up to two-thirds of the time.


Although rating systems


may have problems, experts agree their use is only going to rise. As insurers and employers try to hold down health-care costs, steering patients toward doctors and other providers who provide the best care for the money is an important priority. Increasingly, employers are


trying to provide employees with financial incentives to use doctors in so-called high-performance networks, says Karen Frost, health and welfare outsourcing practice leader for benefits consultant Hewitt Associates. While insurers and


physicians battle it out, consumers are left feeling confused. As Chris Worthington of Rock Hill, N.Y., learned, sometimes a high-performance rating may not even have much to do with patient care. When the 45-year-old middle school teacher was trying to research doctors on her health plan’s Web site, she learned that a four-star rating was based on whether a doctor used electronic medical records. “I think they have the information there that’s most important to the insurance company, not the consumer,” she says.


Some of the measures that


matter most to consumers aren’t included in many rating systems, experts say. They include doctors’ interpersonal skills and other concerns such as: Do the doctors spend enough time with patients and answer their questions? Do they stay on schedule or do patients have long waits? “These are some of the best


predictors of patient satisfaction, and even outcomes,” says McGlynn, noting that no matter how clinically competent a doctor is, a patient’s health won’t improve if he doesn’t understand how to take the prescribed medication. Consumers sometimes turn to independent sites to get a glimpse of what a particular doctor might be like. The sites —such as HealthGrades, RateMDs.com and Angie’s List —differ in some respects: They may or may not permit anonymous comments, for example, or charge a fee. But they all provide a forum for people to learn what other consumers have to say about specific physicians. Since moving to Indianapolis,


Dan Tuten has used Angie’s List to help find four doctors. The 69-year-old retired software engineer says it takes a while to learn how to extract useful information. “These are just regular folks commenting, and you tend to see a lot of ‘A’ ratings,” he says. But Tuten says he wouldn’t trust an insurance company rating. “My impression is they steer you to a doctor because they’re the least expensive,” he says. In trying to research doctors,


Tuten and Worthington are in the minority of consumers. Most people don’t do any research, suggesting that health-plan rating sites may face a difficult task getting consumers to use them. In a 2008 survey by researchers at the Center for Studying Health System Change, half of the respondents said they relied on friends or relatives to choose a primary-care physician. Nearly 40 percent turned to a doctor or other health-care provider. Only a little over a third used information from their health plan.


“Picking a physician is a very personal choice, and often you rely on people you know,” says study lead author Tu. “It’s not necessarily true that they’ll trust a health plan to provide them with information about doctors.”


This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente. E-mail: questions@kaiserhealthnews.org.


KLMNO


TUESDAY, AUGUST 3, 2010


Psychologist helps ‘campers’ face their fears ocd continued from E1


ing “Virtual Camping” — a two- hour after-dark excursion and germfest that was part of the 2010 International OCD Founda- tion Conference held at the Hyatt Regency last month. “What can you do in one night?” Grayson had asked as the evening began. “You can take a step toward learning how to deal with uncertainty.” Then he led the participants into the steamy streets of Crystal City, where, among other things, they would be encouraged to shake the hand of a homeless man (to fight more contamination fears), to chant “Crash and burn” to passing mo- torists (to show that thoughts would not cause actual harm) and to touch ripe garbage with their bare hands (contamination, again). OCD, which affects approxi-


mately 2.2 million American adults, is characterized by recur- rent unwanted thoughts (obses- sions) and/or repetitive behav- iors (compulsions). Desires for certainty and perfection are also hallmarks of the disorder, said Grayson, director of the Anxiety and OCD Treatment Center of Philadelphia.


Screaming and moaning Grayson, 58, has been offering


“Virtual Camping” at the OCD conference for 10 years, after tak- ing patients on actual camping expeditions and watching them successfully confront their fears of dirt, lack of control and unpre- dictable situations. He doesn’t consider the virtual version a substitute for therapy. “It’s a convention demonstra- tion,” he said. “But it can inspire


people to go to treatment. And there are people who have made real gains here.” Wearing an Indiana Jones-


style hat, Grayson herded the group from spot to spot, making jokes, issuing challenges and ral- lying the nervous and the timid. Standing below a street lamp in an empty parking lot, he asked: “Is anyone afraid they’ll hurt someone?” About 10 people stepped forward. Grayson issued each of them a paring knife and told them to walk through a gantlet formed by the other members of the group. “Your job is to hold the knife in front of you,” he said, “and we’ll see if you kill anyone.” The participants started out


tentatively, limply wielding their weapons, until Grayson com- manded, “Hold it like you mean it!” To heighten the sense of dra- ma, he directed the people in the gantlet to scream and moan as though they were being stabbed. Hilary Zurbuch emerged with one hand trembling around a knife handle and the other cover- ing her eyes. “That was pretty anxiety-provoking,” said the 30- year-old Pittsburgh resident, whose disorder, diagnosed when she was 19, has become so severe that she has been unable to per- form her job as a psychothera- pist. Later, Grayson ordered a group hug — a germ-spreading exercise made even grimier and sweatier by the 95-degree urban heat.


First he asked everyone to turn in their hand sanitizers so they would not be tempted to disin- fect themselves afterward. In- stead, they’d have to fully experi- ence their contamination anxiety


and wait until it dissipated natu- rally, an important step in the therapy known as exposure and response prevention, or ERP. “That wasn’t just Purell,” Zur- buch groused, after coughing up her sanitizer. “It was Bath & Body Works. It was the good stuff.” She shrugged. “It’s gone.” But a mo- ment later, she grinned and con- fided, “I have another bottle back in my room.”


‘I couldn’t do it’ Contamination was a big deal


for Mariann Kruer, too. The wisp- like woman from Floyds Knobs, Ind., refused to touch a cigarette- butt-chewing-gum combo that Grayson had lifted from the grimy rim of a sidewalk trash re- ceptacle and passed around. “I couldn’t do it,” said Kruer, 33, who also avoided gripping the handrail of the hotel escalator as the group made its way to the restrooms and the evening’s grand finale. “My mind was run- ning through where the gum had been.”


But Kruer, who like many OCD


sufferers attends therapy and takes medication, somehow sum- moned the courage to participate in the toilet/Tic Tac ritual. After- ward, though, she sobbed in the arms of her husband, Phil, who stood outside the restroom. Noticing Kruer’s


taminated and, as a result, the two have been unable to attempt to conceive a child, despite their strong desire to start a family. “But it’s gross,” she said of the


toilet she’d just touched. “It is gross,” agreed Grayson, who had taken part in that exer- cise himself. “You might even get sick, although you’re actually more likely to die in a car crash.” The two kept talking, and


something apparently persuad- ed Kruer to continue. The next morning, she attended a work- shop in which both she and her husband ate breath mints off the floor and chewed “ABC” gum, Grayson’s term for “Already Been Chewed.” (When people are disturbed by that last image —and who wouldn’t be? — Gray- son tells them to consider the people they’ve French-kissed. He insists there’s no difference.) Going to such extremes, Gray- son explained, is a way to make them confront their disorder rather than run from it or en- gage in useless rituals. By lunch, Kruer seemed like a


distress,


Grayson approached her after dismissing the rest of the group. He asked about her dreams for the future, then told her that OCD was interfering with these goals. “You’re putting your fears in front of everything you want in life,” he said. Kruer nodded and confessed


that, since September, she’d con- sidered her husband to be con-


different person: emboldened, hopeful and more connected to her husband, who she now be- lieved understood her disorder. “I was just sort of here at the conference, taking it all in, until Friday night and the Virtual Camping,” Kruer said. “Now I feel like I want to move forward. I want to reconnect with my husband and my friends and everyone that I couldn’t fit into my old routines and my house- bound life.


“I want to be a mom.” health-science@washpost.com


Scarton, a freelance writer, lives in the District.


PHOTOS BY XIAOMEI CHEN/THE WASHINGTON POST Kathleen Rupertus, right, helps Kate Leis get through the task of touching a toilet, then eating a Tic Tac before washing her hands.


Why physicians hate to admit their errors, even to themselves


by Danielle Ofri Precisely two weeks after com-


PHOTOS FROM BIGSTOCK; WASHINGTON POST PHOTO ILLUSTRATION


pleting my medical internship, I proceeded to nearly kill a patient. July marked the start of my sec- ond year of residency at New York City’s Bellevue Hospital, and it was my first time being ful- ly in charge of a patient. He ar- rived in fully developed diabetic ketoacidosis (DKA), a life-threat- ening condition in which lack of insulin causes a metabolic cata- clysm. It was a classic Bellevue DKA patient story: arrested dur- ing a small-time drug deal, tossed into a holding cell, unable to access insulin. The patient sat in the cell as his sugar soared to stratospheric levels. When he be- gan to vomit and his speech slurred, the police brought him to our emergency room. While a new intern looked to me for guidance — me with a scant single year more experi- ence — I placed the patient on an intravenous insulin drip. DKA is one of those rare, grat- ifying conditions in which a pa- tient arrives in extremis and,


with deft handling of insulin, can be readily “cured.” I felt a surge of pride as we watched over the course of eight hours as our pa- tient gained consciousness, got cranky, demanded double por- tions of food. We were in a cramped, dingy corner of the ER, stuffed next to a narrow desk, while paramedics wheeled in survivors of motor ve- hicle crashes and patients with shotgun wounds. After our DKA patient’s glu-


cose returned to normal, I hand- ed a triumphant “d/c insulin drip” order to discontinue the in- travenous insulin. I was officially declaring our patient cured. The nurse took the order from me. “Do you want to give an in- jection of long-acting insulin be- fore stopping the insulin drip?” she asked, as a clerk pressed two more charts in her direction. I thought for a moment. Why would I want to use the sledge- hammer of long-acting insulin after eight hours of our meticu- lous adjustments with the in- sulin drip? “No,” I said, turning to my intern, capitalizing on the teaching moment. “If we push


him overboard with long-acting insulin, it’ll be stuck in his sys- tem for hours, and his sugar could bottom out. Let’s just keep checking his glucose hourly and give him short-acting insulin as needed.” The nurse raised her eyebrows


ever so slightly, then shrugged and went back to her work. My logic was obvious. It was also wrong. Right-out-of-the- textbook wrong. The very thing you are supposed to do in DKA is administer long-acting insulin just before stopping the insulin drip. Otherwise a patient will turn right around and plunge back into DKA.


When blood tests revealed


dangerously rising levels of po- tassium and acid in my patient, I panicked and paged the senior medical resident for help.


‘What were you thinking?’


My intern and I stood nervous- ly while the senior resident scru- tinized the numbers. She shot me a withering look. “Didn’t you give him long-acting insulin before you turned off the insulin drip?” she demanded. “A little longer


like this and he’ll be comatose! Next thing you know we’ll be calling a code for his cardiac ar- rest.” I tried to describe how logic would dictate — wouldn’t it? — that we shouldn’t muck up a ten- uous situation with long-acting medications, that we wouldn’t want to harm the patient by pushing his sugar too low, that we . . . . My words began to run up against one another, progres- sively garbling under the weight of her granite stare. “What were you thinking?” the senior resident asked, her voice now like a drill sergeant’s. I stood there stone still as my


brain cells slowly dissolved into muck. “What were you thinking?” she


repeated, her voice thundering through the ER. What had I been thinking?


Had I simply forgotten the part about the long-acting insulin? Had I misread the textbook? Was I simply not smart enough to be a doctor? In the presence of my intern the humiliation was unbearable. The senior resident wrenched


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