Gaming the system: There’s a definite downside to publicizing procedure mortality rates of cardiac physicians. Expect to see the same thing with pay-for-performance:

“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.”