Health Care Reform Is on the Way: Do We Want To Compete on Quality?

Conversations about health care reform, even those involving physicians, usually focus on cost and access: Should there be a single-payer system? How will managed competition save money? Should patients pay a large deductible or have co-insurance? Will dental and mental care be part of the basic benefit plan? It is strange that these conversations ignore how clinical practice should be altered.

In this issue of Annals [1], Topol and Califf endorse a fundamental clinical change involving the release of physician-specific information about performance. In particular, do the patients of physician A do better, after controlling for sickness, than those of physician B? Although proposals for public release of information at a physician-specific level are not new [2-6], this article is important because it comes from physicians in cardiology departments of two prestigious institutions and because it is about releasing information on the outcome of cardiovascular procedures. Until now, calls for public release of information about physician performance have usually emanated from business, government, or physicians who would like to see physicians in other specialties release their data. Does this article represent a paradigm shift? Does it represent the realization that the future U.S. health care system will involve competition about quality at a physician-specific level? If so, what are the likely consequences?

Let us consider two different worlds. World 1 represents the present system in which physician-specific performance data are not released, and world 2 represents the release of such data. In world 1, as cost containment occurs, the …