Kyruus Blog

Challenging Volume as a Proxy for Quality: Is It the Best We Have?

In late October, nearly a hundred clinicians and health executives met in Boston for our ATLAS conference to discuss – amongst other key issues in healthcare – the imperatives behind better matching between patients and providers. One of the resounding takeaways was that matching is an immensely complex problem fraught with clinical, operational, and political implications that must be carefully considered – all of which are captured in Dr. Anand’s blog post below. 

 I never used to take notice of the “Top Doctors” page in in-flight magazines, but I saw an older gentleman on a recent flight tearing out a page featuring a “top” orthopedist sports medicine doctor – a designation given by a third-party rating system.

 I sat there and started to think about what this really meant – what actually makes a “top” doctor, and what are the associated implications for healthcare providers? It goes well beyond a third-party ranking, to be sure, yet this is the most prevalent measurement system we have.

Understanding the “right” doctor for a specific case is a dynamic question that requires the ability to integrate and filter across multiple factors. If a patient needs a flu shot, the “right” provider (who may not even be a doctor) is down the street, with availability today for a small co-pay. If bypass surgery is needed, the “right” doctor is a highly trained cardiothoracic surgeon for whom the patient may be willing to wait several days and drive a great distance, with the expectation that the surgeon has performed the procedure frequently and effectively. In short, it depends.

There are numerous ratings systems for measuring physician performance, all of which take a variety of metrics into consideration. However, there has never been a definitive approach that enables hospitals and health systems to refer and patients to select the most appropriate doctor. This must change – and it is.  

The Volume Proxy

One metric that has been gaining recent traction is volume – in other words, measuring the number of cases that the orthopedic surgeon performed to gauge the quality of his or her care. Common sense – and a recent U.S. News study & World Report study – suggest there is clear correlation between the number of times a provider performs a procedure and the quality of outcomes delivered. And there have been other historical pieces indicating the same, such as several The New England Journal of Medicine studies correlating the annual number of certain types of surgeries with postoperative mortality.[1],[2],[3]

But as recently reported by ProPublica, in certain instances, relying on volume alone could be a dangerous way to pair a provider with a patient. In fact, while the comparison between volume and quality has long been explored, it has also long been challenged with some studies suggesting that higher-volume physicians can also carry higher rates of complications.

The bottom line? This isn’t a simple question to answer. I’d venture that we need an entirely new way of looking at quality, one that takes advantage of recent advances in data and analytics.

A New Quality Proxy

Instead of continuing this never-ending cycle of conflicting studies around volume and quality, it’s time to rethink the very way that we measure quality. There’s no one-size-fits all way to measure physician results; indeed, the very process of pairing a patient with a provider holds challenges due to the inherent complexity in identifying the right physician the first time.

So instead, let’s flip the model on its head. Instead of assuming that volume alone dictates quality, let’s assume that a provider’s unique ability and experience in dealing with a particular subset of patients are what lead to quality.

At first glance, this seems obvious. Patients who are matched to the wrong provider may end up being re-referred, or worse, experience poor clinical outcomes. The process itself may have deleterious effects on patient satisfaction, an area healthcare providers are being forced to measure – and are rewarded or penalized for – given its correlation with outcomes.

The challenge – and opportunity – rests in how we identify the right provider-patient match in the first place.

Health systems are uniquely equipped to improve this experience for patients since they are intimately familiar with their physician base and the associated clinical assets. And the complexity and risk inherent in this process are forcing them to take notice and start to take charge of this process.  

Best Practices for Health System Quality

As a physician working at a company that solves the complex puzzle of patient-provider matching for healthcare organizations, I wanted to share a few considerations to empower health systems to identify the right providers for their patients – in the very first interaction.

  • Recognize the complexity in the process and that no single variable – such as volume, patient rating, or practice reputation – is the answer when it comes to who the “right” provider is. Volume does matter – but not always. But myriad other factors, like insurance acceptance, availability, and location might matter more in a given circumstance.
  • Take stock of the number of patient access channels – from call centers to consumer websites – and create standard technologies, processes, and operations for matching patients to providers within each of them.
  • Accept that technology can only take you so far and invest in provider engagement. To really create a robust system of appropriate patient-provider matching, you must have cultural alignment from providers, practice managers, and organizational leadership. This is hard, boots-on-the-ground work, but the end result is worth it.
  • Leverage data to drive change management. Sharing a provider’s own performance data against his or her peers can create a much-needed dialogue that can spur real action.

Every year, nearly 20 million patients are matched to an inappropriate provider based on their clinical needs, insurance coverage, geographic location, or even their personal preferences. This translates to billions of dollars in wasted spend, delays in care, and massive frustration and demotivation for both patients and physicians. The idea of matching the right patient with the right provider at the right time has significant implications for not only patients, but also hospitals and health systems.

Provider organizations must have an ability to understand their clinical assets in a way that allows them to meet the unique demands of every individual patient – which keeps both the patient and provider happy. I see amazing things for a future of transparency around providers and patients having the power to truly identify the appropriate provider for their needs.


[1] Luft, Harold S., Bunker, John P., and Enthoven, Alain C.  “Should Operations Be Regionalized? — The Empirical Relation between Surgical Volume and Mortality.”  N Engl J Med (1979): 301:1364-1369.
[2] Birkmeyer, John D., et al. “Hospital Volume and Surgical Mortality in the United States.” N Engl J Med (2002); 346:1128-1137.
[3] Birkmeyer, John D., et al. “Surgeon Volume and Operative Mortality in the United States.”  N Engl J Med (2003); 349:2117-2127.
Topics: ATLAS Conference