Choosing the Right Doctor or Hospital: What to Consider
Phil Denniston, President, DDI
You want a good outcome for your member or claimant, and a fair price. How do you help them find the right doctor? And what does it mean, to be the “right” doctor? Outside of major treatment failures, like hospital readmissions and mortality, the healthcare system has little information on positive outcomes, specifically: Was the patient able to achieve a successful result
Quality
To best determine health outcomes (quality), we must examine and measure three main factors – Experience, Complication Rates, and Overtreatment-
(1) Experience. For every procedure, experience is the primary predictor of successful outcomes. The more times a doctor has performed a procedure, the more confidence you can have it will be successful. This is true not only for surgery, but for diagnostic experience in determining the right condition and navigating effective care pathways. Experience is tied exclusively to each service. For example, not all orthopedic surgeons are good at every orthopedic procedure. If you are looking for the best knee replacement surgeon in your area, you should consider a ranking that is specific to knee replacement. Tools that offer star ratings without drilling down to individual procedures do not provide valuable insight as the rating for a doctor should be connected to the specific services that doctor is proven willing and capable of doing.
(2) Complication Rates. Adverse events, such as mortality, readmission, reoperation, infection, and more, can destroy outcomes. These are not always tracked in the medical record but, when they are, they need to be incorporated in the evaluation of quality. In choosing an open-heart surgeon for coronary bypass, fatality rates can vary from under 1% to over 5%. In choosing an ablation doctor to fix AFib (an abnormal heart rhythm), some doctors are likely to get it right the first time, whereas others may perform the same procedure five or more times on the same patient, getting reimbursed each time, without success. Whenever complication rates are available, it is critical to consider it in your search for a high-quality doctor. Risk adjustment is also important, as many of these differences can be tracked back to the underlying patient population (age, co-morbid conditions, and lifestyle choices).
(3) Overtreatment. In the US Fee-For-Service healthcare system, overtreatment – excessive or inappropriate utilization of medical services – is rampant. Evidence-based medicine from peer-reviewed medical journals should play a role in selecting medical treatment or evaluating providers: Is the treatment medically necessary and efficacious for the patient in their current condition? Well-known examples of overtreatment include lumbar fusion for nonspecific back pain, coronary stents for stable heart disease, cesarean sections prior to 39 weeks of pregnancy without clear medical necessity, and knee arthroscopy for meniscal tears and localized arthritis. Even a doctor experienced in these procedures with few complications is treating inappropriately if his or her patients aren’t carefully selected for medical appropriateness.
DDI’s Provider Ranking System™ (PRS) has rated over two million US medical providers, including doctors, hospitals, Ambulatory Surgery Centers (ASCs), and ancillary providers grounded on an evidence-based proprietary algorithm that incorporates the three criteria listed above. Each provider is rated from 1 to 5 in each category, with 5 being the best, and then an overall Composite Ranking Score is calculated, and that is translated into a letter grade from A to F. Here is an example:
100%=A+
Ranking of CRS by Medical Specialty:
Orthopedic Surgery
#1131 of 25204 – US Ranking (95.51th Percentile)
#2 of 213 – Local Ranking (Zip3 900), Los Angeles, CA (Main 1)
(99.06th Percentile)
Experience: 5/5
Overtreatment: 5/5
Complications: 5/5
A significant database of claims is required to populate these measures. DDI has accumulated this data from a variety of sources, including Medicare, Medicare Advantage, commercial healthcare claims, and workers’ compensation, to obtain sufficient data on over two million U.S. medical providers.
Cost
One would expect to pay more for higher quality, but what we learned from the Transparency in Coverage (TiC) legislation is that in US healthcare, that isn’t necessarily so. Reimbursement variability in every major network in every market is about 10-15x, with no correlation to quality. In addition, cost can also depend on whether a provider is in-network or out-of-network for the patient’s plan. Those differences are evaluated in DDI’s PRS add-on, Healthcare Pricing Guide™ (HPG).
For in-network care, TiC rules require payers to publish negotiated rates in Machine Readable Files (MRFs). They contain actual contracted amounts payers have agreed to pay for specific services to specific providers. DDI ingests and validates the MRFs, incorporating network rates into HPG, then introduces PRS quality data to surface the best providers at the best prices, allowing plan sponsors, care navigators and members to see both clinical performance and cost side-by-side, as well as combined into a single Smart Score. This turns abstract data into actionable guidance: a high-quality doctor whose rate is competitive is clearly preferable to a similarly skilled doctor who is more expensive.
Out-of-network (OON) situations require a different approach. When no contracted rate exists, HPG delivers a Median Local Commercial Reimbursement (MLCR), pronounced “Mil-Sir” as a transparent, market reference. MLCR reflects the median amount commercial payers reimburse for a given service in a geographic area. MLCR can serve as a Reference-Based Price for an RBP plan or as a Qualifying Payment Amount (QPA) under the No Surprises Act. By anchoring OON payments to MLCR, plan sponsors gain a defensible, fair, data-driven benchmark that protects members from balance billing while still directing care toward higher-quality providers. Some payers have tried Medicare multiples (~1.4x), but these are not market-based and tend to encounter resistance due to their reputation being unfairly low. That is not the case for MLCR, because they are true market-based rates, defined as prices that are agreed to between willing buyers and sellers, not imposed by government.
Together, these quality rankings and price intelligence give care navigators a complete picture. The goal is not simply to find a “good” doctor, but to identify the “right” doctor for the member’s needs who is most likely to produce a successful outcome at a fair and predictable cost.
Picking the right doctor is no longer a matter of chance, reputation, convenience, or incomplete consumer ratings. It requires systematic measurement of experience, complication rates, and evidence-based practice patterns, combined with real price information drawn from Transparency in Coverage rule and market benchmarks such as Median Local Commercial Reimbursement (MLCR). DDI’s PRS and HPG bring these elements together so that plan sponsors, care managers, and members can make informed choices. When quality and cost are evaluated together, better outcomes and lower total spending become attainable, achieving the long-awaited goals of the No Surprises Act.