An App I'd Never Heard of Told My Patient I Was a Good Surgeon

I recently saw a patient in my clinic who told me she made an appointment with me because I was a highly rated surgeon—at least according to her Garner app. 

I had never heard of Garner.

So I looked into it. I discovered that a private company had been analyzing my performance without my knowledge, comparing me with other surgeons and steering patients my way. Naturally, I was happy to learn that Garner considered me a good surgeon. But I was curious about how it decided which doctors were good.

Garner Health is part of a growing industry that helps patients navigate the healthcare system. Companies such as Included Health, Quantum Health, and Transcarent help patients navigate benefits, coordinate care, obtain second opinions, and find providers. Others, such as Carrum Health, direct patients to designated centers of excellence for major procedures. Consumer-facing platforms such as Healthgrades and Zocdoc also help patients choose doctors by using factors such as patient reviews, credentials, and convenience.

Self-insured employers purchase Garner's service and offer it to their workers as a benefit. But rather than relying primarily on patient reviews, reputation, or hospital prestige, Garner analyzes vast amounts of insurance claims data to identify individual doctors who achieve better outcomes at lower overall costs.

Garner says its database includes more than 60 billion de-identified claims involving roughly 320 million patients and that it evaluates doctors using more than 550 metrics across over 80 specialties. It then designates high-scoring doctors as "Top Providers." Garner also uses AI to review medical research and help keep the clinical measures it uses to evaluate doctors up to date.

Employers give their workers a reason to pay attention to those recommendations. Depending on the employer's plan, patients who choose a Garner-recommended doctor may get reimbursed for some or all of their copays, coinsurance, or deductible expenses.

The incentives are straightforward. Patients receive information about physician performance and can save money by acting on it. Employers hope that steering workers toward doctors who achieve better outcomes will reduce their healthcare costs. Doctors whom Garner rates highly may attract more patients.

Garner appears to have found a market for that proposition. The company raised $100 million in May at a $2.74 billion valuation and said it now serves more than 2.5 million people.

But measuring an individual doctor's quality is notoriously difficult, and as a surgeon, I can readily see some of the problems.

Insurance claims were designed primarily for billing, not for evaluating clinical performance. They can tell an analyst a great deal about what happened to a patient, but they don't necessarily capture disease severity, anatomy, functional status, operative complexity, or other clinical details that influence outcomes.

Risk adjustment creates another problem. Imagine that out of two surgeons, one routinely accepts frail 85-year-olds, difficult reoperations, and complicated referrals that other surgeons decline. The other operates mainly on relatively healthy patients with straightforward problems. Even an elaborate statistical model might struggle to determine whether differences in their outcomes reflect differences in surgical skill or in the patients they were willing to treat.

That matters because physician report cards can create perverse incentives. If doctors know that poor outcomes will hurt their rankings, some may become reluctant to treat the very patients most likely to experience them.

Garner says it addresses this problem by adjusting outcomes for patients' comorbidities and demographics and by excluding unusually complex cases when it cannot reliably adjust for their risk. Whether any algorithm can fully account for the patients whom doctors actually choose to treat is another question.

To a physician, it's slightly unsettling to discover that an algorithm you didn't know existed has been grading you. Physicians can't simply log on to Garner to see their individual scores or learn exactly how the company arrived at them. 

Still, compare Garner's admittedly imperfect approach with the traditional ways patients choose doctors: word of mouth, a friend's recommendation, hospital reputation, an online review from someone angry about spending 45 minutes in the waiting room, or a photograph on a billboard.

None of those methods includes reliable risk adjustment either.

That's what makes Garner interesting. It aims to reduce one of healthcare's most persistent information asymmetries: Patients usually know far less than providers about the quality of the care they're buying.

Garner doesn't have to devise a perfect method for identifying good doctors to provide useful information. And nobody has to decree that Garner's method is the correct one.

Employers voluntarily pay for the service because they believe better information can lower their healthcare costs. They decide whether to follow its recommendations. Garner says these customers reduce their annual healthcare spending by an average of 12 percent. If its recommendations consistently lead patients to higher-performing doctors at lower costs, more employers have a reason to use it. If they don't, employers have a reason to look elsewhere.

Competitors also have an incentive to devise better ways to measure quality. 

I still don't know exactly why Garner thinks I'm a good surgeon. But my patient's visit introduced me to an intriguing experiment aimed at addressing one of healthcare's oldest problems: How does a patient who isn't a doctor figure out which doctor is good? 

Markets find ways to deal with imperfect information all the time. They don't need to wait for someone to invent a perfect rating system. They let people try different ways to find out what they want to know and give others an incentive to find something better. The more useful information patients have about the doctors who treat them, the better equipped they are to make their own healthcare choices. Giving patients more control over those choices strengthens their autonomy.

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