Doctors and health policy analysts at the Massachusetts General Hospital in Boston recently examined performance measures for physicians – this is the data from the surveys you fill out occasionally when your insurance company asks you to rate your doctor. They found that doctors who take care of poorer patients (as measured by annual income) generally receive poorer performance ratings. This is a somewhat counterintuitive finding; most physicians perceive that patients with higher incomes (and generally higher corresponding educations) are more difficult to please.

This has serious implications for the future of performance measurement. Because insurers and Medicare want to link these performance measures to physician payment, anything that affect them is going to be closely analyzed by doctors, who naturally want to maximize their pay. If taking care of poorer (but insured) patients decreases doctors pay, doctors will be less likely to take care of this class of patient. On the other hand, adjusting the formula by which performance is measured to correct this specific imbalance will be politically difficult; physicians who have few of these types of patients will feel they are being penalized for their patient mix or choice of practice location.

Unanswered in all of this is the question of why these physicians get poorer ratings. All of the physicians in the study are in the same practice group; there is no mechanism by which patients can tell which doctors take care of poorer patients (so wealthier patients are not able to tell by looking at the patients around them whether their doctor is taking care of “rich” or “poor” patients, for instance). Do patients of higher socioeconomic status simply have an easier time communicating with doctors, and hence are more satisfied with their care than less-well-off people? Inquiring minds want to know (and are probably working on it even now).

This kind of data helps to craft better performance ratings, and may also help explain some aspects of health disparities. While some aspects of your health are solely under your control, knowing why people act a certain way towards health care providers can help you control those aspects better.