View this article online: https://www.claimsjournal.com/news/national/2007/02/09/76830.htm
A less confident physician might have been humbled by the letters Dr. Mike Kelly received last year from two insurers.
Regence BlueShield and UnitedHealthcare informed Kelly that he failed to qualify for their respective designations as a high-quality doctor. Health insurers are increasingly rating doctors and often charge patients a lower copayment to see those they deem exceptional providers.
“I did doubt myself initially when I got the letters,” said Kelly, a family physician in practice outside Tacoma, Wash., who is now suing Regence over its program. “But eventually I realized I didn’t do anything wrong and I felt, ‘how dare they do this?’ I think it is all about money. They just want networks of doctors that don’t spend a lot of money.”
That’s false, insist insurers such as UnitedHealth Group Inc., Cigna Corp., Aetna Inc. and WellPoint Inc. which all either started or expanded their physician quality ranking programs this year. They said the programs are an attempt to help employers struggling with ever-rising health care costs to ensure that their money is well spent.
“We believe consumers should have information and access to all their doctors but we want to (give them incentives) to go to high-quality providers,” said Dr. Jeffrey Kang, senior vice president and chief medical officer at Cigna. Such products can lower health care costs by 3 percent to 5 percent, he said.
Cigna expanded its program, which charges lower co-payments, to 42 new markets this year, for a total of 58. Aetna rates 12 different specialties in 27 different markets, up from 6 specialties in three markets three years ago; some employers do offer lower copayments based on quality. Meanwhile, this marks the first year Wellpoint is offering employers a rating system.
Employers have expressed interest in such plans but are hesitant because of the lack of universally accepted quality measures, said Blaine Bos, a partner at Mercer Health & Benefits LLC. Last year, only 9 percent of employers with 500 or more employees had program that tiered doctors by quality, according to a study by Mercer.
Many physicians suspect insurers’ motivation and some are fighting the programs. The American Medical Association along with several doctors sued Regence BlueShield last year, claiming libel and deceptive business practices. The program has since been discarded, but the suit is continuing. Meanwhile, late last year Blue Cross and Blue Shield of Texas agreed to postpone listing doctors’ rankings on its Web site after physicians cried foul.
“We’re concerned that as insurers try to maximize profits they are saying that the doctor that charges the least amount of money is the highest quality,” said Dr. Jim Rohack, a cardiologist who is an AMA board member.
Insurers deny such accusations, noting they use a combination of cost and quality measures developed from information from medical societies and the federal government.
Doctors say part of the problem is that the measures are applied to patients’ claim data — information they say only tells half a story. Such data will display what tests or services a patient had but doesn’t disclose what a doctor ordered.
For example, an insurer may look at an older female patient’s claims data and see that she hasn’t had a mammogram — information that would reflect badly on a doctor. But that record won’t show that the patient simply refuses to get a mammogram.
Insurers concede that claims data is not perfect and that sometimes records can be incorrectly coded.
Kelly said Regence criticized him for not taking good care of diabetes patients but one-third of the patients it cited didn’t even have the disease.
“They (insurance executives) get six-figure salaries to throw bombs in our way,” said Dr. Michael Schiesser, an internist with a practice in Bellevue, Wash., who is also suing Regence.
Two years ago, he said Regence sent him a $5,000 check for his performance but last year excluded him from the high-quality network. The reward could have been the mistake, but either way it shows the programs aren’t well designed, Schiesser said.
Using physicians’ medical records would be a better vehicle but insurers say that isn’t economically feasible until they are all available electronically and employers can’t afford to wait as health care costs jump.
“The measures we have aren’t perfect but they are best that are available and they are very good,” said Dr. Jeffrey Robertson, chief medical officer at Regence Group, which includes Regence BlueShield. A spokeswoman said Regence was disappointed at the doctors’ suits, and added “this is not how you resolve problems.”
Ranking physicians is a good idea, said Stephanie Bertholf, director of benefits policy and strategy at Boeing Co., which spends $2 billion a year on health care.
Last year, when Regence set up a network of high-quality physicians for Boeing, some employees got letters saying their doctors didn’t meet quality standards and asking them to choose a new physician. Boeing received complaints from employees and doctors and the program was eventually dropped.
Boeing later introduced an Aetna plan that rates doctors without significant reaction, Bertholf said.
The key is to work with physicians so they understand the product and the rating system, said Dr. Charles M. Cutler, chief medical director-national accounts at Aetna.
Cutler said it isn’t easy to have conversations with doctors about why they need to be ranked. But he added that after the meetings, physicians understand companies’ desire to determine if they are getting a good value for their health care expenses.
Part of the problem is that there aren’t real incentives for doctors to practice cost-effective medicine, and they don’t necessarily know how much different items cost, Cutler said. For example, he said most don’t understand the major financial difference between operating in a hospital instead of a surgery center when appropriate.
Dr. Lewis Sandy, executive vice president of clinical strategies and policy at UnitedHealth, said he understands that patients are wary of getting quality scores from companies with a vested interest in the cost of the care. It’s better not to link performance to copayments, at least initially, he said. UnitedHealth was widely criticized for a pilot program two years ago which tied copayments to cost and quality.
“We’re saying let’s put it out there and let patients make their own decisions,” said Sandy.
Patients need information on physicians’ quality to make better decisions, said Steven Findlay, a health care analyst at Consumers Union.
There is a concern that doctors who treat very sick patients might be somehow penalized for spending more on care, he said. But Findlay also noted that insurers’ stance that there is a significant amount of excessive and inappropriate care is correct.
“In the next 10 to 15 years we’ll figure out a happy medium on ranking,” said Findlay. “The data (now) has to be taken with a grain of salt. But we’d still rather have the data.”