Some physicians and physician groups are quite upset about insurers’ recent moves to offer employer customers tight, small networks of providers based on quality and cost criteria. In an effort to block these new plans, the AMA and other groups are focusing on the few problems with ratings and avoiding the larger issue – some physicians are just bad actors.
What they should be doing is working closely with health plans and regulators to ensure the rating process is transparent, fair, and objective.
Insurers, governmental agencies, employers, coalitions, organized labor, all have been involved in assessing provider performance, many for years. CMS has launched several initiatives including measures for nursing homes, hospitals, and more recently, a nascent physician quality reporting program.
In the private sector, a Mercer survey [purchase required] indicates 14% of large employers were using such “high-performance” health-provider networks in 2009, an increase from 12% in 2008.
According to the AMA, “Physicians’ reputations are being unfairly tarnished using unscientific methodologies and calculations.” The complaint appears to be based in part on concern that individual physician ratings may be derived from too few data points and some physicians may treat more severe or complex cases, and therefore their ratings will suffer – unfairly.
Health plans responding to the concerns contend they have dealt with the issue by rating physician groups instead of individual physicians.
The AMA’s contention has some validity, just as the health plans’ responses should be taken seriously.
The larger point is simple – networks based in large part on provider ratings are absolutely, inevitably the wave of the future. Some provider organizations, including the Minnesota Medical Association, have already bought into the trend, are engaging with payers, and helping to improve the assessment process.
The attempt by some ‘provider advocacy’ (my term) organizations to stop or hinder this is misguided and eventually counterproductive. Throughout history, guilds and labor organizations have tried to protect all members, including members they should censure, in an effort to keep control of their industry. Eventually, these efforts all fail.
What does this mean for you?
Providers would be well served to focus on substantive issues in provider rating systems, and realize protecting the bad actors hurts all providers and helps none.
Jul
20
Quite right, Joe; rated physician networks are coming, and faster than we thinks. Humana, Aetna and UnitedHealth already have these for self-insured customers in many markets, and I’m sure other carriers do too.
It’s amazing to me that the guild mentality remains among these supposed grown-ups. By the time they were in their teens, my kids already understood the idea that if there’s a conflict among them, they solve it themselves, or it will be solved for them and they won’t like the outcome.
One of the problems with provider rankings, report cards and other means of selecting “good doctors” is the lack of data available to gauge performance. Unless you’re one of the big insurance carriers, many don’t have access to the data necessary to create a system of rating providers.
What seems crazy to me, especially in the comp. environment, is that you have states mandating TPAs, Carriers and Self Insureds report comp data to the state. Moreover, those who do not comply are subject to huge penalties and fines. And what does the state do with all this data? They develop fee schedules and guidelines right? No. Instead they rely on Medicare to help write their fee schedules and guidelines, while all of the data is then used for god knows what or turned over to “research” groups in the state to run studies on.
But at least those TPAs, Self Insured and smaller carriers can access the data since they helped contribute to it, right? Unfortunately the answer is No…unless of course your name is RAND, WCIRB, CWCI or the like.
You are right on. As the Executive Director of a chiropractic ppo network we have been warning our doctors this is coming and to be prepared to perform well or be left out of contracts.
Unless they use a valid and reliable measure to adjust for disabled patients, it would appear that this practice is a violation of the ADA.
As usual, Joe is on top of the issues — and this is a critical one, of course.
I’ve posted my own short response to this item in my own blog, including a one-question survey on what it will take to make ratings systems work:
http://nexthospitalmanifesto.wordpress.com/2010/07/21/health-plan-doctor-ratings-will-they-ever-be-fair/
As you’ll see, my take is that insurers face too much of a conflict of interest to institute a fair, uniform ratings system. Anyone got a vote on who should create the system if the insurers bowed out of the role?
Anne, I would agree however EVERYONE has a conflict of interest in this type of reporting…whether it be RAND, CWCC or any other not-for-profit group, they still have not yet demonstrated a willingness to take on such a venture despite having the data to do so. My guess is a fear of lawsuit is behind why it has not yet been done.
Unfortunately after 7+ years in the Work Comp industry it seems to me that the problems within the WC system will never be solved because there is more money in the various “solutions” than there is a single solution. In fact, the pie hasn’t necessarily gotten any smaller or larger but the hands taking a piece of the pie continue to grow year after year.