The bright light of practice evaluation is making more than a few physicians uncomfortable; these docs have decided that it is somehow unfair for insurers to suggest members go to specific physicians.
So, like all red-blooded Americans, the docs are suing the insurers.
While the docs in question may think they are standing up for their rights, their actions look more childish than professional from here.
The protestations concern a move by CIGNA and UnitedHealthcare to reduce copays for members seeing certain specialists. The motivation for CIGNA and UHC is clear; lower costs and hopefully better outcomes.
But the docs not on the ‘A List’ are screaming “unfair”, accusing the health plans of unfair discrimination on the basis of faulty data. The group suing the health plans claims that they are only using claims data to evaluate providers, and this somehow is unfair and biased and does not provide a complete picture.
While claims data may not provide a ‘complete picture’, it certainly provides a lot of information that can be used to evaluate certain practice patterns and the effectiveness of treatment and follow up. ‘Claims data’ typically includes patient demographics, primary and other diagnosis codes, procedure codes, and medical documents – treatment notes and reports and the like. There’s a lot of solid, useful data there that can paint a picture that if not complete is certainly a lot more than a sketch.
There are two closely related issues here – the providers’ refusal to understand that these payers are well within their rights to encourage their members to use certain docs, and the arrogance that seems to be behind the providers’ behavior.
What does this mean for you?
Remember the golden rule – s/he who has the gold rules.
Hi Joe:
With all due respect, I couldn’t disagree with you more. My research suggests that while claims data is noteworthy, formulas for quality are still far from defined enough to direct large numbers of patients based on those assumptions.
What’s more, if the evidence piles up that the plans are steering patients to physicians who charge less–as the state of NY has alleged–then I have a big problem with the practice.
I don’t know if doctors suing the plans is the appropriate remedy, but in my opinion, it’s appropriate to shine a spotlight on this practice, which to me has the hallmarks of a scheme to save money at the expense of patient care quality.
-Anne
Joe, I am running off on vacation so don’t have time for a long reply, or a post on HCR, but…
There is at least 20 years of scholarly health care literature on the problems of using claims data to measure quality.
To be very brief, the first problem is inaccuracy. The diagnostic information in claims data is notoriously noisy (because it is not collected for clinical care reasons, and often not entered by clinicians, among others). It is also lacks a time element in many cases, so you can’t tell if condition A lead to condition B, or the reverse.
Then, claims data is lacking in clinical information (symptoms, signs, test results) so it does not say much about disease severity. It also lacks information about patient health status and quality of life. (I challenge you to show me any claims data that includes “treatment notes,” as you asserted above.)
Finally, claims data does not record patient preferences.
Yet the optimal decision for a given patient ought not to be just based on whether or not they had diagnosis x, but on the severity of their disease, their general health status and quality of life, and their preferences.
Judging quality by using claims data to try to determine whether a doctor used the right test or treatment for patients with a given diagnosis is likely to lead to nonsensical, or even perverse results.
If you are interested, when I get back I could pull out a big, thick file of articles to document the above, some of which I have written.
Again, maybe a lawsuit is not the appropriate response, but the idea that insurers or the government can rate physicians’ (or hospitals’) quality using claims data is a dangerously bad idea.
I am a claims data junkie and can tell you the data I pull from huge databases of claims info can more than provide enough eveidence to select providers. I agree that when looking at a few claims, data can be misrepresented but when I am pulling data reports on 250,000+ claims I think the averages that come out can be very useful in selecting providers.
Joe:
If you think there is an outcry now. Think what would happen if doctors were required to publish their real outcomes (including patients they kill) and their real costs (including unnecessary tests they order from their own labs). All this will be necessary for patients to make informed consumer decisions. Hopefully that is the direction we are going in this country.
Of course Doctors don’t think we can make informed decisions. Or that we even should have the data to make decisions. We only need to do what the doctor tells us to do and pay what we are told to pay, regardless. This point is made by my favorite doctor joke which nurses and non-doctors love (doctors absolutely hate it).
A businessman dies unexpectedly and finds himself in line to the Pearly Gates.
He is enjoying his wait to get up near to St. Peter when a man in a white lab coat with a stethoscope around his neck runs past the line and St. Peter throws open the gates for him, he rushes right in.
The businessman finally gets up to St. Peter. St. Peter looks through his book, asks a few questions and then welcomes the businessman to heaven. The businessman makes his thanks to St. Peter but then says,
“St. Peter it bothers me a little that you make us all wait in line but when a doctor comes up you let him in immediately”.
St. Peter laughed, and replied,
“Son, that wasn’t a doctor, that was God. He just thinks he is a doctor”.
Best regards,
Charles Read
The long term history of the medical profession is one of trying to stifle competition and accountability at every turn. Most recently, the AMA is trying to ban retail clinics staffed by NP’s and PA’s, probably because it fears the competition. The Dartmouth Atlas data tells us that Medicare spends almost three times more per beneficiary in Miami than it does in Minneapolis with no difference in outcomes. More utilization does not mean better care and often causes worse outcomes. There is no reason why analysis of huge numbers of claims can not produce reasonable conclusions as to which doctors are cost-effective and which are not. The differences relate more to utilization than to charges per procedure.
Doctors drive virtually all healthcare spending, and, as a taxpayer, I’m getting tired of their arrogance. Join the real world. Accept price and quality transparency and competition where appropriate. If you don’t like the insurers’ methods for measuring quality and cost-effectiveness, engage you medical specialty societies to come up with something better that you can live with. The days of don’t dare question our medical decisions and just pay us our fee promptly are over.
While claims data isn’t perfect, or maybe even good, it is the best that exists today.
The outrage is good, but the answer isn’t a lawsuit. Docs have proprietary information that today does not get captured because they don’t put it in things like EMRs.
My challenge to my fellow physicians is: if you don’t like the metrics used coming off of claims data, provide better data, propose better metrics, and challenge the insurance companies with more relevant data.
If you create a system that consumers embrace, the markets will move with you–the providers–not the insurance companies. This has already played out in the HMO/ PPO wars.
While claims data isn’t perfect, or maybe even good, it is the best that exists today.
The outrage is good, but the answer isn’t a lawsuit. Docs have proprietary information that today does not get captured because they don’t put it in things like EMRs.
My challenge to my fellow physicians is: if you don’t like the metrics used coming off of claims data, provide better data, propose better metrics, and challenge the insurance companies with more relevant data.
If you create a system that consumers embrace, the markets will move with you–the providers–not the insurance companies. This has already played out in the HMO/ PPO wars.
Until there is one definitive rating system in health care these battles will continue to rage. Claims data says nothing about the “experience” with the physician. I am hoping that some of this clinical data is balanced by viral and social reporting on the internet. I ruffled a few feathers with my Health Leaders retail clinic article taking physicians to task for not stepping up and learning from these competitors. I don’t think there are clear answers here and will not be until we figure out a way to stop our health system from imploding on itself.
Best,
Anthony Cirillo, FACHE, ABC
Perhaps we are distracted by what insurance companies are doing. We seem to be ignoring what the medical providers have done – or, have not done – to narrow the range between top and bottom in a quality scale that would be acceptable to them.
For example. Have health care providers taken or sponsored meaningful discipline over incompetent or dishonest or impaired practitioners? (I suppose it’s possible there AREN’T any incompetent or dishonest or impaired practitioners . . . )
For example. Will medical providers address the desire of the public for more effective management of the dollars flowing into health care? (I suppose it’s possible that health care in this country is already optimal . . . )
For example. Have medical providers been in the forefront to provide evidence that the public can understand that they are providing ever more effective, safe, less expensive, and more transparent care? (I suppose it’s possible that health care in the U.S. is as effective, safe, economical and transparent as it can possibly be . . . )
Nature abhors a vacuum. If providers aren’t doing these things, someone else will try. IMO, medical providers have done far too little to manage their situation and far too much to resist others’ actions that impinge on their trade. No different from any other trade union. And in following that strategy they have opened the door to others whose actions they object to. Well, that does not arouse my sympathies.
We often read that, somehow, health care is “different” from other goods and services available in the economy. But responding to public needs by defending one’s turf is not different e.g., from other trade unions. Wouldn’t you be more comfortable if medical providers acted different – at least in regard to patient safety, accessibility, cost, and transparency? I know I would.
What do physicians do?
They see you in their offices; and, generally, schedule return visits;
Their staff will draw some blood, collect some urine and maybe perform
some minor lab tests there and/or send the rest out to an independent lab
for more extensive tests (the lab bills them and they bill you for that
amount + retail, which might be X 3);
They may decide to use the X-Ray they bought when they set up practice or
they may send you down the road for an MRI or a CT Scan which may actually
get read or perhaps just dropped into your chart;
They will write some scrips; often more than one and ask you to come back
in order to get authorization for a refill;
They may refer you to their friend, the —ologist who, conceivably may
start you on a ring-around-the referral rosy with stops at multiple
specialists each of whom have their own tests to do;
They perform outpatient procedures either in-hospital or in their own
facility;
They admit you as an inpatient to the hospital where they order more tests
and perform procedures or order procedures to be performed by others;
They write orders for Physical Therapy, Rehab, Home Health Care and
Durable Medical Equipment;
And then they want to see you again.
About the only slice of the health care industry dollar that physicians do
NOT control are ancillary services like chiropractic. All the rest is
either performed directly by them or is ordered by them.
Remember, hospital administrators cannot admit patients, only physicians
can.
Bottom line? 99% of ALL health care costs are attributable to physician
practice patterns. Some are conservative, others are not. Please do not
suggest that they are the poor, misunderstood step-children of the
industry. Without them, nothing happens. Comparing the costs of different
practice patterns (including Dartmouth’s comparison of geographic
differences) is not only appropriate; it is critical if we are to reform
health care finance.
Finally, remember that this is not about ALL physicians versus NO
physicians. It is not an either/or situation; it is a both/and situation.
It is not a matter of ALL physicians practicing inappropriately. Some
physicians practice appropriately, some do not; some do some of the time;
some (perhaps) do all of the time; some (perhaps) do none of the time.
Physicians do themselves and their patients a disservice when they react
as though any criticism was an attack on the profession.
I know a little about the UHC program. In their case, the Premium designation is based on how the mass of claims data compares to the standards of care as set forth by the AMA. They only use external measures to compare against. Also, just because a doctor is considered a premium provider, doesn’t necessarily translate into an efficient provider. They actually disclose this in their rating system. That being said, the efficiency designation can only be applied to the docs that are designated as premium per the aforementioned external metrics.
It is not the case in all specialties, but usually a provider practicing along the recommended guidelines of the AMA will have better outcomes than those who do not. Better outcomes often mean less future care and that means less claims dollars going out the door.
One last item. It is my understanding that this type of co-insurance discount for premium designation is only applied to certain plans. Clients could choose for themselves if they want a plan like this or not.
Thanks for the forum to discuss.
Doctors who provide medical care for our company only do preventive medicine. How are they rated by their claims data? We only do physical examinations and refer to a primary care doctor (or a specialist if there is an urgent issue) for follow-up. I’m concerned that due to our relatively high claim amount per patient, we will be dropped from the “A” list (or all the lists).
Gregg
Our company uses Aetna. they tell us their program does not apply for primary care, but only to practitioners in about a dozen specialties. In that case, you would not even be rated by Aetna.
I work for CIGNA and I’m aware of our developing CIGNA Care Network. I’m sure initially it will have a lot of bugs to work out but:
1) We as a nation are spending “too much” on health care (at least our appetite is greater than our ultimate ability to pay)
2) As many reports have demonstrated, we have some significant quality gaps.
Someone, somewhere has to start address cost and quality. Will it be perfect? NO Is the status quo “good enough” NO
mw
If a little bad data is bad data is bad, how can a whole lot of bad data be better?
If you want to select your physician based on metrics, then be careful which metrics you want and who collects them. The insurance industry and physicians will be doing it for money (and perhaps some pride in the latter case) and the government will be doing it for politcal reasons. Metrics from all sources should be measured and published and if you can’t collect them then that says something about you too. Practically claims data is nothing but trash, easy to manipulate, useless to direct care. But it is all most folks have to go on. Come to my web site, 100% of my appropriate patients have been conselled regarding pneumovax, Pap Smears and smoking. Less then 1% of my non-hospice patients I hospitalize die in house. Sure, I can manipulate my data, but at least I have data that can be manipulated. Once the expectation that every provider has data available then people can factor that in to their care decsion. Don’t expect too much movement though, experience teaches that selecting healthcare is more visceral than empirical
[reprise]
Nature abhors a vacuum. If providers aren’t doing these things, someone else will. IMO, medical providers have done far too little to manage their situation and far too much to resist others’ actions that impinge on their trade. No different from any other trade union. And in following that strategy they have opened the door to others whose actions they object to. Well, that does not arouse my sympathies.
As a consumer, I would like to see quality data clearly separated from cost data. Trading off quality versus cost is a tradeoff that only I should make, especially because quality in health care might be life/death issues. It would be terribly offensive to me for an insurance company to hide their cost/efficiency/profit perspectives in Quality Ratings.