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AIS's Health Business Daily
Featured Story May 8, 2008 National Physician-Rating Systems and High-Performance Networks Face Major HurdlesReprinted from HEALTH PLAN WEEK, the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans. By Steve Davis, Managing Editor, (sdavis@aispub.com) Health plans have long argued that physician-ranking systems and high-performance networks (HPNs) help ensure quality, improve outcomes and reduce costs. Providers, however, contend that such strategies are used merely to trim costs and improve the bottom line for health plans. On April 1, a group of unlikely allies — health plans, providers, labor organizations and business groups — set their differences aside and announced support for an initiative that could lay the groundwork for a national standardized physician-rating program. Such voluntary guidelines, supporters say, would improve the accuracy and fairness of physician ratings. While industry observers applauded the move, they agree that myriad challenges still must be overcome. The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs would create "a national set of principles to guide measuring and reporting to consumers about their doctors' performance," according to a prepared statement from the Consumer-Purchaser Disclosure Project, which is spearheading the effort. The project has financial backing from the Robert Wood Johnson Foundation. The strategy has been endorsed by several major health plans, including CIGNA Corp., Aetna Inc. and UnitedHealth Group, as well as by groups such as the AFL-CIO, National Business Coalition on Health, American Medical Association and industry trade group America's Health Insurance Plans. If consumers were to get care from the top one-third of best-performing hospitals, there would be a 40% reduction in mortality rates, a 35% decrease in complications and a 45% drop in total medical costs, says Jeff Kang, M.D., chief medical officer at CIGNA Corp. On the physician side, if consumers saw only the top one-third best-performing specialists, total medical costs would decrease by 8% to 12% and clinical measures would improve by between 4% and 6%, he says. In October, 2007, CIGNA said it would add measures to the provider-ranking criteria used in its New York physician quality program under an agreement with New York Attorney General (AG) Andrew Cuomo (D). Last summer, Cuomo's office requested information about provider-ranking systems used by several health plans that operate in the state, including CIGNA, UnitedHealth Group, Aetna and WellPoint, Inc. unit Empire Blue Cross Blue Shield. Rating systems used by the insurers, the AG contended, were used to drive patients to the least expensive providers. Health Plans Must Merge Claims Data The Patient Charter provides a framework that will "help provide nationally consistent reporting for health plans, yet recognizes the local nature of health care delivery by offering enough flexibility to provide information to our members that is meaningful," says Aetna spokesperson Karin Rush-Monroe. Achieving nationally consistent data will be difficult. A single insurer typically doesn't have enough claims data to accurately rate a physician, providers contend. For the initiative to be effective, data from all insurers and the federal government would need to be combined to achieve valid ratings. Claims data typically have a "life" of about three years. And those data represent a small subset of a physician's practice, says Geof Baker, CEO of Med-Vantage, Inc., a health informatics company that helps develop pay-for-performance programs, HPNs and transparency initiatives. He explains that those data would be far more useful if claims from all health plans and the government were aggregated. The model also should require health plans to conduct "detailed chart reviews" to verify accuracy of provider ratings. The quality of claims data can vary widely from health plan to health plan and could be incomplete, adds Jim Frankfort, M.D., vice president of performance management at Med-Vantage. Medical claims, he explains, were designed for determining payments and not for rating physicians with outcomes metrics. How a physician scores on a measure may have as much to do with the source of the data as it does with how they practice, Baker says. "Different interpretations of an ICD-9 code could affect a physician's rating from one health plan to the next," he says. This could mean that the same physician could receive both a "good" and a "bad" rating by two different insurers (or by a single insurer in consecutive years), says Burton Rubin, M.D., president of the Fairfield County Medical Association in Connecticut. Last summer, the association and nine physicians filed suit against CIGNA and UnitedHealth Group, alleging defamation resulting from their ranking programs. Baker says it will be difficult to overcome problems tied to claims data until paper claims are replaced with electronic medical records (EMRs). Along with aggregated claims data, the provider-ranking system also would need regular "validity checks" of the data that would be conducted by a third-party organization, Baker says. He adds that physicians will be dubious of any physician ratings data that come directly from a health plan. Aetna agrees and says the biggest weakness in performance-ratings systems is the lack of externally validated clinical quality measures. To remedy that, the insurer says it tries to partner with "external organizations committed to quality measurement and improvement." The Patient Charter advocates a method for physicians to challenge their ratings. Aetna says it recently implemented a more formal process for reconsideration about rankings based on clinical performance. "The Patient Charter requires that efficiency also be included, so we are adding an efficiency component to our appeals policy," the insurer says. However, Rubin contends that such a process could be an "overwhelming burden to individual physicians…even if they are provided with raw data by each of the insurers." Baker agrees and says physicians need sufficient time to evaluate results and correct errors. He adds that health plans will likely need to offer financial incentives to physicians to ensure their participation. "This won't be a free ride for the payers," Baker says. For more information
about the Patient Charter, visit http://healthcaredisclosure.org/docs/files/
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