Doctors are openly criticizing growing efforts by health plans and health insurers to direct patients toward certain physicians based on perceived cost or quality, arguing that the rankings may be unreliable and unfair. In response to new evidence that patients are receiving inaccurate physician profiles from health insurers, the American Medical Association (AMA) delivered letters today to the nation’s largest health insurance companies asking for immediate action to improve the accuracy, reliability and transparency of physician ratings.
The AMA sent letters to 45 health insurance companies nationwide asking them to verify that their physician rating programs are accurate by allowing outside experts to analyze them. Forty-seven (47) state medical societies also signed the letters. The AMA is concerned that health plans are not providing customers with accurate information when they rate physicians based on cost and quality. Physician ratings have grown in popularity as insurers seek to provide more information to members and employers to evaluate the quality and cost of services. The AMA cites a March study by the RAND Corp. published in the New England Journal of Medicine that indicated physician ratings by health insurers can be wrong up to two-thirds of the time for some groups of physicians. In that study the final conclusion was that current methods for profiling physicians with respect to costs of services may produce misleading results.
Patients should always be able to trust that insurers are providing accurate and reliable information on physicians,” said AMA President Cecil Wilson in a statement. Robert Zirkelbach, spokesman for America’s Health Insurance Plans said that insurers are working closely with providers to develop these measures. “This is an ongoing process that is continually improving.” That comment however, begs the question of just who is it that is making up the measures? Who has input? Are physicians and others involved in an open process, or is this a closed door endeavor. Health plans after all, are funding agents, taking in premiums and making payment for services. They keep the margin – which goes up if doctors have fewer visits, order less tests and do fewer procedures. So, is ” quality” really being measured by most health insurers, or in the end, is it overall cost to the health insurer that rules the day?
Having said all that, we know that the primary rating measure for insurer is cost – read, what they have pay out to providers (doctors, hospitals, labs, etc.). Yes, they look at other things such as certification, specialization, office hours, convenience for patients, locations and the like. But in the end, they look and profile based on visits, tests and procedures. Health plans quantify these measures via the CPT coding system and they then look at overall costs. In the end, the most “cost efficient” doctors (read cheapest), are for the most part who are found on select panels. This process reached a peak with the failed HMO craze of the 80’s and early 90’s. More and more, open panels have become the norm. However, in light of a likely squeeze on health insurance profits, health plans are looking to resurrect many of these programs to limit physician panels and therefore limit access of their subscribers. The end result will be to reduce costs – as well as increase health plan profits.
Measurement of physician and surgeon “quality” in the end, is exceedingly difficult, beyond the most obvious of measures such as overall mortality and morbidity associated with interventions performed by an individual physician. We applaud the AMA and other medical societies for publicly calling out health plans and health insurers. They should and MUST make their profiling measures public so that they can be independently reviewed for accuracy, veracity and reliability. Also, physicians need to know what they are being judged on by these payers, and patients must have confidence that these ratings and rankings are of some real value . . . jomaxx and obi jo
AMA and State Medical Societies Call on Insurers to Publicly Document the Accuracy of Physician Cost Profiling – http://www.ama-assn.org/ama/pub/news/news/physician-cost-profiling.shtml
AMA presses insurers on doc-rating programs – http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100719/NEWS/307199967
Doctors Slam Insurers Over Their Rankings – http://online.wsj.com/article/SB10001424052748704720004575377523886401684.html
Physician Cost Profiling — Reliability and Risk of Misclassification – http://content.nejm.org/cgi/content/short/362/11/1014
AMA wants Humana, others to consider quality more in ranking doctors – http://www.courier-journal.com/article/20100719/BUSINESS/7190349/1003/rss03
AMA battles insurers over doctor ratings – http://www.startribune.com/lifestyle/health/98797709.html?elr=KArksD:aDyaEP:kD:aUt:aDyaEP:kD:aUiD3aPc:_Yyc:aU7DYaGEP7vDEh7P:DiUs
Medical Groups Criticize Insurers on Rating Doctors – http://prescriptions.blogs.nytimes.com/2010/07/19/medical-groups-criticize-insurers-on-rating-doctors/
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