Family doctors turn the tables, grade insurers

Health plans are known for grading physicians on any number of measures. Now the American Academy of Family Physicians is joining a small number of physician organizations giving its members a chance to tell health plans what they think of them.

The academy is launching an online survey that asks members to grade plans on their payment rates, claims processing, formularies and other factors, with results scheduled to be published in the April 2007 AAFP publication Family Practice Management.

"There's not a lot for our family physicians to access when it comes to how a health plan is doing when it comes to timely payments," said Trevor Stone, AAFP's private sector advocacy manager.

"It allows physicians to get a better picture of how the health plans stack," he said. "When it comes time to negotiate, our members wanted to have some sort of way to measure how the health plan is doing with respect to other health plans."

Stone says there is another motivation to the survey -- giving physicians a chance to turn the tables on health plans that are increasingly using claims data and other means as a way to rate physicians for pay-for-performance or tiered network plans.

While the survey is only open to AAFP members, Stone said its results are applicable to other specialties because it spends time focusing on generalizations about physicians' interactions with health plans. For instance, the survey asks physicians to submit comments about plans and to identify which payer they would contract with if they could pick just one.

Physicians can choose up to 10 plans to grade, including Medicare, in the state or states identified by the participating physician. Physicians are asked to grade on a scale of A for excellent to F for failing in 11 different categories including prior authorizations, appeals processes and adherence to current procedural terminology in claims processing.

Stone said results will be shared with insurers once the survey is complete and will help bolster AAFP's advocacy positions on behalf of its members. The AAFP hopes to attract about 1,500 of its 57,000 members to participate in the survey.

Other medical societies have also done health plan report cards. The American Medical Association has provided medical societies with a template that includes questions about customer service, credentialing and health plans' appeals processes. The AMA conducted its own survey in 1994.

The Greater Albuquerque Medical Assn. in New Mexico conducted surveys in 2002 and 2005.

Daniel Derksen, MD, professor and vice chair of Family and Community Medicine at the University of New Mexico, said in the first survey in 2002, most payers failed to reach an average score of 3 on a 5-point scale. 'This isn't the kind of report card you want your kids to come home with," he said.

Dr. Derksen said when the results were shared with health plan medical directors the responses were mostly positive. He said one plan removed one of its prior approval policies because it was found to be prohibitive to physicians.

When the association completed its second survey there was some improvement, though Dr. Derksen said plans still scored mostly in the lower grade ranges.

In 2000, the North Carolina Medical Society spent nearly $100,000 to conduct a survey in partnership with North Carolina State University. Carol Scheele, NCMS associate general counsel, said the health plans' internal studies didn't capture the essence of what physicians were complaining about to the medical society. Scheele said she doesn't think the board will pay to conduct another formal survey. However, the society annually polls physicians via e-mail.

"It has certainly increased our depth of knowledge about what people think of health plans," she said.

It's not just medical societies that are ranking health plans. Earlier this year, Athenahealth, a Watertown, Mass.-based claims processing company, developed what it calls the PayerView ranking system, which can be viewed online (link). The system ranks plans using claims data it gathers based on seven categories, including days in accounts receivable, denial rates and first-pass pay rates. Some health plans criticized the methods as flawed because the number of claims Athenahealth used wasn't sufficient to get an accurate tally.

America's Health Insurance Plans spokesman Mohit Ghose said he plans to reach out to AAFP staff before and after results of the study are published to see how the organization can help better interact with physicians. "Whenever we can have a more collaborative environment, that will be a good thing for providers and payers, but most importantly, patients," Ghose said.