Coping with rankings: Still time for challenges

More health plans are rating physicians, but patients aren't keeping score. Doctors still have time to pressure insurers for accurate data or none at all.

By Jonathan G. Bethely — Posted June 18, 2007

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Whether physicians like them or not -- and generally, the answer is not -- efforts by health plans, private companies and others to rate doctors based on quality are not likely to go away.

And efforts to make bottom-line decisions based on those ratings appear to be here to stay, too, as some insurers use ratings in part to decide whether a physician is allowed into a "preferred" network, or as the basis for a pay-for-performance plan.

In the eyes of many physicians, ratings often are based on inaccurate or unreliable information, such as data pulled straight from claims. They see the scores as being based on criteria that appear to be focused more on saving money than treating patients. So what are physicians supposed to do when they see themselves rated, and the information is opened to the public? Ratings have been "one of the most gut-wrenching issues for our members since tort reform," said Teresa Devine, director of health care financing for the Texas Medical Assn.

Some physicians and experts say the first thing to do is to take a deep breath and realize there is time to challenge rankings and otherwise deal with them before patients trust them. Most surveys show that very few patients -- often, fewer than 1% -- choose a doctor based on outside ratings.

"The strongest line to physician choice is the relationship," said David Knowlton, president of the New Jersey Healthcare Quality Institute, a coalition of businesses, unions, health plans, and hospital and physician organizations, including the Medical Society of New Jersey. "So that's the strongest tie, and that's good news to doctors because it gives them time."

But that time has to be used in coming up with an effective strategy and response to ratings, experts say. For instance, Knowlton's New Jersey institute has a link on its Web page to physician, hospital, home health and nursing home ratings for New Jersey, New York and Pennsylvania.

The basis of that strategy -- speak up. Demand to see plans' methodology for ratings. Challenge any misinformation that has been used in compiling your ranking. Tell a medical association what's going on, so it can work on your behalf. Also, lead a group effort to ensure that ratings are based on sound information -- information that is made transparent to physicians.

These strategies have had success in at least forcing plans to scale back or rethink ratings. For example, physician outrage in Texas and a push by the Texas Medical Assn. led BlueCross BlueShield of Texas to postpone a ratings plan called BlueCompare that would have used claims data to rate physicians on quality and affordability, and make those ratings publicly available.

Among the concessions Texas physicians received: the right to get individual information about themselves from the claims data used for their rankings, the right to review and respond to those ratings, and the right to opt out of being listed publicly. The association also appointed a 30-member committee to review the performance measures for what it calls "their scientific basis, clinical appropriateness, and potential for cost reduction." The Blues will use the findings to recommend which measures to alter or eliminate.

Pressure from payers

Demand is up for publicly available performance measures for physicians because, experts say, corporations buying health insurance are demanding them more and more. Michael E. Speer, MD, a neonatologist at the Baylor College of Medicine in Houston and a TMA trustee, said in meeting with the Blues that he got the sense the plan is feeling a "horrendous push" to come up with such measures, and that it wanted to throw ratings out as quickly as possible "to satisfy what their employers wish to see."

Dr. Speer said doctors don't mind being measured -- "if you measure us accurately."

"Physicians should embrace [ratings] because we should be trying to do whatever we can to improve outcomes and our individual performance," said Richard Gilbert, MD, an anesthesiologist with Southeast Anesthesiology Consultants in Charlotte, N.C. But using the wrong data to do so won't get doctors to embrace ratings, he said. "Physicians will change their behavior, but they've got to believe the data."

The AMA-led Physician Consortium for Performance Improvement, a group of more than 100 national and state medical societies as well as the Centers for Medicare & Medicaid Services and others, has created 184 measures it believes are accurate evidence-based clinical performance measures and outcomes reporting tools. But in most cases, plans have yet to adopt them, instead grabbing information from claims data.

Based on how data are crunched, information from similar sources can produce two different quality ratings for a physician. So experts advise physicians to check on their ratings to examine the methodology behind them.

Physicians might not feel they have the time to do this, "but they really need to if they want to protect themselves," said Mary Jo Malone, CEO of the Physician Advocacy Institute, an organization formed out of the settlements related to federal court cases fighting health plans' payment strategies. "They can ask for meetings with health plans. They should ask for patient lists that were used to determine the ratings. Physicians need to understand their patients' data better than the health plans do. This will be worth it in the long run."

Malone said a few plans have been cooperative in sharing methodology. Physicians should get as much information about it as they can, said Elaine Kirshenbaum, vice president of policy, planning and membership with the Massachusetts Medical Society.

"You really should be asking for drill-down information," Kirshenbaum said. "The more you ask and demand, the more you'll get."

But sometimes that's not the case. Alan Beason, CEO and administrator for Cardiovascular Consultants, an 11-physician group in Shreveport, La., said the plans with ratings systems involving his practice have not been keen on sharing every detail. Instead, his practice has pored over the data in ratings reports. Some data have been helpful in alerting the practice to services it failed to document, legitimate fixes it could control, and things the health plan rated that the practice could do nothing about.

"This is a rather new concept," he said. "There's more questions than answers. There's no relief in sight. We're trying to position ourselves for the future. From our perspective, we may not like it, but we've got to play by the game as the rules change."

Bringing in help

If the ratings game is upsetting you, experts say one no-no is getting your patients involved. Ratings or no ratings, you already have the advantage of personal relationships with them. Trying to explain why the rating is wrong isn't going to help.

Your explanation could be the first time patients might become aware of your rating. According to recent Harris Interactive polling, fewer than 1% of patients use ratings as a basis for selecting a doctor. Most still rely on word of mouth from friends or relatives.

Physicians should "use their diagnostic skills to look at the problem," Knowlton said. For example, many ratings dings come because doctors haven't documented treatment or services they have performed. But they should not "fire an angry letter to their patients. The reason for that is from a public relations standpoint, it gives credibility to the problem. ... In a certain sense, they have a right [to complain to patients], but you're hurting yourself to knee-jerk."

If you're not getting any help from the health plan, experts say, you're better off to contact your medical society. The AMA and state medical societies track complaints about health plans, including those regarding ratings.

Organized medicine has had some success in beating back or forcing revisions in ratings systems. Along with the TMA's successful fight to get its state's Blues plan to alter its system, the AMA and state and local medical societies in Missouri applied pressure to get United HealthGroup to back off its original plan to rate doctors in that state and to put higher-rated doctors in a "preferred network."

Also, less than a week after the American Medical Association/State Medical Societies Litigation Center joined the Washington State Medical Assn. in its lawsuit to stop Regence BlueShield from implementing its Select Network, in December 2006 that plan dropped the ratings-based network.

"Whatever is measured needs to be for the patient's benefit," the TMA's Dr. Speer said. "Whenever someone comes up with a measure, if it doesn't benefit the patient, it's a waste of time."

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A chance to respond

Current AMA policy on physician access and comment regarding outside ratings:

  • Physicians must have the ability to review and comment on data and analysis used to construct any performance ratings before the use of such ratings to determine physician payment or for public reporting.
  • Physicians must be able to see preliminary ratings and be given the opportunity to adjust practice patterns over a reasonable period of time to meet quality objectives more closely.
  • Before release of any physician ratings, programs must have a mechanism for physicians to see and appeal their ratings in writing. If requested by the physician, physician comments must be included adjacent to any ratings.

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Measuring performance

The AMA-convened Physician Consortium for Performance Improvement has been working to come up with evidence-based clinical performance measures and outcomes reporting tools for physicians. The goal is to have organizations use these data, rather than claims data or similar information, as a means to enhance quality patient care and create "effective and relevant clinical improvement activities." So far, the consortium has come up with 184 performance improvement measures, including:

Complete clinical and technical specifications

Adult influenza immunization *
Chronic stable coronary artery disease
Colorectal cancer screening *
Heart failure
Major depressive disorder
Preventive care and screening (5 measurement sets)
Problem drinking *
Screening mammography *
Tobacco use *

Measures "mini-sets"

Adult diabetes
Chronic obstructive pulmonary disease
Prenatal testing

Measures worksheets

Acute otitis externa/otitis media with effusion
Emergency medicine
End-stage renal disease
Eye care
Gastroesophageal reflux disease
Hepatitis C
Perioperative care
Stroke and stroke rehabilitation

Note: * Indicates performance measures included in the Preventive Care and Screening measures collection.

Source: AMA-convened Physician Consortium for Performance Improvement

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