Resistance builds against insurers' tiered networks

A lawsuit in Connecticut is the latest battle being waged on networks that doctors say use cost, not quality, data to rank them.

By Amy Lynn Sorrel — Posted Sept. 17, 2007

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Could someone fairly rate the quality of a restaurant based solely on the check they get at the end of the meal?

Most likely not. But some physicians say it's analogous to what health plans are doing when they crunch claims data to grade doctors' performance before placing them in a "preferred" network.

"The check has nothing to do with the meal. It's just a way to get paid," said Burton R. Rubin, MD, a family physician in Old Greenwich, Conn. "I could talk to a patient for 20 minutes about depression, and the bill is not going to reflect that. It ... doesn't give insurance companies an accurate description of the visit."

Dr. Rubin and 2,000 Fairfield County, Conn., doctors are suing UnitedHealthcare and Cigna to put a halt to what they see as flawed insurer ranking programs. The lawsuit, proposed as a class action, was filed July 26 by the Fairfield County Medical Assn. and nine individual doctors from Connecticut Family Orthopedics PC. The suit claims the networks defame physicians and deceive patients. Doctors also accuse the plans of breaching their contracts.

The physicians are not alone in their fight against so-called tiered networks, which purportedly drive patients to selected doctors as a way to curb health care costs. Battles have been waged coast to coast.

The Connecticut lawsuit is similar to one the Washington State Medical Assn. brought in September 2006 against Regence BlueShield over its "Select Network." The insurer called off the program indefinitely soon after the American Medical Association/State Medical Societies Litigation Center joined the suit in December 2006. In an August settlement, Regence agreed to involve the WSMA in developing quality measures.

Last month in New York, Attorney General Andrew M. Cuomo cautioned that Aetna's and Cigna's ranking programs could be deceptive to patients and employers, and asked the insurers to disclose their profiling methods. Cuomo's warning followed a legal threat in July against United if it proceeded with its "Premium" network that month as planned.

AMA policy opposes tiered networks that deny patients access to, or steer them toward, certain doctors primarily based on cost factors.

"Patients don't want the cheapest care, they want the best care, and there's no way on earth insurers can make that decision based on claims data," said AMA Immediate Past President William G. Plested III, MD. "We are determined to see these practices stopped." The AMA is not involved in the Connecticut lawsuit.

United is expected to roll out its program in Connecticut, New Jersey and New York by the end of the year, but it is up and running in 94 other markets across the country. Meanwhile, Cigna's Care Network went into effect in 58 areas, including Connecticut, in January.

In their lawsuit, Connecticut doctors say the plans' "elite" designations of certain doctors are based on inaccurate claims data rather than medical records. So some doctors are excluded arbitrarily, and patients get the idea that a star or other symbol means some physicians are better.

"The most important thing is this is confusing to patients," said Dr. Rubin, who also is the county medical society's president. He explained that United, for example, faulted him for not treating patients that weren't his, and for failing to treat a condition that he never diagnosed.

Norwalk, Conn., gastroenterologist Claudia B. Gruss, MD, said she had yet to see any data from Cigna and had no idea what her "status" is.

"You may never know either way unless a patient tells you," she said. "Even if you want to be part of a tiered network, you don't have much leverage," because the criteria may vary from insurer to insurer, and it's hard to know how each one uses the data to make its determinations.

But United spokesman Tyler Mason said the lawsuit is "without merit" and that the program's methodology is well-founded. It's what patients and employers want, he said.

"This is a national consumer trend," Mason said. "Employers and [patients] want and need reliable data to help make important health care decisions, especially as they are becoming responsible for paying a greater share of their health care costs."

He said the network designations rely on national, evidence-based guidelines, along with feedback from network physicians and organizations such as the National Committee for Quality Assurance.

Cigna declined to comment on the lawsuit or its network.

Transparency, doctor voices needed

With the proliferation of tiered networks unlikely to dissipate, doctors say their input is crucial.

"This lawsuit gives [insurers] the opportunity to understand how difficult it is, and they are nowhere close to being able to make quality assessments," Dr. Rubin said.

The AMA's Dr. Plested also said measuring physician quality is a "totally unsettled" area. He said the AMA has told various insurers that their methods are unfair and that it will consider litigation, if necessary.

But health plans insist that transparency and collaboration are shared goals. Mason said United delayed implementing the Premium plan to give physicians more time to review it. Meanwhile, the company is complying with New York Attorney General Cuomo's request, he said.

An official from Aetna, which was not named in the Connecticut lawsuit, also said the company is responding to Cuomo's concerns, while reaching out to doctors for feedback on their data. But Aetna's Aexcel network is here to stay, spokeswoman Cynthia B. Michener said. "[It] is an initial step at developing meaningful clinical and cost-efficiency information for our consumers and members," she said.

The Fairfield County Medical Assn. is working with Aetna to improve the insurer's program, said Executive Director Mark S. Thompson. United and Cigna, however, did not respond to the society's letters expressing reservations about rating methods. The lack of response led to the lawsuit, he said. "Just because it's the 'best' data you have, doesn't make it right."

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Cigna's standards

This is an example of what Cigna tells its members about physicians selected for its Cigna Care Network. The excerpt refers to a nephrologist:

Designation: This specialist has received the Cigna Care Network designation.

The Cigna Care Network designation reflects a partial assessment of quality and cost efficiency. It should not be used as the sole basis for decision-making. We encourage you to consider all relevant factors and to consult with your treating physician as you select a specialist for your care.

When you receive covered services from a Cigna Care Network specialist, you receive the in-network benefit level, and your co-payments or level of co-insurance will be lower.

Quality and cost-efficiency standards

First, the specialist must meet our criteria for board certification and, if the specialist was evaluated under [certain evidence-based quality measures], the specialist's performance must exceed our minimum threshold for these measures.

Then, we evaluate the specialist's relative efficiency using the Episode Treatment Groups methodology ... [that] looks at medical costs (inpatient, outpatient, laboratory, radiology, pharmacy, etc.) for a given episode of care and profiles specialty care physicians against physicians in similar specialties. ETGs include case-mix adjustment to help account for differences in the severity of patients' illnesses and provide a consistent and reliable way to measure and compare costs.

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