New York agreement refines doctor-rating criteria

An agreement that was struck between a health plan and regulators in New York won't stop insurers' use of physician rankings, but it might make them more acceptable to doctors.

Cigna and New York Attorney General Andrew Cuomo's office on Oct. 29 struck an agreement that requires the insurer to submit to the state the rating criteria it plans to use to place doctors in tiered networks, in which members pay a lower co-pay or otherwise get discounts for seeing favored physicians. Cigna is one of many health plans that have received letters from Cuomo's office stating that its physician-rankings plan might be misleading to consumers because, in part, it appeared to focus on cost more than quality.

The rankings plan Cigna adopts must use independently accepted criteria -- not claims data -- to rate physicians on quality measures without taking cost into account. Physicians also would get the chance to see those criteria and appeal their rating.

Cigna Senior Vice President and Chief Medical Officer Jeffrey Kang, MD, MPH, called the agreement a "national model for the entire health insurance industry." Robert Goldberg, DO, president of the Medical Society of the State of New York, called the deal a "milestone in assuring that patients have a prime role in selecting physicians based on what is important to their personal health care needs."

"The attorney general struck what is a good balance between the needs of patients, the rights of physicians and, frankly, the needs of health plans as well," said American Medical Association President-elect Nancy H. Nielsen, MD, PhD, an internist in Buffalo, N.Y. Dr. Goldberg and Dr. Nielsen appeared with Cuomo at a New York news conference announcing the deal, and their organizations assisted the attorney general's office in its investigation.

Other health plans, including Aetna, UnitedHealth Group and WellPoint's Empire BlueCross BlueShield subsidiary, responded to the agreement by saying they either planned to work or already were working under the same framework with the attorney general's office, or independently had decided to change their ratings systems. Analysts say regulators in other states could follow Cuomo's lead in insisting on transparency from the health plans, and Dr. Nielsen said she hopes that indeed would be the case.

But Cigna has not yet determined the exact details of its ratings system, which has physician organizations still cautious.

"The devil is in the details," Dr. Nielsen said. "We are awaiting the implementation and will be monitoring it closely."

Warning letters

Cuomo's office launched an investigation earlier this year into whether health plans were trying to direct members to certain physicians based mainly on cost. In the agreement, Cigna did not admit to any wrongdoing.

The company began posting physician-level quality and cost-efficiency information in 2005 for doctors in six markets, including part of New York, Dr. Kang said.

Cuomo's office sent its first letters to UnitedHealth Group on July 13, then on Aug. 16 sent letters to Cigna, United and Aetna asking for more information about their programs. On Oct. 18, Empire BlueCross BlueShield, Preferred Healthcare and HIP Health Plan of New York received similar letters.

The letters did not explicitly threaten litigation but stated that the department was determining "how best to protect consumers."

Cigna spokesman Wendell Potter said the company had decided to cooperate with the attorney general's office because it believed the modifications to its program could be done without "significant cost" and that it was consistent with Cigna's "commitment to transparency." Earlier, United had agreed to delay implementation of its tiered network until December because of the attorney general's concerns.

Fights over physician ranking programs aren't isolated to New York.

A group of Connecticut physicians earlier this year sued Cigna and United over their ratings programs. Those cases are pending. In other states, physician protests have led health plans, including BlueCross BlueShield of Texas and UnitedHealth Group, to either pull or alter physician ranking programs. State medical associations and the AMA have gotten involved in many of these fights.

The AMA's policy is that ratings systems should be transparent and based on quality rather than cost. It also states that health plans must give physicians the ability to review data used to construct the ratings and appeal them. In 2000 the AMA convened the Physician Consortium for Performance Improvement, a group of state and specialty medical societies, to develop and promote the use of evidence-based quality measures it believes are a more accurate reflection of quality than are claims data. So far, 213 measures have been developed.

Deciding on measures

According to Cigna's agreement, the company will pay for oversight by an independent ratings examiner, which is defined as a "nationally recognized standard-setting organization." The company also agreed to pay up to $100,000 for a third-party communications outfit to plan a campaign to educate members and physicians about the new program.

Dr. Kang said Cigna was working to identify the organization that would serve as its ratings examiner. The company's nomination would be subject to the approval of the attorney general's office.

Potter said the Physician Consortium for Performance Improvement, as a physician-run organization, would not qualify as an independent examiner. But he said its measures might be used if there were not independent quality standards available elsewhere.

Cigna agreed to make the changes to its program within 30 days.

The Cigna deal could set the stage for other state regulators to reach formal agreements with health plans over physician rankings, said Kristen Madison, PhD, a law professor at the University of Pennsylvania Law School in Philadelphia who studies health care policy. Potter said Cigna "will be looking at implementing the program in our other markets going forward."

Making preemptive changes could be to health plans' advantage, Dr. Madison said. "If insurers adopt the measures discussed in the agreement for all of their programs nationwide ... they may reduce the regulatory pressure they might otherwise face in other states," she wrote in an e-mail.