Insurers agree to more transparent physician ratings

Two more health plans reach an accord with the New York attorney general to submit their tiered networks to outside scrutiny.

By Emily Berry — Posted Dec. 3, 2007

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Just weeks after it was signed, Cigna's agreement in New York to modify its physician ranking tool is set to have a ripple effect across the country.

Aetna and Empire BlueCross BlueShield, a WellPoint company, have signed similar agreements with New York Attorney General Andrew Cuomo's office. Aetna signed its deal on Nov. 13, while Empire followed the next day.

Aetna immediately pledged to apply the terms of its New York agreement to all of its tiered networks nationwide. Cigna made a similar pledge the same day Aetna did. WellPoint said it is not ready to make such a promise.

Under their separate deals, all three plans have agreed to make the basis of their physician ranking programs transparent to members, base those rankings on nationally recognized quality standards and submit their programs to outside evaluation.

Cuomo began looking into health plan physician-ranking programs this summer, based on concern that consumers would be directed to certain physicians based solely on cost, not quality.

"Attorney General Cuomo's model ensures transparency for both patients and doctors -- patients will now understand the criteria upon which doctors are ranked, and doctors will be able to provide input into the ranking system," said Robert Goldberg, DO, president of the Medical Society of the State of New York. Dr. Goldberg is a physical medicine and rehabilitation specialist in New York.

The Cigna Care Network designation for the plan's tiered networks is used in 58 markets from Los Angeles to Washington, D.C. At the time it signed its deal with Cuomo, Cigna said it was likely the parties would expand the reach of the agreement to cover its tiered networks nationwide, though it didn't make that announcement immediately.

Aetna operates its Aexcel "performance network" in 35 metropolitan areas.

About 41,000 physicians are "designated Aexcel," and nearly 600,000 members have access to the Aexcel network, company spokeswoman Cynthia Michener said.

Aetna Chief Medical Officer Troyen Brennan, MD, said it simply made sense to make the changes in New York apply across the nation.

"We don't feel like our physicians or members in New York are any different than our members and providers elsewhere," he said. "Insofar as we found these changes to be quite reasonable, it was a completely easy decision."

Empire's parent company WellPoint has put its Blue Precision program in place in other states, but had held off on launching in New York. Empire has more than 5 million members in 28 counties in New York, and plans to launch Blue Precision there in 2008.

For now, the agreement's precise terms will apply only to the New York program, WellPoint Chief Medical Director Sam Nussbaum, MD, said at a news conference announcing the agreement.

"However, the principles and guidelines we are announcing will provide the framework for the refinement of our Blue Precision programs across the plans we have in place today and those that are under development," he said.

"We did this because it was the right thing to do," Empire spokeswoman Lisa Geiner said.

Representatives of organized medicine welcomed the news of further agreements with the attorney general's office.

"Aetna's decision to join Cigna in agreeing to patient protections required by the Attorney General is an important step toward ensuring that physician evaluations are used primarily to enhance the quality of patient care," said American Medical Association President-elect Nancy H. Nielsen, MD, PhD, an internist in Buffalo, N.Y.

The AMA has advocated for transparency in health plan physician ratings and worked to establish standard, evidence-based quality measures. It has led the Physician Consortium for Performance Improvement, which has developed 213 measures.

The Association offered expertise and consulted with officials in Cuomo's office throughout negotiations with Cigna, and Dr. Nielsen said the AMA would continue to be involved as watchdogs to make sure the company follows the agreement.

Cigna's agreement calls for the company to use a standard set of quality measures recognized by the National Quality Forum. But company officials have said the PCPI measures would not be eligible, even though they are endorsed by the National Quality Forum. Cigna agreed to change its program within 30 days of signing the deal with the attorney general's office Oct. 29.

Aetna isn't working within a specific timeline, Michener said. "The foundation of our program -- designation criteria, performance measures, etc. -- is unaffected by the agreement. We will be working with the external [ratings examiner] over coming weeks and months," she wrote in an e-mail.

In addition to looking closely at Empire, Aetna and Cigna's existing programs, Cuomo's office sent letters to officials with UnitedHealthcare, Preferred Care and HIP Health Plans, warning the companies not to establish new rankings systems without checking with the attorney general first.

In United's case, Cuomo's office threatened to sue the company if it implemented its tiered network as planned in July. The company delayed the network until January 2008.

Asked Nov. 15 about a potential agreement with the attorney general's office, Ilene Margolin, spokeswoman for GHI/HIP Health Plans, said, "Not yet."

Gary Hughes, spokesman for Preferred Care parent company MVP Health Care, said the company was "making good progress" toward an agreement with the attorney general's office.

United spokesman Tyler Mason said the company is still in discussions with Cuomo's office.

"What we've seen with the agreements so far ... seems to be that the rankings be based on quality," not solely cost, he said. "Ours has always been a program in which you cannot even qualify for an efficiency ranking until you have a quality ranking."

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