Opinion

Putting the quality in rankings

An agreement between the New York attorney general and Cigna promises to curtail flawed systems that rank physicians more on cost than on care.

Posted Dec. 3, 2007.

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Who's a good doctor? Typically, it's a question of quality. Certainly, patients understand it that way. So do employers, who expect results after footing so much of the bill.

Yet many insurers have interpreted this query in their own, sadly predictable, fashion. To them, it's a question of how much the physician costs the health plan.

Such has been the history of tiered networks that claim to rank physicians by "quality," but use flawed means -- claims and cost data -- rather than credible quality measures. Employers are sold the plans on the basis of cost-effectiveness. The plans offer patients lower co-pays, deductibles or premiums to encourage them to select less costly practices for treatment. Even doctors who make the cut tell AMNews that the criteria used by health plans don't seem to have much to do with quality.

This has led to contentious battles between physicians and insurers. Some plans have delayed or altered tiered networks in the face of opposition from organized medicine, which in a few cases has sued the insurers.

However, there is new hope that physicians may soon expect to be rated on true quality measures, that the basis for ratings will be disclosed, and that errors will be corrected.

All this thanks to a groundbreaking agreement between the State of New York and Cigna Corp. The Oct. 29 deal grew out of Attorney General Andrew Cuomo's investigation of numerous health plans in his state that have, or intend to have, tiered networks. It marked the first such settlement between a state regulator and an insurer.

The agreement requires Cigna to use independently developed quality criteria, to be shared with physicians if they want to appeal their rankings. It prohibits the company from using cost data to rank doctors. And it requires Cigna to pay for a third-party ratings examiner, subject to Cuomo's approval, to ensure the company complies with the agreement.

The American Medical Association and the Medical Society of the State of New York, among others, gave input as Cuomo put the deal together.

Already, this agreement is influencing how other insurers construct tiered networks.

On Nov. 13, Aetna agreed to similar terms with Cuomo as Cigna's -- and then pledged to follow those terms in all of its markets. That same day, Cigna said it would take the terms of its deal nationwide. On Nov. 14, WellPoint's Empire BlueCross BlueShield division -- which planned a tiered network but had not yet launched it -- signed a deal with Cuomo as well, although WellPoint said it had no immediate plans to apply its terms to tiered networks in other states.

One key variable is exactly what methodology the plans will use in their revised quality rating systems, which Cigna and Aetna are expected to implement by early 2009.

The AMA-led Physician Consortium for Performance Improvement has developed standards that the plans could use. It now has 213 quality measures that have been endorsed by the National Quality Forum. Similar endorsement will be required for any quality measures adopted by plans under the Cuomo deals.

Cigna has said it likely can't use the consortium measures because the group's association with physicians makes them not "independent." However, Cuomo's office has made no official determination on this point.

The AMA and other physician organizations say they will keep a close eye on these developments to ensure that the details of the health plans' new rankings systems fulfill what the companies have promised. Even with the uncertainty, however, this agreement is a positive move and one that other insurers would be wise to follow -- sooner rather than later.

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