Fight over physician quality ratings moves to Massachusetts

The dispute focuses on tiered networks covering public employees and a state insurance commission's request for rankings data.

By Emily Berry — Posted Dec. 24, 2007

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Despite deals in New York that insurers pledge will improve their tiered networks nationwide, physicians are not assured that networks based on quality ratings will be to their liking.

One of the hottest battles over tiered networks is going on in Massachusetts. It involves the tiered network system mandated by the Massachusetts state employees health insurance program, the Group Insurance Commission. In November, the GIC started accepting proposals from health plans that would set up networks covering not only 250,000 state employees, but also potentially another 330,000 municipal employees as the program expands to cover any state and local public employee.

The commission and its insurers actually released their first networks based on quality ratings in April, but the expansion of its networks, and physicians' dislike of how ratings are established, has the Massachusetts Medical Society speaking out against the commission's tiered networks. In this fight, allies include legislators pushing House and Senate bills governing standards for tiered networks, and, in a case of strange bedfellows, BlueCross BlueShield of Massachusetts, which said it would refuse to submit a proposal.

Katherine Atkinson, MD, a family physician in Amherst, Mass., said GIC health plans have sent notices to physicians informing them that they are in low tiers without offering an explanation, and without any chance to appeal their ranking.

Worse, she said, the rankings are based largely on cost, but patients don't know that -- they assume the doctor must be incompetent or have committed malpractice.

"I have a colleague who was ranked on the lowest level because of cost," Dr. Atkinson said. "A patient walked in and said, 'Who did you kill?' "

Fighting over standards

New York's fight over tiered networks led the state's major health plans to sign deals with Attorney General Andrew Cuomo pledging that they would use independently derived quality measures to establish tiered networks, which allow health plan members to pay a lower premium or co-pay if they use only highly rated doctors or groups. The New York deal also gave physicians the right to see how their rating was derived, and to appeal it.

The deal fit in with policies of the American Medical Association, which was involved in the New York talks, that tiered networks should be based on quality metrics, not cost, and make measures transparent.

Plans such as WellPoint, UnitedHealth Group, Aetna and Cigna have pledged that they would use this deal as a template for their tiered networks across the nation, though they said full implementation would take some time.

Tiered networks are nothing new to Bay State physicians. BlueCross BlueShield for years has rated groups for tiered networks, for example.

The Group Insurance Commission's networks are part of its Clinical Performance Improvement initiative, which began in July 2006 with a stated goal of holding down costs without sacrificing health quality.

The commission pools health plans' performance data to come up with its ranking system. Patients pay more to see a doctor in a lower tier, typically $25, compared with $15 for a high-tier doctor.

Massachusetts Medical Society President B. Dale Magee, MD, an ob-gyn from Shrewsbury, said the commission's ranking program provides no way for physicians to dispute their scores or understand why they are placed in a certain tier.

"As it is currently designed, there is not a mechanism in place for any of us to improve the way we practice based on this," he said. On Nov. 3, the society passed its own policy on tiered-network standards. The policy includes having physicians involved in developing quality measures, using "clinically important and sound performance measures," and ensuring transparency of all quality and cost-effectiveness measures.

The society also testified before state legislators in favor of House and Senate bills that would, among other things, improve the transparency of data used to create a tiered network. Those bills, however, have been stuck in committee since summer and are not yet scheduled for votes.

The Massachusetts Blues, which hasn't participated with the GIC for a decade, said the commission's data were "unreliable" -- in part because there are no accurate data available to rate individual physicians, spokesman Chris Murphy said. The Blues plan instead is offering its own municipal program to compete with the commission's.

The GIC's executive director,Dolores Mitchell, said the Blues and the medical society are "just wrong" about whether performance measures can be used accurately on an individual physician basis.

"I know that health plans have been measuring individual physicians within their networks for years," Mitchell said. "They have that data."

Despite the New York agreements, Massachusetts is an indication that battles over tiered networks likely will continue across the country, said Peter V. Lee, chief executive officer of the Pacific Business Group on Health, and co-chair of the Consumer-Purchaser Disclosure Project, a broad-based coalition advocating public reporting of quality measures.

"I think Massachusetts is one leading example of what is happening in virtually every state in the country," he said. "Physician measurement has arrived. The question is, how to make sure we do it right."

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Ranking the rankings

In the midst of the state public employees' insurance commission requiring its health plans to submit tiered networks, the Massachusetts Medical Society House of Delegates in November passed policy to spell out what they believe a ratings system should look like. It is similar to AMA policy -- and dissimilar to what the Massachusetts society says is going on in its state. The MMS principles say tiered networks programs should:

  • Aim to strengthen patient-physician relationships.
  • Involve physicians in the design and implementation of all programs.
  • Use performance measures that are clinically important and sound.
  • Ensure sample sizes adequate to support meaningful data analysis.
  • Rely on meaningful data and analytic techniques.
  • Share and review data with physicians or practices before public release.
  • Ensure transparency of all quality and cost-effectiveness measures and methods.
  • Identify practice characteristics that may require special attention in quality and cost-effectiveness monitoring.
  • Use uniform reporting formats.
  • Minimize unintended harmful consequences of quality and cost-effectiveness monitoring and public reporting.
  • Be pretested before implementation.

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