Massachusetts society evaluates health plans' doctor-rating programs

With health plans increasingly issuing ratings of physicians by cost and quality of care, some physician organizations are turning the tables and issuing their own ratings of insurers.

The latest to do so is the Massachusetts Medical Society, which in January released a report detailing how the state's health plans are aligning with its principles on physician tiering, pay-for-performance and prior-authorization programs.

"If data are good, if reporting is good, shining a bright light on operations is good, then certainly the plans are not beyond criticism," said MMS president and Shrewsbury, Mass., ob-gyn B. Dale Magee, MD.

The report's authors found that plans were at least partially meeting the society's guidelines for pay-for-performance, tiering and prior-authorization programs.

The authors included a series of recommendations, including that the health plans adopt a formal appeals process for physicians who are ranked in tiering programs, that they move from prior-authorization programs to prior-notification programs, and that performance measurement be limited to groups until more reliable data are available to measure individual physicians' work.

Dr. Magee said the health plans have, for the most part, been receptive to the report.

Marylou Buyse, MD, president and chief executive of the Massachusetts Assn. of Health Plans, said the group always welcomes physician feedback. But she said she didn't agree with every conclusion in the report.

"We would agree the programs are imperfect," she said. "But if we wait for them to be perfect, the health care system is going to collapse of its own weight."

Specifically, she said the health plans hadn't been given enough credit for diminishing the administrative burden of some prior-authorization programs, and said although they are not flawless, the measures used now in pay-for-performance programs are "credible and reliable."

Other organized medical groups also have been busy analyzing health plans' cost and quality programs. A report issued in November 2007 by the Minnesota Medical Assn. looked only at the pay-for-performance programs in its state and found that, as in Massachusetts, health plans were, for the most part, following the group's guidelines.

The AMA recently examined incentive programs offered by United Healthcare and Wellmark Blue Cross and Blue Shield to see how they conformed to the Association's pay-for-performance principles.

In each case, both programs met some standards, but fell short by, for example, using data that might not be evidence-based and limiting payments to a certain number of physicians, rather than rewarding all doctors who had quality improvements.

With pay-for-performance, tiered-network and prior-authorization programs now widespread, physicians are moving on to improving the programs' accuracy and precision, said James Maxwell, PhD, Director of Health Policy and Management Research for John Snow Inc., a public health consulting firm based in Boston.

The question is, "How do you work with health plans to make them more transparent and make them more effective?" he said.

For the Massachusetts study, the medical society gathered publicly available data on health plans' programs, interviewed chief medical officers and other health plan personnel, and allowed plans to review the research for factual inaccuracies.

The Massachusetts study avoided giving an overall ranking of plans according to which ones met the most principles and which met the least, but it did detail each plan's conformity with its principles. The report is available online (link).

In its report, the society detailed how plans' practices compared with others. For example, Fallon Community Health Plan was deemed the least intrusive on prior authorization for radiology, requiring it only for PET scans. Aetna, Cigna, Health New England and Tufts Health Plan were the most intrusive, the society said, requiring prior authorization for all nonurgent MRI, CT and PET scans, and do not reimburse physicians for nonauthorized imaging procedures.