Massachusetts doctors sue, saying ranking program is flawed

A lawsuit wielded by the Massachusetts Medical Society and five physicians is the latest attack on insurers' ranking systems, which doctors say put cost ahead of quality patient care.

Doctors sued the Group Insurance Commission, a state agency that oversees health insurance for state employees, and two participating health plans to block a physician tiering program the commission mandated two years ago. The Clinical Performance Improvement Initiative, a program four years in the making, purports to improve health care quality and restrain costs by grading doctors based on those two measures.

Patients get an incentive, in the form of discounted co-payments, to choose so-called better-performing doctors, who are labeled "Tier 1." The GIC program affects about 300,000 state employees.

In their lawsuit filed May 21, doctors say the tiering methodology is flawed. They point to inaccurate records gleaned from claims data and faulty computer tools used to arbitrarily rank physicians in one of three tiers. In the process, doctors contend the initiative defamed them and misled patients about the quality of care.

It's not the first time doctors have fought such tiering networks.

Their complaints have reverberated nationwide with legal battles waged in Washington, Connecticut and New York. Some of those actions helped pave the way for collaborative efforts to set uniform, national standards for grading doctors' performance.

Meanwhile, Massachusetts doctors are asking the Suffolk Superior Court to halt the commission's tiering system or require specific standards such as disclosure of the ranking methodology, physician input, prior notification, processes for appeals and corrections, and independent oversight.

"There are good reasons to do this if [insurers] can provide meaningful reports," MMS spokesman Frank Fortin said. "But that doesn't exist now, and these ratings are next to useless to doctors because there is nothing they can do to act on it."

Standards challenged

According to the lawsuit, the GIC downgraded some doctors for procedures they did not perform, or miscategorized treatments. One plaintiff alleges she was penalized because her multiple sclerosis patients required expensive, multidisciplinary care.

Fortin said the program disrupts doctor-patient relationships by encouraging patients to switch to lower-tier doctors to avoid higher co-payments. Rather than saving money, "patients are forced to pay more based on a program that doesn't work."

When cardiologist A. Kim Saal, MD, chief of cardiology at Mount Auburn Hospital in Cambridge, noticed his low scores, he requested the health plans' data so he could match it to his patient records. After wading through documents that Dr. Saal said were difficult to decipher, he found that more than 50% of the patients attributed to him were not his. He interpreted their ECGs and stress tests but otherwise was not involved in their care.

"I thought, this doesn't pass the smell test," said Dr. Saal, who participated on behalf of the MMS in a physician advisory committee the GIC established when it began developing the quality ranking initiative in 2004. The commission adopted some of the medical society's recommendations for improvement, but the final product still fell short, forcing doctors to turn to the courts, he said.

Legislative efforts also have stalled. A pair of bills introduced last year calling for greater transparency and accountability remain in committee.

"If I got a report saying patients are not on cholesterol-lowering medications when they should be, I'd say thank you," Dr. Saal said. "But [the commission and insurers] haven't even told physicians what the quality measures are, so we don't know what to be thinking about."

In addition, as the practice of medicine becomes more integrated, measuring physician performance at the individual level can be unreliable, he said.

Doctors aren't the only ones who have rebuffed the commission's initiative.

BlueCross BlueShield of Massachusetts, which does not participate in the GIC, turned down the agency's bid to join the insurer's ranking program. Blues spokeswoman Susan Leahy declined to comment on the commission's program. She said the company's network "uses a different methodology for tiering that tiers [doctors] on a group level," rather than individually.

Work in progress

Though not perfect, Massachusetts' tiering program is a step in the right direction, said Dolores L. Mitchell, the GIC's executive director.

She called the lawsuit "regrettable, given the extreme concern we all have about the escalating cost of health care and the significant evidence that much can be improved if we measure what's being done, establish quality standards and work collectively to steadily improve."

The GIC aggregates claims data from six participating insurers. Mitchell said the system uses nationally recognized analytical tools and measures -- such as those from the Agency for Healthcare Research and Quality and the National Quality Forum -- to create the report cards.

She also reiterated that the rating methodology was developed with input from the MMS. "We've said from the beginning that this is a work in progress but [doctors] don't have veto power."

The two health plans named in the lawsuit -- Tufts Health Plan and UniCare, a WellPoint company -- declined to comment on the allegations, though both said transparency was the goal.

Dr. Saal agreed. "We should do this. But we should be doing it right, and this is sending the wrong message to patients as to who they should pick as physicians."