Five Insurers Now Agree to New York Physician Ranking Rules

A total of five health insurance companies -- including the top three in the country -- have now agreed to comply with rigorous new rules for physician ranking plans, setting a benchmark for the development of a nationwide standard. United Healthcare and the Group Health Insurance/Health Insurance Plan (GHI/HIP) of Greater New York this week joined Aetna, CIGNA, and Wellpoint in accepting the principles developed by New York Attorney General Andrew Cuomo.

Aetna, Cigna, United, and WellPoint will apply the principles nationwide.

The New York model expands on the principles for physician tiering programs that the Massachusetts Medical Society adopted earlier this month. The Massachusetts Group Insurance Commission (GIC) requires its participating health plans to utilize a proprietary ranking system. The system affects nearly 300,000 state and municipal employees in Massachusetts.

“While the GIC has made some changes in its program in response to physician concerns,” said B. Dale Magee, M.D., president of the Massachusetts Medical Society, “it has not been able to ensure accuracy, reliability, or validity. It falls significantly short of the New York attorney general’s mandate for these principles, as well as for independent oversight.”

Cuomo’s office drafted its model with input from the Medical Society of the State of New York, the American Medical Association, and several consumer advocacy groups. It requires insurers to fully disclose all aspects of any ranking system and hire an independent “ratings examiner” to monitor compliance.

The New York settlement agreements declare, “Consumers are entitled to receive reliable and accurate information unclouded by potential conflicts of interest. The independence, integrity, and verifiable nature of the rating process are paramount.”

“GHI and HIP believe that consumers must have access to accurate and useful information about their physicians,” said HIP’s executive vice president, Dan Dragalin, M.D.

According to a statement from Cuomo’s office, insurers will:

• Ensure that rankings for doctors are not based solely on cost and clearly identify the degree to which any ranking is based on cost;
• Use established national standards to measure quality and cost efficiency, including measures endorsed by the National Quality Forum  and other generally accepted national standards;
• Employ several techniques to foster more accurate physician comparisons, including risk adjustment and valid sampling;
• Disclose to consumers how the program is designed and how doctors are ranked, and provide a process for consumers to register complaints about the system;
• Disclose to physicians how rankings are designed, and provide a process to appeal disputed ratings;
• Nominate and pay for the ratings examiner, subject to the approval of the New York attorney general, who will oversee compliance with all aspects of the new ranking model and report to the attorney general’s office every six months. The ratings examiner must be a “national standard setting organization” and will be national in scope, independent, and an Internal Revenue Code § 501(c)(3) organization.

United Healthcare had been scheduled to start its ranking program in New York in December. It said it will comply with the agreement before launching the program. GHI/HIP accepted the agreement prior to designing its program.