Consternation over Tiering Continues as “Select and Save” Plans Take Effect

by Tom Walsh

For Emlen H. Jones, M.D., an Amherst pediatrician, the news that he was a tier-2 doctor according to one Massachusetts “Select and Save” health insurance plan for state em­ployees came early in May via a phone call -- from the father of two of his ­patients.

“They’d been my patients for a ­decade,” Dr. Jones said. “They were switching health plans to Unicare, and my name was not on the plan’s website list. Only tier-1 physicians were listed.” Dr. Jones commented he received no direct communication from Unicare about tiering. “It was just a fait accompli,” he said.

Dr. Jones’s lament was a familiar one among physicians interviewed for this ­Vital Signs story.

A subsidiary of Wellpoint, Inc., Unicare and its two Commonwealth Indemnity Plans are among eight Select and Save options offered to state workers by the Group Insurance Commission (GIC). The program went into effect July 1.

“Select and Save” plans tier physicians based on claims data. Most of the 266,000 state workers, retirees, and their dependents are rewarded for selecting tier-1 doctors with copays that are $10 lower than those of other physicians.

Unlike other plans in the program, which rated physicians in groups, Unicare’s program involves individual physician ratings.

Distressed and Puzzled
Dr. Jones, a veteran pediatrician and managing partner of Amherst Pediatrics, was puzzled and distressed to learn he was the only one of five physicians in the group practice not rated tier 1.

His calls to Unicare seeking an explanation were fruitless. “They seemed insulted that we were even calling,” he said. Finally, after consulting a different plan in the GIC program, Dr. Jones found what might be an explanation: two patients with whom he has a consulting relationship suffer from hemophilia, for which standard care requires expensive medication. “It should be clear from these claims that these were consults,” Dr. Jones said. “If we are going to look at how efficiently doctors provide care, let’s do it in a way that makes sense. This is clearly a retroactive punishment program, not a quality improvement program.”

At the MMS’ suggestion, Dr. Jones then spoke directly with Unicare’s physician network director, who agreed that those patients’ pharmacy costs should not be factored into Dr. Jones' individual rating. As a result, Dr. Jones was placed in Unicare’s Tier 1.

Physicians Should See Data First
Kenneth R. Peelle, M.D., MMS president, said Dr. Jones’s plight illustrates a problem with the GIC program that the Society continues to work on. “Data should be released to physicians in advance,” he said. “They should have ample time to analyze the data and correct mistakes before it goes to the public. Physicians who don’t agree with the data should call the plan and ask for an explanation.” After hearing about Dr. Jones’s experience contacting Unicare, Dr. Peelle noted that the MMS has received similar complaints involving that particular plan.

Dr. Peelle added that the tiered plans should not let consulting relationships such as the one Dr. Jones has with his hemophilia patients “count against you.”

Robert Sorrenti, M.D., Unicare medical director, said tiering information was sent in mid-April to large physician groups including the Cooley-Dickenson Physician Health Organization, to which Dr. Jones belongs. “We labored under the presumption that [physicians in the organization] would talk to each other,” Dr. Sorrenti said. “It was not as though we were sitting on this information.” Still, he conceded that when communicating with physicians, “you can always do more, and our intent is to work on that.”

Dr. Sorrenti added that physicians who ask Unicare for their personal tier-related information will receive it, but he was quick to deflect any “expectation that [Unicare] will make wholesale changes in the tiering.”

Administrative Woes Foreseen
For Cindy Mayo, R.N., who manages Northampton Pediatrics, an eight-physician practice, tiering presents administrative headaches. “In pediatrics, there’s a lot of cross-coverage among doctors,” she said. “Children sometimes see someone other than their ‘regular’ physician.” Mayo’s practice has seven physicians rated tier-1 and one rated tier-2. That means a patient might see a tier-2 physician during one visit and a tier-1 doctor at the next. “This could get very confusing for our front-desk people,” she said.

Mayo added that the practice’s lone tier-2 doctor is a young physician who was not practicing during the entire time data was being gathered. Dr. Sorrenti confirmed that Unicare automatically put physicians without sufficient data into tier 2. From Mayo’s perspective, that constitutes “a case of guilty until proven innocent” because the public might interpret the ratings as an indication that the tier-2 physician is not as good as the others. In reality, she said, “We’re a good practice, and all our physicians are good.”

Without Data, No Improvement
In Boston, Richard Parker, M.D., medical director of the 1,400-physician Beth Israel Deaconess physician organization, said good intentions may underlie tiering, but that without detailed data matched to specific physicians, there is no way for individual doctors to use data to improve.

“Right now, it’s data without information, and it’s impossible to interpret,” Dr. Parker said. Just prior to the July 1 start date, his physicians had heard no significant patient feedback about the program. However, he predicted that if copay differentials increased from $10 to $50, the health plans “better be ready for prime time.”

Barbara Spivak, M.D., president of the 450-plus-physician Mount Auburn-Cambridge IPA, said her doctors also have heard little from patients about the tiered plans, but the physicians are still distressed because they don’t understand how the ratings were derived. “We’d all like to improve the quality of care and control costs,” she said. “But we question whether this is the best way.”

The MMS continues to work with the GIC and individual health plans regarding tiering and related issues. We encourage physicians to contact specific health plans for more detailed information about individual or group ratings.