Physician Ratings Leave Patients and Doctors Confused

by Tom Walsh

A radical new approach to health insurance in Massachusetts is about to begin on July 1. That’s when approximately 266,000 Massachusetts state workers, retirees, and their dependents whose health insurance is handled by the state’s Group Insurance Commission (GIC) will be covered under health plans that rate doctors by cost efficiency and, in some instances, quality. The GIC’s new “Select and Save” plans require higher member copayments for choosing physicians with lower ratings. The program’s objective is to enhance quality of care and curb rising costs.

However, physicians remain confused and minimally informed by both the state and the health plans about their ratings.

“Most physicians are still not aware of what’s going on,” said Kenneth R. Peelle, M.D., MMS president. “This was rolled out on a fast time schedule and was based on information that was not shared with doctors far enough in advance.”

Timely, Accurate Information
The MMS embraces the state’s goals to boost quality and control costs. However, Elaine Kirshenbaum, MMS vice president for policy, planning, and member services, cautioned that the data used to establish physician ratings and guide patient health care decisions must be accurate, meaningful, timely, and valid. “Fairness dictates that the information get to physicians six to eight months before it goes public,” she emphasized.

Dr. Peelle said the best way to rate physicians is by both cost effectiveness and the quality of their performance. However, he said, “the state of the art of measuring cost or quality is not very advanced.”

He added that doctors want to improve the cost effectiveness and quality of patient care. “We feel that if you give physicians their performance data, they will use it to improve themselves,” he said. Only if they don’t, he added, is it appropriate for health plans to assign physicians a lower rating.

How HPHC Devised Its Formula
Roberta Herman, M.D., chief medical officer and senior vice president of health services at Harvard Pilgrim Health Care (HPHC), said her plan based its physician ratings on cost efficiency only. HPHC collects physician quality data, but it was not used for ratings in the GIC program.

All HPHC-contracted specialists, Dr. Herman said, began in the “Tier 2” category of the HPHC rating process. However, she added, using episode treatment groups, or ETGs (see Vital Signs, October 2005, page 2), HPHC identified specialists in cardiology, dermatology, gastroenterology, general surgery, and orthopedics who were more efficient than average, and they were moved up to Tier 1.

Unlike HPHC, other plans in the GIC program did blend quality information with efficiency data to determine physician ratings. “The fact that plans did not all use the same criteria to establish their evaluations adds to the confusion surrounding this issue,” said Kirshenbaum.

Despite being encouraged by the MMS to rate physician groups rather than individual doctors, UniCare, a health plan that covers nearly half of all participating state employees, issued individual ratings for nearly every physician in the state. Doctors for whom there is not enough efficiency or quality data to determine ratings are automatically assigned to the higher-copay tier.

Physicians Needed More Time
Physician group medical directors and individual physicians did not receive notification of ratings until late March or early April. With the GIC enrollment period starting in mid-April, that did not leave enough time for doctors to digest and respond to their ratings.

For its part, HPHC wrote letters to group medical directors and to physicians in individual practices. The plan also sponsored “town meetings” to explain the methodology and solicit physician feedback. “So far, it’s been quite well received,” Dr. Herman maintained. “We’ve tried to keep physicians as well informed as we could.”

Dolores L. Mitchell, GIC executive director, acknowledged that MMS leaders “were not happy with the way this was rolled out.” Mitchell encourages physicians who are unhappy with the rating system to get in touch with the health plan that ranked them.

Dr. Peelle reiterated that the MMS accepts the GIC’s cost-containment goals, “but we’re not sure this is the best way to do it. We want to work with the plans to make sure this is done right. We certainly do not want any program to disrupt patient-physician relationships.”