Physician Quality Ratings Imperfect, But a Start

A few years ago I moved from my long-time home to a new city. As anyone who has ever relocated knows, settling in is a process that extends well beyond the arrival of the family furniture. There are schools to consider, restaurants to find, churches to join and friends to make.

To find our dentist, doctors and vet we did just like we did at our former home—we asked our friends and neighbors.

I will admit that not once did I consider looking at any of the physician ratings so proliferate on the Internet. Because I write about healthcare I knew that insurers were busy developing and introducing their own grading systems to guide members to “high quality” and “cost-efficient” physicians but I did not check on those either.

I know what I am looking for in a physician. Top on the list: Listens to me. There probably is not an effective quantitative method to measure that. And that is the root of the problem many physicians have with profiling or rating systems. From New York to California physicians have countered that the quality assessments are faulty and are really just a way for insurers to favor lower cost physicians over more expensive ones.

Payers have been dipping their toes into the profiling pond for several years now. The first efforts were more or less PR disasters for the health plans with the programs in Tennessee and Texas put on hold while state medical associations and Payers worked out the details.

But with all of the recent finger pointing regarding the high cost of healthcare, payers have persisted and developed some sophisticated models to assess their high volume physicians in terms of quality patient care.

What has emerged is a familiar list of best practices that, if followed, can often lead to improved patient outcomes in terms of breast and cervical cancer screenings, diabetes and cardiovascular care, and the monitoring of patients on persistent medications. The programs are mostly focused on a few specialties, including allergy, cardiology, endocrinology, family medicine, pediatrics, orthopedics and infectious disease.

Aetna, UnitedHealth, CIGNA and Anthem each have profiling programs underway. BlueShield of California will launch its program later this year. A few days ago, the insurer prevailed in a class action suit filed by the California Medical Association to contest the implementation of the Blue Ribbon Recognition Program. The complaints raised in the suit were common to physicians across the country: the scoring system is flawed, there is no review of medical charts, and no evaluation of patient outcomes.

It definitely is not a perfect system. A 2010 RAND Corp. study based on insurance claims detailed how unreliable measures of physician performance can lead to flawed assessments of the cost effectiveness of treatment by one physician versus another. That study, which was published in the New England Journal of Medicine, concluded that profiling was a strategy to reduce costs but that more accurate tools needed to be developed to create reliable profiles.

Because I am not a high volume user of physician services, I probably am not in the target market for profiling information. But if I were, I could see why my insurer might want to direct me to a particular physician and seal the deal with a financial incentive. At UnitedHealth for instance, members who use physicians in the insurer’s premium designation program pay a $30 copay for an office visit rather than $50.

Physicians are going to have to get accustomed to ratings and profiles---just like health plans have done. In the California case the system has the support of almost all the movers and shakers in healthcare---with the exception of the California Medical Association, which resigned from the project and instead filed an unsuccessful lawsuit.

As the national debate over healthcare costs goes on and on I hope the players will spend less time in court and more time working toward some real solutions.