Physicians Claim Doc Rating System is Misleading Patients

Cheryl Clark, April 20, 2010

A coalition of 35,000 California physicians Monday angrily withdrew its participation from Blue Shield's new "Blue Ribbon" rating system saying it will harm the reputations of good practitioners by giving patients misleading and faulty data about their care.

In a statement, the California Medical Association said the system, the California Physician Performance Initiative (CPPI), scheduled to go public June 1, will provoke doctors "to order tests or procedures that have already been done," and will score doctors on data that often is not relevant because it is based only on billing claims.

"For instance, physicians who don't order cervical cancer screening tests for their patients, even if the patients have already had hysterectomies, would get a lower rating," the CMA says.

Some 13,000 high-volume physicians would be scored on evidence-based healthcare quality standards.

"We're being ignored and our concerns aren't addressed. No point in participating if they're going to publish and not make an honest effort to address our concerns," says Andrew LaMar, CMA spokesman. "I don't know what the end result is if patients and payers and physicians and everybody who is supposed to benefit from this don't have confidence that these are reasonable ratings that use a process that's accurate and fair."

The system also would reduce scores for doctors whose patients saw an out-of-network, non-contracting provider for their pap smears and didn't tell their primary care physicians. That physician "would be penalized because there would be no pap smear claims data submitted to the health plan," according to the CMA.

LaMar says the CMA blasted the rating system the same day that Blue Shield announced the program would be the "largest initiative in California history to measure physician performance."

Blue Shield officials took strong exception to CMA's criticism saying that the scoring template was worked out over years with numerous stakeholders in the interests of transparency.

"We want to get individual information about physicians, and people want to know which providers have a tendency to follow evidence-based guidelines," says Blue Shield spokesman Aron Ezra. He added that CMA's concerns that a doctor might not do a test on a patient for legitimate reasons are ill-founded.

"It's not like one specific example would throw off the data," Ezra says.

The CMA had worked for two years to produce the system, along with health plans, purchasers, consumers, and health data experts affiliated with the Pacific Business Group on Health, a coalition of 50 purchasers and the nonprofit Blue Shield. The initiative began in 2006.

In a news release Monday, PBGH President and CEO David Lansky said "we know that the doctor-patient relationship is at the core of our healthcare system. That's why the CPPI is so important to California's employers and families ¬to help patients make the best decisions about where to seek care."

Groups that support CPPI are the American Association of Retired Persons, the California Public Employees' Retirement System, the Service Employees International Union, the California Health Care Coalition, the California School Employees Association, and Southern California Edison.

CMA's concerns
In an April 15 letter to Blue Shield President and CEO Bruce Bodaken and Lansky, the CMA listed a number of other concerns:


  • Doctors may be persuaded to not see non-compliant patients because they would negatively affect that provider's score. "For example, one physician declined to pursue recommending colonoscopy to his bed-ridden dying patient; 2) Another patient delayed a recommended procedure because she lost her job; 3) Some patients may forego recommended care because they are on vacation, out of the country or they dropped their health coverage and 4) other patients by choice may simply refuse to adhere to certain procedures."
  • Inaccurate financial claims data used by insurers for the CPPI may mislead patients in choosing or retaining physicians, irreparably harm a physician's professional and personal reputation, and may not necessarily address payer concerns about costs.
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