Payers have various rating, tiering, and ranking systems that attempt to assess a physician's performance against his or her peers. Some of these systems may be tied to reimbursement rates, but mostly they are used to steer patients to physicians in the higher-quality tier.
Often, say critics, the criteria on which the ratings are based are not disclosed to physicians in advance—when they could make changes to their practice. Moreover, many providers and consultants say the ratings are often incorrect, or at least imprecise. They also say the ratings may have more to do with cost than quality.
These rankings are an increasingly important part of marketing for health plans, so it's unlikely you will be able to opt out of them, says Jeffrey B. Milburn, Colorado Springs–based independent consultant at MGMA Health Care Con-sulting Group. But you can probably include provisions in your contract to help ensure accuracy. Milburn says such provisions should include:
The opportunity to review how the program operates. Ninety days would be ideal, but usually you can get 30–60 days notice, Milburn says.
Knowledge of the data being used. You want to be able to confirm that quality rankings are based on quality measures and not cost (efficiency) measures.
Knowledge of where data come from. You want something more detailed than someone saying, "It comes from claims."
Knowledge of the plan's methodology. How is the plan using the data?
Knowledge of the specific standards. Is the plan using a legitimate third-party organization?
Consideration of acuity. Too often, acuity isn't considered, Milburn says. You don't want the plan merely to acknowledge this; you want to see how it's factored in. Otherwise, you may be placed in a different tier because you have more severely ill patients.
An opportunity to appeal before the rankings are published. If you have concerns, you want them addressed before the rankings are made public.
If you think the data are incorrect, ask for a meeting. "I haven't had anyone turn me down. If the representative is reluctant to meet, appeal to the plan's medical director," says Milburn. If the plan is unwilling to give you that access, you may have a problem.
This article was adapted from one that originally appeared in the December 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
Doctors in Europe have been warned not to respond to flirtatious approaches from patients on social networking sites like Facebook. The United Kingdom's Medical Defence Union said it was aware of a number of cases where patients have attempted to proposition doctors by sending them an unsolicited message on Facebook or similar sites. The medical body said it would be "wholly inappropriate" to respond to a patient making an advance in such a way. A legal adivsor for the Defence Union said the pitfalls posed to doctors using social networking sites and inadvertently breaching patient confidentiality had already been well documented, but the dangers of patients using the sites to approach doctors were less well publicized.
There is a new iPhone application that allows radiologists to read scans from their phones. Using a $20 iPhone application called OsiriX, radiologists made correct diagnoses of appendicitis in 124 of 125 computed tomography scans, researchers reported.
At the end of a third day of Senate debate over healthcare legislation, Democrats and Republicans said that they had broken an impasse over the question of how and when to vote on the first amendments, the New York Times reports. But even as lawmakers announced an agreement to begin voting, Democrats accused Republicans of stalling debate and obstructing the legislation. Republicans said it was unrealistic to expect quick action on such a big bill, and they denied they were stalling, reports the Times.
Republican lawmakers pressed their case that new U.S. recommendations advising against routine mammograms for women in their 40s could be used to ration healthcare under reform legislation before Congress. The guidelines, issued Nov. 16 by the U.S. Preventive Services Task Force, scaled back recommendations for annual mammograms to screen for breast cancer in women in their 40s with an average risk for the disease. At a hearing of the House Energy and Commerce Committee's subcommittee on health, members of the task force acknowledged that their description of the new guidelines might have been "poorly worded," leading people to think they were suggesting that screenings were unneeded for any patients in their 40s, the Washington Post reports.
The California Medical Association is opposing healthcare legislation being debated in the U.S. Senate, saying it would increase local healthcare costs and restrict access to care for elderly and low-income patients. The Association represents more than 35,000 physicians, making it the second-largest state medical group in the country after Texas. They group join a handful of other state medical associations that have opposed the bill in recent weeks, including those in Florida, Georgia, and Texas, the Los Angeles Times reports.