Insurers offering help picking doctors

If you hurt your knee and needed to see an orthopedist, how would you pick the right one?
Would you ask another doctor for a referral? Talk with friends, family and co-workers?
Maybe it doesn’t matter – you could get lucky and, even at random, pick someone excellent. But with something as valuable as your knee at stake, don’t you want to know for sure?
That is the idea behind UnitedHealthcare of New England’s Premium Designation Program: to help patients connect with the best doctors in each specialty, based on how they measure up to standards set by national experts and professional organizations.
Need a cardiologist? There are 147 listed within five miles of Providence’s East Side, including 96 with a “Premium” rating for both quality and cost-efficiency, and 19 just for quality.
The quality ratings, UnitedHealthcare says, are based on criteria set by groups such as the National Quality Forum and the Ambulatory Care Quality Alliance, as well as professional groups such as the American College of Cardiology. For each doctor, United has looked at one to three years’ worth of claims and/or practice data for UnitedHealthcare members – for at least five patients per doctor – to gauge how his or her practice measures up to the standards.
Once doctors have made the cut based on quality, United evaluates them for “cost-efficiency” based on their use of diagnostic tests, prescribed medications, procedures and follow-up care in comparison to colleagues in the same area, adjusting for the kinds of patients they treat.
“We think our premium designation program is the most robust health care provider quality and cost-efficiency tool in the marketplace available to consumers,” UnitedHealthcare of New England President and CEO Stephen J. Farrell said in an interview.
The program, launched last fall, is on the vanguard of a national trend. As health care “consumerism” has taken hold, leaders in business, government and even among providers have pushed to make quality and cost information publicly available so patients can make better choices – and, presumably, push providers to do better.
Such is the faith the U.S. Centers for Medicare and Medicaid Services’ (CMS) have in this approach that last month, the agency launched a major ad campaign promoting Hospital Compare, a Web tool that allows consumers to see how hospitals rate on 26 quality and patient-satisfaction measures, and also provides some cost data.
CMS has also been aggressively promoting Nursing Home Compare, a similar Web tool that covers the long-term care market.
But while hospitals and nursing homes have long accepted quality reporting as a fact of life, among doctors, it’s been a much tougher sell.
The same day that CMS launched its Hospital Compare campaign, May 21, the Massachusetts Medical Society announced a lawsuit to “correct the wrongs” of the physician ranking program implemented by the Massachusetts Group Insurance Commission, the purchaser of health insurance for most Mass. state employees and retirees.
The GIC’s Clinical Performance Improvement Initiative ranked doctors in three tiers, using various cost and quality measures, and charged patients higher co-payments if they visited doctors in the lower two tiers.
In its suit, the society said patients had been defrauded and harmed, and physicians had been defamed, by the program, and it asked the court to stop the program or make it adhere to new standards including transparency, a formal feedback process, and independent oversight.
This isn’t the first major dispute over physician rankings. In November, N.Y. Attorney General Andrew Cuomo settled a complaint against CIGNA and other national health insurers that required new transparency, fairness and oversight measures. And in 2006, the Washington State Medical Association sued Regence Blue Shield over its program, leading to a settlement in which the insurer agreed to involve physicians in the process.
Now UnitedHealthcare is being sued, along with CIGNA, by the Fairfield County Medical Association in Connecticut for its ranking program; that lawsuit is still pending.
Locally, Blue Cross & Blue Shield of Rhode Island has avoided ranking doctors so far, though it does have quality-based incentive deals with individual practice groups, such as the 173-member Rhode Island Primary Care Physicians Corporation.
In an interview, Dr. Gus Manocchia, chief medical officer at BCBSRI, said there are many challenges involved in setting up a good rating system for doctors.
There are disputes over the standards by which to judge quality, Manocchia noted, but more important, there’s a lot of controversy over the use of claims data.
But Blue Cross is slowly moving toward doctor ratings. Manocchia said the company is working with R.I. Health Insurance Commissioner Christopher F. Koller to set some local standards, and it’s also awaiting guidance from the Blue Cross Blue Shield Association.
In the meantime, starting July 1, BCBSRI will pay higher fees to primary care doctors who use electronic medical records – and meet certain standards in doing so – on the belief that EMRs can help doctors better serve patients.
Dr. Albert Puerini, president of Rhode Island Primary Care and a practicing family physician in Cranston, supports that more cautious approach. He believes Blue Cross’ deal with his group has worked very well because the quality benchmarks are set locally, based on conversations between Blue Cross and the doctors, and results are based on complete patient data, not just claims. And EMRs, he said, have indeed helped the doctors improve their work.
UnitedHealthcare’s Premium program, by contrast, has been “very frustrating” and “very generic,” he said, with dictates coming from Minnesota and minimal involvement from local doctors.
But the insurer stands by its initiative. This summer, it’s even rolling out a new product, called Edge, which provides incentives for patients to use doctors in the program.
UnitedHealthcare also plans to reward doctors financially for meeting its standards. •