Doctor groups criticized growing efforts by health plans to steer patients toward certain physicians based on cost or quality, arguing in a letter to insurers that the rankings may be unreliable and unfair.
The letter, sent by several organizations including the American Medical Association, is the latest shot by doctors at such grading efforts, which have led to years of tensions between physicians and health plans. Insurers, for their part, said they are already working with doctors to ensure their ratings are accurate and transparent.
Insurers have long charged patients greater out-of-pocket fees when they see doctors who are not in the health plan's network of contracted physicians. Now, insurers and employers are taking this a step further by dividing doctors into tiers based on factors such as quality and cost. For example, doctors deemed to be more efficient than average, perhaps because they order fewer questionable imaging scans, might rank in a higher tier. Performance, including favorable patient outcomes, also could boost a doctor's rating.
In such "tiered," or "limited," network setups, consumers may get lower out-of-pocket charges if they see a doctor in a preferred ranking. Patients would typically pay more out of pocket to see doctors who are ranked lower. At the most extreme, consumers may have to pay the full cost of seeing a physician who doesn't make the favorable list.
Mercer, a consulting unit of Marsh & McLennan Cos., found in a 2009 survey that 14% of large employers were using such "high-performance" health-provider networks, up from 12% in the 2008 poll and 11% the year before. Moreover, as the new federal health-overhaul law kicks in, such options may become more appealing, partly because employers will lose some flexibility in terms of the benefits they must provide and may look for other ways to cut expenses.
In the letter, sent to major insurers, the doctor groups argued that recent research from Rand Corp. showed that the health-plan rankings are unreliable. They highlighted a study published in March in the New England Journal of Medicine that used claims data from four health plans in Massachusetts. It found that a two-tiered rating based on costs would incorrectly classify an estimated 22% of doctors.
"Physicians' reputations are being unfairly tarnished using unscientific methodologies and calculations," the letter said. The doctor groups asked the insurers to work with them to re-evaluate their ranking programs.
An AMA spokesman said the group had provided some funding for one of the three relevant Rand studies, but was not the primary source.
"There are serious flaws in health insurers' programs to try to rate individual physicians," said Cecil Wilson, president of the AMA, who said the group feels the rankings shouldn't be primarily focused on costs.
Insurer Cigna Corp. said its doctor-rating program already answers the concerns raised by the Rand research, particularly because it focuses on physician groups, not individuals. But tiering efforts generally make sense, said Dick Salmon, vice president for network performance improvement and quality. "End of the day, some physicians do provide higher-quality or more-efficient care, and it makes sense to provide modest incentives for choosing that care," he said.
WellPoint Inc. said it's "taken a thorough and thoughtful approach in introducing comprehensive measures of physician quality and cost effectiveness" and is "collaborative with the physician community."
A spokesman for America's Health Insurance Plans, an industry group, said insurers are already working closely with doctors to improve ratings, and "quality is the most important factor" in insurers' ranking and tiering efforts, not cost.
