Like Teachers, Docs Don't Like Being Graded

Physician groups are reacting negatively to the increasing trend of tiered or high performing networks:

Doctor groups are slamming insurers for increasingly using rankings "to steer patients toward certain physicians based on cost or quality," The Wall Street Journal reports.

A letter, sent Monday "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."

The ratings may be used to divide "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." But in their letter, doctors cite a study suggesting that the ratings are unreliable and often inaccurate (Mathews, 7/20).

The New York Times: "Citing research from Rand, the physician groups ... argue that the methods are too flawed to be used to direct patients to individual doctors. 'Physicians' reputations are being unfairly tarnished using unscientific methodologies and calculations,' the societies said." The research, "which looked at physician profiling by commercial insurers in Massachusetts, points out numerous shortcomings. The researchers conclude that 'the work strongly suggests that current methods of physician-cost-profiling are not ready for prime time'" (Abelson, 7/19).

I know every time I mentioned developing these networks at my former health plan employer owned by providers, the network director would run away. She did not want to deal with the politics of it. But it can be done. Priority Health in Michigan has had such a network in place for at least 6 yrs. And it is provider owned.