Insurers are rating the quality of your care. Do you know what they're saying?
Michael Schiesser, MD, never expected to be penalized for not administering a pap smear to a patient who'd had a total hysterectomy and no prior cancer history.
An increasing number of plans have begun publishing ratings of individual physicians, in part to steer patients to doctors who follow generally accepted standards of care. Quality ratings initiatives typically rely on claims data to measure how often a doctor's patients receive treatments or tests deemed appropriate for their conditions, such as blood-glucose tests for diabetics.
"I was shocked by the lack of precision on their part," he says.
Schiesser's rating plummeted. As a result of the downgrade, his patients who were covered by that plan and wanted to continue seeing him would have been required to pay all costs out of pocket.
The insurer later dropped its quality ratings initiative, due in part to complaints from patients and physicians. Schiesser, five other doctors, and the Washington State Medical Association (WSMA) filed a defamation suit before the parties reached an out-of-court settlement in which the insurer agreed to consult with the WSMA before launching any future physician-performance-measurement programs.
As part of the settlement, Schiesser agreed not to publicly criticize the insurer. He spoke with Medical Economics on the condition that he be permitted to abide by the terms of the settlement by not identifying the insurer. A spokeswoman for the insurer declined to answer specific questions about Schiesser's case.
Though Schiesser was ultimately vindicated, his experience with ratings left behind an unsavory taste. He calls them "an offensive tactic that gives power to the insurance companies. Any time you create a judgment or report card, you're exerting a force that puts the other party on the defensive."
Though his experience may be far more extreme than that of other physicians, Schiesser is not alone in his distaste for the current model of quality rating. Critics say rating systems are inherently flawed, based on incomplete data, misleading to patients, and potentially damaging to physicians' livelihoods.
Backers of the plans, meanwhile, say they create more-engaged, better-informed consumers and can aid in the delivery of more affordable health care.
David Page, MD, a family physician in Camillus, New York, believes properly implemented rating systems can promote adherence to generally accepted standards of care. "If [insurers] do it on the right stuff and in the right fashion," he says, "it will improve quality."
But according to American Medical Association President Nancy Nielsen, MD, such systems still have room for improvement.
"Doctors are not thrilled about them at all," she says. "These are doctors' reputations. This is serious business when [ratings] go out to the public."
Susan Pisano, spokeswoman for America's Health Insurance Plans, a trade group representing insurers, says her organization doesn't track the number of insurers that have introduced quality ratings or the number of states in which the programs exist.
But such programs have proliferated in recent years, and most major health plans now make them available to members in some form. Cigna, for instance, offers rating programs in 28 states, accounting for 88 percent of its members. UnitedHealthcare provides them in 132 markets nationwide, and Aetna reaches 35.
Quality reporting is also a priority for the federal government. The Centers for Medicare & Medicaid Services has begun offering bonus payments to physicians for reporting quality data that could be used to overhaul how CMS pays physicians. Already, CMS requires hospitals to report data for 42 quality measures. Hospitals that fail to do so can be docked up to 2 percent of their reimbursement, according to CMS. (To learn more about CMS's Physician Quality Reporting Initiative, read the web exclusive "From PQRI to P4P?" at http://www.memag.com/PQRI.)
But some doctors might need more convincing before they embrace ratings.