Part of the stated mission of the Health Care Quality and Cost Council, established by the health care reform law, is "to develop and coordinate the implementation of health care quality improvement goals that are intended to lower or contain the growth in health care costs while improving the quality of care."
One approach that I feel should not be used to accomplish this mission, as it relates to physicians, has become known as "tiering," a process that, in theory at least, is supposed to improve physician performance as it relates to efficiency and quality. This program, currently using claims data from health plans, is being used now by the State's Group Insurance Commission for its 285,000 state employees and retirees. Similar physician rating programs have come under fire (and the object of lawsuits) by physicians in Washington state and Connecticut. And New York's Attorney General has called the practice into question, saying it could be deceptive and confusing.
I am not opposed to cost and quality measurements. Indeed, I welcome whatever information that will help me improve patient care and outcomes. But I am concerned about unintended consequences of the current system of tiering; I believe it is simply the wrong approach.
Some of the flaws:
The current system uses years old claims data; the data has little clinical relevance; physicians are not given the data for validation before it is made public; little information is available to physicians, and in too many cases, the information that has been available has contained errors. Also, the health plans providing the data vary so much in their methodology, that the same physician, rated with the same data, can be placed in different tiers by different plans.
Furthermore, for group practices, individual tiering creates costly administrative havoc for patients and office staff trying to accurately assess different co-pays for different physicians in the same group covering each other's patients. Since the data available to physicians and patients is not actionable for physicians to improve cost and quality, the system is essentially punitive for both physicians and patients and does little to improve the overall system of high quality efficient care. The result is confusion for physicians and patients and potential harm to quality care and the doctor-patient relationship.
To its credit, the Group Insurance Commission and insurers have listened to the concerns of physicians and instituted many changes. But the potential for unintended consequences still exists: Physicians’ reputations could be harmed, access to care delayed, and costs unfairly shifted to patients. While we continue our dialogue and exchange perspectives with the GIC and health insurers to reach common ground, let me offer an alternative way to measure cost and quality.
National leaders on quality improvement such as Dr. Donald Berwick have emphasized that successes on improving quality in other industries such as airlines have focused on re-engineering the system rather than on blaming the individual (i.e., victim as well) and only trying to change individual behavior. In the health care industry, Blue Cross has been a leader in this model by providing positive incentives to physicians to do electronic prescribing. As an example of a systems change, this prompts physicians to prescribe less costly generic drugs and monitor drug interactions, side effects, and allergies and eliminates the risks of patient harm from hand-writing problems with drug doses.
We are all agreed on the same goal - to improve quality, control costs, and enhance patient care. We need to make sure that the tools we use to reach that goal are the right ones. Dolores Mitchell, Executive Director of the state Group Insurance Commission, in a September 4 posting on this site, said "In the last analysis, giving patients information is the best consumer protection – and the best road to lasting health care reform."
No argument there. But that will happen only if that information is accurate, reliable, timely, meaningful enough for patients to benefit, and significant enough for physicians to act on and improve patient care.
Michael W. Yogman, M.D. is a pediatrician in Cambridge, Mass.
This program aired on October 10, 2007. The audio for this program is not available.