"Good Intentions: A Pediatrician's Perspective" by Sally Ginsburg, MD

This article is more than 12 years old.

"One way or another, it’s time to look more critically at what we are getting for our health care dollars and identifying which providers serve us better with both skill and efficiency. In the last analysis, giving patients information is the best consumer protection – and the best road to lasting health care reform." Dolores Mitchell Sept 4, 2007 - Commonhealth blog

As I understand it, the Massachusetts Commonwealth Group Insurance Commission, had a mission. They needed to come up with an effective way to reduce health care costs. Their choice was to partner with a few consulting firms (Mercer Consulting and Resolution Health) to generate a platform- a "methodology"- by which they could use physician claims data to rate physicians on quality and cost efficiency. The internet is ripe with articles, blogs, and case studies about the efforts and "successes" of this GIC endeavor. They have used claims data, not clinical data, as the basis for this approach, also known as tiering. Each insurance company contributes its claims data to GIC and to the data mining firms. This data once run through software and analysis is sent back to the insurers to be used as they see fit. Some have used it to develop threshold levels to rank physicians as Tier 1 (excellent), Tier 2 (good), and Tier 3 (standard.) The tiers are then attached to a different co-pay, the physician is listed on the insurer website as a "Tier 1-2 or 3" quality doctor and patients and their families are required to pay a higher copay, the lower the tiering.

As a pediatrician in the state, my "tiering," has resulted in being among the group rated as Tier 2.

In my practice, all but 2 of the physicians are Tier 2 on one plan and 3 of us are Tier 2 on another plan. Some of the other GIC insurers have thankfully decided not to use tiering, "yet."

GIC has stated, in some of their literature, that one of the benefits of tiering is to try to get physicians to learn how to be more efficient and be better doctors. I tried to obtain my data (to become a better doctor.) I called the GIC and was informed that I needed to call each insurer independently to obtain this data. I did. I am still waiting for some of it. When it did arrive in my "inbox" it was an Excel spreadsheet of numbers along with a list of diagnoses. No patient names, no dates of visits used- just numbers. I called the insurers and asked for names to be attached so I could research how to best "learn" from this information. I am still waiting for this. I spoke with the medical director of one of the insurers and was informed that he could not understand why I could not figure out what I needed to do with this information. So I say, the GIC intentions may have been good, but the results are not what they may have intended. Some of these results are reviewed below.

Location Bias:
Here in the western part of the state, during the years 2005-2007 (years the data has been collected), we had no hospitalists, and were rounding on our patients in the hospital. It would be likely that if we were compared to physicians in the eastern part of the state, our "facilities" charges would be higher due to this, not due to a "quality" differential.

Gender Bias:
In my practice of 8 physicians, there are 4 men and 4 women. ALL of the women are Tier 2 and only 2 of the men are Tier 2 on one plan, and 3 of the women and none of the men are Tier 2 on the another plan. Many female patients prefer to see female doctors. Parents will now have to pay a higher copay for their children to see any of the female physicians. Is it possible that the methodology used by the data miners did not take into account the added expenses of working with adolescent female patients (birth control pills, pelvic inflammatory disease, polycystic ovary syndrome, dysmenorrhea, pregnancy etc.?)

Premature Infants Bias:
Newborn premature infants require an inordinate amount of healthcare dollars. One particular medication costs thousands per year, BUT is considered "standard of care" by any medical measure. If a physician follows a number of premature infants (in my case 2 sets of premature twins in one calendar year) and prescribes this medication to my patients, as the AAP recommends, should I be rated a Tier 2 doctor? Please help me understand! I have asked the question, "How am I supposed to change what I do when I am doing what is recommended?" There is no answer coming from the insurers or anyone at the GIC. Best I can tell the only thing that tiering has done is frustrate and denigrate hundreds of pediatricians in the state.

Logistical Nightmares:
My practice is open 7 days a week, 365 days a year. We see patients on the weekends and evenings and all holidays. In the winter there are two physicians to cover the office. If one of the Tier 1 physicians is working and one of the Tier 2 physicians is working, we will have to charge a GIC insured family different copays for each MD. Are they supposed to make their sick child wait until a Tier 1 MD is available so they can avoid the higher copay? This is not a small issue given the economy, particularly in our part of the state.

How would the insurers prefer we deal with the situation when parents brings their 2 children in for well child care- one teenage girl sees the female physician and the teen boy sees the male MD-and there is a 10 or 15 dollar difference in the copay for the 2 children?

Emotional Energy:
For the record, it does not feel particularly good to be selected out to be posted on the internet as a "good" doctor as compared to an "excellent" doctor. All the education about ETGs and HEDIS and PQP data does not make it any easier to see my name as a lower "quality" and lower "cost efficient" MD. Yes, we are labelled as lower QUALITY. There is no way the "average Joe/ Joan" out there is looking at this information and thinking that I am as good as my fellow MD with a Tier 1 rating. Is this slander? Yes, I think it is, particularly if the methodology used is biased and the data employed are flawed. I defy anyone to interview one of these GIC hired consultants and ask them if they have any clinical basis on which they can truly report that I am a lower QUALITY physician than any other physician. The people who are doing this are statisticians-"data miners"- they are not MD's, they are not clinicians. Their sole purpose in developing this data is to SAVE MONEY. All well and good, but don't drag my name in the mud to save money. Tell your patients that you are selecting out the "expensive" doctors. Do not tell them we are a lower quality.

As I see it, although the purpose of the "Tiering of Physicians" by GIC was purportedly to improve the quality and cost efficiency of Massachusetts physicians, it has resulted in none of these things. Physicians cannot figure out, nor do they have the time or the resources to wade through the hundreds of thousands of numbers generated about and "for" them by the consulting firms hired by the GIC. What this has done is pit the patients against the physicians, the physicians against the insurers, and patients against the insurers. Best I can tell, the only beneficiaries of this disastrous experiment are the consulting firms, the people employed by them, and the shareholders of the global consulting firm (parent company of Mercer Consulting) Marsh and McLennan.

There are better ways to contain and reduce health care costs. The state needs to look at the bigger picture. Start at the beginning. Reintroduce physical education and exercise back into the schools. Spend some money to improve the nutritional quality of school lunches and breakfasts. Work on developing after school programs that involve exercise and education about good health habits. These things will prove to decrease obesity which is one of the most expensive problems in health care today. Look at where the BIG health care money is really being spent- high cost, end of life care and very costly and sometimes futile beginning of life care. Stop playing this out on the primary care physicians, before there are none of us left in the state.

Sally Ginsburg is a pediatrician in Longmeadow.

This program aired on April 1, 2009. The audio for this program is not available.