Alice Coombs, M.D., president of the Massachusetts Medical Society, says "tiering," or "cost profiling, " a system used to rate physicians' performance, is deeply flawed: Today, the American Medical Association, the MMS, and our colleagues in 46 other state medical societies delivered a letter to health insurance plans across the country, calling on them reevaluate the programs they’re using to profile physicians’ performance. We want the insurers to demonstrate that their programs are accurate, valid and reliable.
Some background: tiering is a practice that came into vogue some six years ago and purports to rate physicians on cost and quality using administrative data – claims information basically – submitted by participating health plans. It is part of the sweeping trend of transparency in health care, designed to reduce the ever-growing costs of care.
Yet physicians across the country have criticized the process, saying the programs have too many flaws, including the use of years-old claims data with little clinical relevance, the inability of physicians to validate data before it’s made public, the scarcity of the information available to the physicians, and in too many cases, erroneous information on physicians. As a result, physicians reputations could be harmed, access to care delayed, costs unfairly shifted to patients, and the doctor-patient relationship undermined.
Massachusetts physicians have balked at the programs since their inception in the Commonwealth.
The letter delivered today follows three separate studies by the RAND Corporation that prove, beyond a reasonable doubt, that these programs are flawed to their core.
As you know, we have been operating under one of the most aggressive physician tiering programs in the country, created and managed by the Massachusetts Group Insurance Commission, the agency that buys health insurance for all state employees and those in several municipalities.
The GIC developed the program in hopes of giving state employees an incentive to choose lower-cost and higher-quality physicians. If a doctor performs better than average, the patients are charged a lower co-pay for each office visit (usually $15). If the doctor performs worse than average, the patients are charged a higher co-pay for each visit (usually $45).
From the very beginning of the GIC’s program in 2006, we heard from physicians that the GIC program did not fairly or accurately represent the care they provide:
• Many physicians said they were assigned costs from patients they didn’t take care of, or for procedures and services they did not provide.
• Further, when physicians asked for detailed information on their care, the process was cumbersome and not transparent.
• While there is an appeals period, it is much too brief to give physicians a reasonable time to comb through the data, determine where the problems are, and ask for corrections.
RAND research proves that tiering does not accurately report the cost performance of an individual physician. For example, for internal medicine specialists, cost ratings are accurate only 50% of the time -you would be just as accurate with a coin flip!
This is particularly troubling for our primary care physicians, who already struggle terribly to keep their practices afloat. We worry that profiling programs like these would be the final blow for some practices.
We’re continuing to pursue our litigation against the GIC and two of its health plans. Five physicians have joined us as co-plaintiffs in the complaint. We want the court to order the GIC to do what the agency has refused to do willingly, which is to correct what’s wrong with the program.
We support, and welcome, holding physicians accountable for the cost and quality of their care. It’s the right thing. But as RAND demonstrates, this tiering program simply doesn’t get the job done.
This program aired on July 20, 2010. The audio for this program is not available.