M.D. ranking pact spawns ire about the practice itself

The new agreement by state Attorney General Andrew Cuomo with CIGNA requiring the health insurance company to adhere to certain standards of measurement and disclosure in its doctor ranking program was hailed by his office as the first of its kind and a model for the nation. While physicians”™ groups were supportive of the agreement, they also questioned the use of doctor ranking programs by insurance companies in the first place, pointing out the inherent conflict of interest due to insurers”™ motivation to cut costs.

“We have an organization that sells a product that”™s in conflict with their bottom line,” said Dr. Stephan Hermele, who has a private practice in Kingston and is secretary of the Medical Society of the County of Ulster Inc. “The fact that (the insurance companies) are doing this evaluation makes it suspect because they”™re expected to err on the side of the bottom line, not patient welfare. If they were truly interested in taking on this case they would do it through an independent entity.”

The attorney general”™s agreement with CIGNA requires the insurer to ensure the rankings aren”™t based solely on cost; use established national standards to measure quality; employ several measures to foster more accurate physician comparisons, such as risk adjustment and valid sampling; disclose to consumers how the program is designed and the doctors are ranked; and appoint a rankings examiner who will oversee compliance and report to the attorney general”™s office every six months.

“I don”™t think it”™s practical,” said Hermele. “(CIGNA) only has to respond every six months and take a pledge they are going by the rules. It”™s a bit of an honor system and there”™s every reason to question it.”

Many people aren”™t aware that insurance companies are ranking doctors on quality and cost efficiency, a practice that started a couple of years ago. Don Moy, general counsel at the Medical Society of the State of New York (MSSNY), based in Lake Success, said some of the plans will add a star to doctors who fail to meet health-quality standards or are seen as cost inefficient.

Moy said the whole notion of quality rankings of doctors by insurance companies is relatively new and fraught with problems. “It can”™t possibly give the entire picture,” he said. “You can”™t judge quality solely on the ranking.” Moy said the agreement reflected the limits of its power: It can prevent fraud and disallow the dissemination of deceptive information, but it doesn”™t have the authority to ban the rankings outright.

For now, most of the insurance company rankings are shared with physicians. However, if the information is distributed to policyholders, the medical societies fear the data could be easily misconstrued. “The science isn”™t complete, and a lot of things can”™t be measured,” said Moy. “But the consumer will only look for the star.” Moy pointed out the huge variation in patients and conditions that could easily skew the rankings. “If a doctor gets a patient who needs a lot of care, he comes across as not cost efficient. If a patient doesn”™t react well to treatment, it could throw off the doctor”™s quality assessment.”

Dr. Gina DelSavio, an orthopedic hand surgeon practicing with Orthopedics and Sports Medicine in New Windsor and a member of the executive committee of the Medical Society of Orange County, said her organization receives a report card from an insurance company and is rated the best of such groups in the county. The report card looks at fairly simple measures of quality, such as how well the specialists communicate with primary care physicians and how long patients had to sit in the waiting room.

“Nothing in these rankings judges the outcome,” DelSavio said. She also objected to another measure that”™s used, which is a comparison of how much is spent on treating patients, such as number of MRIs conducted and the amount of therapy. “That will vary tremendously by specialty and type of patient,” she said. “If this information is published to the public without an explanation, it”™s misleading.”

DelSavio also noted there is no reward attached for a high ranking; the reimbursement levels stay the same. “Unfortunately, the insurance company has a different goal than the patient, which is to steer patients to the doctor that costs the insurance company less money, not the one that necessarily provides better care.” DelSavio said she fears this is the first step by the insurance companies to start limiting their reimbursements to doctors based on certain criteria, which is what they”™ve been doing with hospitals.

So far, the type of rankings CIGNA is doing seem fairly innocuous. CIGNA spokesperson Wendell Potter, based in Philadelphia, said the measures include whether the physician is board certified. The rankings are restricted to specialists, and policyholders can access them through the Web. He said no independent ranking organization exists, so the insurance companies don”™t have that recourse.

“We believe our health plan members have the right to know the best available information regarding the quality and cost efficiency of health care providers,” he wrote in a statement. “We have worked collaboratively with both physicians groups (300) and other organizations to develop measures that are widely agreed upon to be useful in identifying practices that are most likely to deliver positive outcomes.”

The MSSNY noted Cuomo has sent out letters to other insurance providers, including Empire Blue Cross, Preferred Care and HIP/GHI, questioning them about their methodology and warning them against using the ranking program to steer patients to doctors based solely on lower cost.

“(The insurance companies) have more control and less constraint,” said Hermele. “They have more and more power as they consolidate.” In New York the power of the health insurance companies is enhanced by the fact that there are no state-regulated caps on premium increases, as there are in New Jersey and Connecticut,” said DelSavio. The burden of those cost increases is being placed on New York businesses, which is in effect subsidizing the cost of health care in those neighboring states, she said.