Docs hail cost-rat­ing cri­tique

22% of physi­cians mis­clas­si­fied, RAND study says

Modern Healthcare - - The Week In Healthcare - Re­becca Ve­sely

hysi­cians are point­ing to a new study pub­lished last week as fur­ther ev­i­dence that the meth­ods health plans use to rate physi­cians based on cost are deeply flawed.

“This is a com­plete sham,” said Mario Motta, a car­di­ol­o­gist and pres­i­dent of the Mas­sachusetts Med­i­cal So­ci­ety, of the health plan rank­ings. “They’ve set this up to charge pa­tients more and blame the doc­tors.”

The study by RAND Corp. re­searchers and pub­lished in the March 18 is­sue of the New Eng­land Jour­nal of Medicine in­di­cated that 22% of physi­cians in 10 spe­cial­ties would be mis­clas­si­fied in a twotiered sys­tem based on cost. At the top end, the rate of mis­clas­si­fi­ca­tion for vas­cu­lar sur­geons was 36% us­ing a com­mon method of eval­u­at­ing physi­cians based on cost.

The re­searchers ex­am­ined claims data from four un­named com­mer­cial health plans in Mas­sachusetts from 2004 and 2005. A to­tal of 12,789 physi­cians were in­cluded in the study of claims data from 2.8 mil­lion peo­ple, or

Pabout 44% of the state’s res­i­dents. Us­ing so-called com­mer­cial soft­ware, the re­searchers sought to repli­cate meth­ods used by health plans to eval­u­ate physi­cians on cost. This meant con­struct­ing cost pro­files of the physi­cians—group­ing them based on claims for ser­vices, de­ter­min­ing the cost of each episode, cal­cu­lat­ing the av­er­age cost of each episode, and ad­just­ing for pa­tient risk, among other com­plex vari­ables.

The pro­por­tion of physi­cians who were mis­clas­si­fied as lower-cost ranged from 29% for oto­laryn­gol­ogy to 67% for vas­cu­lar surgery. The pro­por­tion of physi­cians who were not classified as lower-cost but who ac­tu­ally were lower-cost ranged from 10% for OB/GYN to 22% for vas­cu­lar surgery, ac­cord­ing to the study. The Amer­i­can Med­i­cal As­so­ci­a­tion seized on the RAND re­port as ver­i­fi­ca­tion of the group’s long-stand­ing op­po­si­tion to such physi­cian cost-rat­ing pro­grams.

“The AMA calls on the health in­sur­ance in­dus­try to aban­don flawed physi­cian eval­u­a­tion and rank­ing pro­grams, and join with the AMA to cre­ate constructive pro­grams that pro­duce mean­ing­ful data for in­creas­ing the qual­ity and ef­fi­ciency of health­care,” AMA Pres­i­dent J. James Ro­hack said in a writ­ten state­ment.

Physi­cian rank­ings based on cost and qual­ity are be­com­ing more pop­u­lar as health plans and em­ploy­ers seek to rein in med­i­cal spending.

Eric Linzer, spokesman for the Mas­sachusetts As­so­ci­a­tion of Health Plans, said that much progress has been in the past five years to re­fine physi­cian rat­ings. “I think we are a long way from where we were in terms of the data pro­vided in the study,” he said. Linzer also pointed to a re­port by state At­tor­ney Gen­eral Martha Coak­ley in Jan­uary that con­cluded that mar­ket clout of cer­tain providers is a main driver of soar­ing health­care costs in the state.

Still, the method­ol­ogy of the rank­ings has come un­der fire.

In 2007, seven health plans op­er­at­ing in New York reached set­tle­ments with state At­tor­ney Gen­eral An­drew Cuomo to re­vise their physi­cian rank­ings. And the Mas­sachusetts Med­i­cal So­ci­ety has sued the state Group In­sur­ance Com­mis­sion—the pur­chaser of health ben­e­fits for state and other pub­lic em­ploy­ees—over physi­cian rat­ings. That law­suit is on­go­ing.

Motta, the so­ci­ety’s pres­i­dent, said that he is ranked in the top tier for Unit­edHealth Group, the sec­ond tier for Har­vard Pil­grim Health Care, and the third tier for Tufts Health Plan. Motta prac­tices at North Shore Car­dio­vas­cu­lar As­so­ci­ates in Salem, Mass.

“That alone shows this is ut­terly un­re­li­able,” Motta said.

Motta: “They’ve set this up to charge pa­tients more.”

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