Amid calls for greater transparency in payers' physician ranking programs, many health plans have agreed to a new national model.
Most of the nation's largest health insurers employ a physician ranking system designed to help guide consumers through the process of choosing a doctor. But as the practice of ranking physicians has become more prevalent, it has also come under increasing scrutiny by medical professionals and lawmakers who contend the rankings are too often designed to steer consumers toward the cheapest, and not necessarily the best, doctors.
Last July, the New York Attorney General's office launched an inquiry into insurers' physician ranking programs, saying that insurer-run programs may present a conflict of interest because they are designed to save money for insurers and are not in the best interest of the consumer. In October, the state AG and a host of major health insurers, including Aetna, UnitedHealthcare, Cigna, Empire Blue Cross Blue Shield and Wellpoint Inc., agreed to a doctor ranking model code that requires insurers to be transparent about how they determine their rankings--partly as a way to ensure that the rankings are not based solely on cost. The model also requires that insurers implement a method for consumers and physicians to file complaints about the system. Additionally, insurers agreed to increased third-party oversight of the programs to ensure compliance with the new model.
Nancy Nielsen, MD, president-elect of the American Medical Association, which helped design the new ranking model, praised the move by insurers to voluntarily adopt the changes. "The entire point behind this is to be clear. If [an insurer] purports that this is the best doctor, then we want to know, what's the criteria for best? Under this new model, they won't be able to rank just on cost alone. We really wanted to make sure that if you're going to report on cost, you also report on quality, so patients have the ability to make a true, informed judgment."
Cigna, which offers its ranking service for doctors to policyholders in 28 states, was one of the first insurers to agree to the new model. The insurer already had in place most of the model's principles but did agree to increased oversight, says Dick Salmon, MD, senior vice president for medical affairs at Cigna. "I think that this agreement will help us build on these kinds of principles, which we are fully in agreement with, to establish a national consensus so that as we develop measures of quality and cost efficiency, that all health plans are doing so in a responsible way," he says.
As part of the agreement, Cigna will contribute as much as $100,000 to an independent organization to develop ways to make it easier for consumers to understand the ranking system.
Part of the controversy surrounding physician rankings has been the practice of rewarding consumers for visiting "preferred providers" by offering them lower copays. Nielson says this type of reward system can crush a physician's reputation. "Sometimes the problem may not even be in the ranking itself, but how the health plan designed the benefit by directing a consumer to one doctor and not charging a copay, but then charging a $50 copay for another doctor," she says. "If [insurers] are going to direct consumers to one physician over another, they have to be transparent about why. Is it cost or quality?" she asks.
Blue Cross Blue Shield Association, which also agreed to the national model through its Empire Blue Cross Blue Shield affiliate, contends it has addressed the quality issue through its national program Blue Distinction, which recognizes centers that offer bariatric surgery, cardiac care and transplant services based on nationally established criteria. Carole Redding Flamm, MD, executive medical director at BCBS, says that unlike typical physician-ranking systems, the Blue Distinction program uses quality care data provided by the specialty care centers themselves as criteria for the designations. "We're transparent with regard to the criteria we're looking at, and we put that criteria out there in almost an open book form, so there's never a question about what data we're looking at," she says.
The group plans to expand the program to include cancer care centers later this year, Flamm says. "We've all seen the gaps in quality in terms of delivering evidence-recommended care. Patients are only getting the care they should be receiving about 55 percent of the time. What we are doing is looking at quality and quality improvement, as well as recognizing physicians and hospitals that are doing a good job."
As the national model begins to catch on, Nielsen thinks more insurers will revise their ranking systems to become more transparent. "Insurers would be wise to use the New York model as a national template, and in fact, most plans are already voluntarily going national. It's really not that hard to be fair and accurate. If an insurer is not willing to be transparent, it makes you wonder what they're hiding."