New York Attorney General

Using claims data for doctor ratings poses big problems

Fri, 23 May 2008 06:59:59 -0400

In theory, physician ratings and rankings aren't as scary as they used to be a few years ago.

With activists like New York Attorney General Andrew Cuomo helping to spark systematic changes in such programs, health plans aren't shooting from the hip as much as they were before. Not only do health plans have to "behave" in New York, they're taking the new standards with them to their entire commercial populations (such as Cigna, which brought in the NCQA to oversee its entire ranking system).

Not only that, it's looking like some big stakeholders are starting to agree on what they want to measure. According to a recent announcement from the oh-so-respectable Robert Wood Johnson Foundation, a group of leading stakeholders in provider rating including the Leapfrog Group, the National Business Coalition on Health, the AFL-CIO, the American Medical Association and America's Health Insurance Plans have all agreed on a "Patient Charter" that sets principles for measuring doctors' performance. That ought to help, right?

Still, not everybody's happy, despite the progress that's been made to date. For example, just consider the Massachusetts Medical Society, which is suing over rankings it says are capricious and actively defraud consumers. It's main beef is that the claims data health plans are using to rank its members just don't cut it.

And there, folks, is one of the most stubborn obstacles to straightening this mess out. Let's say that the industry's leaders all agree on what's fair and reasonable to measure clinically, and that they reach some grudging consensus that cost is an issue worth using as some form of ratings scale. Given the extraordinarily complex, flawed and cryptic puzzle that is claims data, it seems unlikely that anyone can use it to make fair deductions about physician performance on a granular level.

OK, I realize that some of you will blanch when you read that, but I have to tell you that the preponderance of what I've read and seen suggests that this is true--if for no other reason than that in attempting to do a good job and pay fairly, the system is breaking under its own weight. (If you think I'm way off base, please feel free to write and tell me so. Some of these folks might be first in line.)

Look, it seems pretty clear that some form of ranking will arrive at some point. But in the meantime, it just isn't going to work to force quality numbers onto a data set that arrives at the door broken. Maybe, when we have a fully-implemented electronic medical records universe out there, we can rethink the whole thing. For now, perhaps health plans can come up with some other way of motivating doctors to play ball? - Anne

CIGNA launches site offering doctor, hospital rankings

Fri, 23 May 2008 06:59:57 -0400

CIGNA has launched a national website ranking doctors and hospitals by cost and quality measures, along with providing its beneficiaries with several additional tools to help them obtain care. Not only does the site rank providers, it also names hospitals in specific regions with the lowest death and complication rates. In addition, it offers lists of questions patients can ask their doctor in regards to specific conditions, and offers patients tools to help them locate nearby pharmacies with the lowest prices.

At least where New York physicians are concerned, Cigna's program will be under the scrutiny of a fierce watchdog. New York Attorney General Andrew Cuomo has investigated several of the state's health plans as they rolled out rating and ranking programs, and Cigna was one of the plans asked to sign an agreement detailing the practices it would adhere to in establishing ranking programs. Cigna has since hired the National Committee for Quality Assurance to oversee its ratings program for the entire U.S.

To learn more about CIGNA's rankings program:
- read this Atlanta Journal-Constitution article

Related Articles:
Cigna hires NCQA to check its doctor rankings
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Physician ratings are here to stay

UnitedHealth's Ingenix faces mounting legal troubles

Mon, 05 May 2008 06:59:58 -0400

A couple of months ago, New York Attorney General Andrew Cuomo rocked the health plan industry when he filed suit against UnitedHealth Group. In the suit, Cuomo argued that UHG was committing consumer fraud in how it sets rates for paying out-of-network physicians, specifically by setting artificially-low rates that leave consumers with big bills. Not only is this a big deal for UHG itself, it's a problem for the health insurance industry as a whole, as several major health insurers also use Ingenix data to set rates.

Now, a consumer is raising the stakes a bit by attempting to get class action status for a suit against Ingenix itself. In the suit, which was filed in Connecticut, plaintiff Jeffrey Weintraub contends that he was defrauded by a conspiracy in which health plans calculate lowball, out-of-network rates using bogus Ingenix data. Weintraub also names UHG, Oxford health Plans, Aetna, Cigna and other insurers in the suit.

Meanwhile, the industry is still waiting for Cuomo to drop the other shoe. While New York's AG has promised to sue Ingenix, he hasn't done so yet. Cuomo has said that he is investigating an "industry-wide scheme perpetrated by some of the nation's largest health insurance companies to defraud consumers."

To learn more about the case:
- read this Modern Healthcare article

Related Articles:
NY sues UnitedHealth over MD payments
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Errors force BCBS of TN to postpone doctor ratings

Tue, 11 Mar 2008 07:59:55 -0400

Dogged by complaints that its data was inaccurate, BlueCross BlueShield of Tennessee has put its planned doctor rating program on hold. During a 60-day review period BCBS gave doctors, the physicians came back with many complaints about inaccuracies. For example, the data sometimes suggested that they didn't perform certain tests, even though the doctors had such tests documented in their own records. In such cases, the health plan has been allowing doctors to submit their records to supplement the claims data it uses for ratings. After it responds to doctors' questions and concerns, BCBS of Tennessee still expects to publish physician quality and cost data, which will be available to privately-insured members through a secure web connection.

Unlike its health plan brethren in New York, BCBS of Tennessee doesn't have to live up to any regulatory or legislative standards in compiling the data. It will be interesting to see whether this furor raises calls to create standards such as those proposed by New York Attorney General Andrew Cuomo and the New York state legislature. My bet is that such state-driven guidelines are likely to pop up in other states soon, and I'm betting Tennessee will be no exception.

To learn more about this controversy:
- read this article from The Tennessean

Related Articles:
New York considers physician-ranking legislation. Report
The fuss over physician ratings. Report
Restaurant ratings firm Zagat, WellPoint rate doctors. Report
TX doctors slam quality ratings system. Report

Cigna hires NCQA to check its doctor rankings

Mon, 10 Mar 2008 07:59:58 -0400

Over the past few months, New York Attorney General Andrew Cuomo has been challenging the physician ranking programs state health plans use. To make peace with the AG, the health plans have agreed to several guidelines for ranking physicians--including hiring an outside "ratings examiner" that would make sure that its physician grades were fair. Now, Cigna hired the the National Committee for Quality Assurance to oversee its program, a move that sets the quality bar high for its competitors and arguably, could expand the overall mission of the venerable quality group. NCQA execs also have said that they expect to announce that they'll be overseeing ratings for several other health plans, as those health plans arrive at final settlements with the state. In the meantime, Cigna's initial review by NCQA should be finished by late May.

What's interesting about this is that with NCQA involved, the New York settlements will have wide ripples nationally. For one thing, NCQA standards will bleed over into rating programs Cigna and others use elsewhere in the country. Meanwhile, since NCQA has a strong employer constituency, its involvement is likely to raise employer understanding of the process. This could prove to be a real turning point in the whole rankings movement.

To find out more about the NCQA's role here:
- read this Modern Healthcare piece (sub. req.)

Related Articles:
Cigna makes MD rating deal with NY. Report
Another two health plans agree to NY doctor-rankings system. Report
Aetna strikes doctor-ratings deal with NY. Report
The fuss over physician ratings. Report
Restaurant ratings firm Zagat, WellPoint rate doctors. Report