Health plans increasingly are introducing physician rating systems to help customers select their doctors--and, in turn, defray rising costs--but it remains unclear whether they actually provide any benefits to customers or are unfair to physicians.
Tiering often ranks physicians based on cost efficiency and adherence to performance benchmarks. Thus, a higher physician rating could lead to lower co-pays and out-of-pocket costs for patients, reports Insurance News Net. However, a recent study in the Journal of Bone and Joint Surgery reveals that physician-tiering guidelines and results are not consistent across insurance companies, do not fully define quality and could confuse consumers.
One particular problem of physician ranking systems is insurance companies' failure to agree on the criteria that vault a physician into the top tier. Since ratings are not consistent among insurers, a physician is often rated differently from one plan to another, the study found. Additionally, patients need more information about physician tiering. While health plans display a physician's tier in online and printed directories, explanation of stratification methodology and its relation to quality of care is limited. Currently, for example, there is no evidence to suggest that physicians ranked in a second tier provide lower quality care, according to Insurance News Net.
One such rating system that has garnered national attention is Blue Shield of California's Blue Ribbon Physician Recognition Program because a physician group filed a lawsuit to stop the ratings. Blue Shield says its program provides members with information identifying physicians who scored highly on evidence-based performance measures. "Quality transparency is critical and long overdue. Californians have access to quality information on hospitals and medical groups, but, prior to the launch of the Blue Ribbon program, had no information on their individual physician," Blue Shield told FierceHealthPayer. "Our Blue Ribbon program ... is breaking new ground in healthcare quality transparency," said the plan.
However, the California Medical Association disagrees, claiming the program could harm doctors and their patients by promoting inaccurate information. CMA's lawsuit alleges that the rating system is flawed and amounts to an economic profiling scheme in which Blue Shield intends to direct patients to doctors who charge less, the Sacramento Business Journal reports.
Blue Shield responded, saying its program "does not consider cost and does not penalize physicians." It clarified that physicians had "ample opportunity" to review their reports. If the claims data did not completely reflect patient care, physicians can enter a reconciliation process to correct any omissions. "Blue Shield proactively notified physicians of our plans and strongly encouraged them to avail themselves of this process," Blue Shield said in a written statement. "The total time for submission of corrections from date of mailing was eight weeks."
Also, once a patient receives a recommended service, all physicians to whom that patient had been attributed received credit for that service, whether that physician or another physician provided the service.
Perhaps the solution to this disagreement, like so many in this world, lies in the middle ground. Insurers could find tools that better analyze physicians' rankings and could improve their description of their rankings for consumers. Physicians could work with insurers to create a more unified system that is based on quality, not cost. But until then, the courts are left to determine whether Blue Shield's rating system will survive. - Dina
Editor's note: Dina Overland is a healthcare journalist based in Metairie, La.