The Massachusetts Medical Society asked 2 consultants to evaluate new programs in place that rate physician performance and reward doctors who do better than others. The press release that explains the conclusions is below. Health insurers and employers are doing this, they say, to help patients get the best care and best value for their money. Many us will soon, if we don’t already, have a higher co-payment when we see doctors with less favorable ratings. But are the ratings fair? Here’s the Medical Society’s assessment…

Waltham, Mass. – Jan. 15 – Independent physician consultants have found that several aspects of the Massachusetts health plan methods of rating physicians on cost and quality do not conform to the Massachusetts Medical Society’s (MMS) principles for fair, accurate and clinically relevant physician tiering systems. The consultants, John D. Freedman, M.D., M.B.A., and Bruce E. Landon, M.D., M.B.A., said these findings “raise concerns about the potential for these programs to adversely affect patients and physicians.”

Freedman and Landon also reviewed the degree to which the health plans conform to MMS guidelines for prior authorization and pay for performance programs. They concluded that most prior authorization programs “are implemented so as to conform to MMS guidelines,” although they represent “an additional administrative burden” for which physicians are not compensated. With regard to pay for performance programs, the authors noted that while health plans generally meet many of the MMS guidelines, some aspects of these programs either partially or completely fail to meet the guidelines.

The MMS guidelines in the three areas – prior authorization for procedures, pay for performance payment systems, and tiering – were developed by the MMS to ensure that cost management and quality improvement initiatives maintain the integrity of patient-physician relationship and support the appropriate delivery of good health care.

B. Dale Magee, M.D., M.S., president of the Massachusetts Medical Society, said, “Drs. Freedman and Landon have provided a valuable service. They have made a painstaking examination of each of the health plan programs, double-checked their findings with the health plans, and indicated where the plans meet the objectives – either completely, partially, or not at all. It’s our hope that plans and purchasers will use this information to improve on these programs.”

Dr. Magee added, “Measuring value and quality in health care can be valuable for patients and physicians, as long as the information being provided is accurate and clinically relevant. The MMS principles provide detailed guidance to health plans and purchasers, and we look forward to working with them to achieve this mutually desirable objective.”

The report analyzed the 2007-2008 tiering programs of the six health plans that participate in the Massachusetts Group Insurance Commission’s Clinical Performance Improvement initiative, as well as for two health plans with tiered physician initiatives that do not participate in the GIC’s initiative. Freedman and Landon’s comments on tiering included:

– For many specialties, the data used are not representative of actual practice
– For both primary and specialty care, “Individual tiering is of concern based on both practical – and analytic grounds.”
– Because physicians in one practice group can be tiered differently, individual tiering adds complexity for both practices and patients
– Tier cutoffs are often arbitrary and could lead to misclassification
– Feedback sent to physicians is often inadequate for improvement purposes

STUDY OFFERS RECOMMENDATIONS

Based on the findings, the study offered numerous recommendations for all three categories, including:

– Exclude highly performing physicians from prior authorization programs, and change prior authorization programs to prior notification

– Because of “substantial limitations” to measuring the performance of individual physicians, consideration should be given to restricting measurement to physician practice sites or groups

– Expand the use of the real-time feedback to physicians

– Adopt common measures, measurement techniques, and common feedback formats where feasible

– Adopt formal appeals processes for physicians rated in tiering programs

– Review health plan initiatives regularly, and modify or eliminate those that do not meet cost or quality goals

– Monitor the potential unintended consequences of these programs on disadvantaged populations and the physicians who care for them