Physician-rating initiative is deeply flawed in practice.

Byline: Frederic H. Schwartz

COLUMN: AS I SEE IT

The Group Insurance Commission is responsible for providing benefits for state employees in Massachusetts, including retirees and their dependents. These benefits include health insurance, life insurance and disability insurance.

The executive director of the GIC, Delores Mitchell, has been understandably increasingly concerned about the three pillars of the health care crisis in this state - access, quality and cost. To address the latter two pillars, i.e., quality and cost, Ms. Mitchell hired a top-dollar human resources consulting firm, Mercer Inc., to develop a methodology that would utilize financial levers to incentivize physician performance.

Specifically, Mercer devised a system that would assign individual physicians to one of three categories of performance: above average, average and below average.

Physicians rated as above average would be rewarded by having their GIC patients having the lowest co-pay for each visit and physicians rated below average would have their patients assigned the highest co-pays. For example, an above-average physician office visit co-pay might be $10, an average physician co-pay $20 and a below-average physician co-pay $30. Theoretically, these financial levers would lead physicians to "improve" their performance and/or patients to change to a "better" physician.

Unfortunately, what may be reasonable in theory has not been implemented appropriately in practice. Despite numerous medical professional organizations (i.e., American College of Physicians, Massachusetts Medical Society) uniting in their recommendations on how to make any physician rating system fair, accurate and meaningful, the Mercer product has failed to achieve these targets.

It is interesting that a recent attempt by two national for-profit health insurers, UnitedHealthcare and Cigna, to implement physician tiering in New York state was aborted by New York Attorney General Andrew M. Cuomo. However, in this case it is a state agency that is using a considerable amount of taxpayer dollars - not to mention dollars that could be potentially used to improve state employee benefit programs - to implement this deeply flawed initiative.

Why is physician tiering as implemented in Massachusetts flawed? First, Mercer, for unclear reasons, did not abide by the principles as agreed to by multiple medical professional organizations. Specifically, the reports that are mailed to individual physicians provide a numerical rating and the category (above average, average, below average) they fall into. However, there is no information as to the number of patients used for the assessment or the specific parameters (i.e., cost or quality measures) applied. The report is essentially unintelligible to the recipient, i.e., physician, and provides no information that would provide opportunities for meaningful changes, or facilitate improvement, in physician practice.

It is for these reasons that the Massachusetts Medical Society is supporting House Bill 4693, currently pending before the Joint Committee on Health Care Financing. This bill, as stipulated by the society's Legislative Committee, would prohibit the GIC or other insurers from using a physician performance evaluation system unless it included appropriate safeguards, such as: prior public disclosure of the methodologies used; meaningful input by independent practicing physicians to ensure that the measures used are clinically important and understandable to patients and physicians; mechanisms to ensure data accuracy and validity that includes feedback and corrections prior to public reporting; and measures to provide physicians with individual patient information on cost efficiency and quality measures.

There is no doubt that our nation faces a health care crisis in terms of access, quality and cost. There is also no doubt that physicians have a significant role to play in addressing these critical deficiencies. Our real challenge is to address these issues in a way that will lead to drastically needed improvements in health care delivery. The GIC initiative, albeit well-intentioned, will not lead us in that direction.

Frederic H. Schwartz, M.D., is a general internist in private practice in Worcester and an instructor, University of Massachusetts Medical School.

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CUTLINE: Frederic H. Schwartz