How Good Are Physician Rating Systems?
I would like to hear from our physician friends on this one.
Here is Jason Shafrin’s summary of the UnitedHealth Premium physician designation program:
For quality measures that evaluate adherence, these measures are mapped to evidence-based practices for specific specialties. For example, asthma is mapped to allergists and primary care physicians.
For cost measures, each episode is assigned (attributed) to the one physician who generated the highest percentage of services in an episode, subject to having a minimum of 30% of charges.
Just one more reason I am glad I have retired.
I think the physicians aren’t going to like it.
The Washington State Medical Association [joined by the AMA] v. Regence Blue Shield was settled favorably for the WMA physicians in 2007. Regence was sued for unfair reimbursement tiering. Ridiculous physician “grading” was allowed by Regence. Participating physicians were unable to get their “grades” properly corrected. Under the settlement, the WMA must be permitted to suggest more objective criteria for measuring physician performance and Regence must allow physicians to appeal their “scores.”
I was suing Regence Blue Cross at the same time on behalf of a patient family who lost their insurance reimbursement for immunotherapy because Regence’s medical advisor said enzyme potentiated desensitization, EPD, was not medically necessary and therefore not a covered benefit. The family was not receiving EPD. I never used EPD for anyone ever. That was a fiction made up by their physician medical advisor. Regence’s board even though the independent reviewing company they employed refused to support Regence. Regence refused to “correct” their error and federal judge Cormac Carney said they didn’t have to and granted Regence summary judgment. The matter was favorably resolved for my patients only because Washington State Regence Blue shield was so bad overall. The Boeing Company dropped them and switched their employees to a much better ERISA insurance company administrator, which restored all their workplace benefits.
For the past 30+ years my practice has been exclusively devoted to refractory allergy-immunology patients. By definition, there are no metrics that can be applied to these sickest outliers. Before PPO’s I received uniform unsolicited compliments from 3rd part health insurers. Their representatives would say they were so relieved their patient finally had a correct diagnosis and appropriate treatment.. . because the cost of patient doctor shopping was exorbitant and they wanted good patient outcomes and satisfied employers.
Physician “grading” is a dangerous distraction to doctors who have spent decades conditioned to getting good grades as the normal academic path to becoming a physician. “Grading” is part of these insurers like Regence to narrow their reimbursement to only what they define as the “standard of care” for an average patient.
Why have I never participated as a network physician for an insurance plan? It means that I surrender review by the only three entities I need to be accountable to: (1) God, (2) the Medical Board of California and (3) the patient in deference to the lowest possible standard – an anonymous insurance company doctor or nurse – “peers” who don’t have any experience with the severely allergic who are also immune deficient. The really reputable insurers give my out-of-network patients the in-network deductible, OOP maximum and reimbursement rate because the care is not available in-network. They understand happy patients who get well despite enormous odds are a good business model.
In general the trend is insurance reimbursement for treating outliers is the same rate as for physicians treating the easy patients – even when the time investment and expertise is so much higher.
We are witnessing a evolving catastrophe. . . rationing of medical care benefits by Medicare, Medicaid and 3rd party insurers to complex outliers. . . an unrecognized GENOCIDE of innocent Americans.
Americans trust that their doctor will go above and beyond for the sickest and most complex patients not seeing that it means the physician’s “grades’ / metrics will suffer terribly and in time the physician’s costs will ultimately exceed their gross income based on these very dangerous insurance games devised by our physician “peers.”
Dorothy Calabrese MD
Allergy & Immunology San Clemente, CA
Dr. Calabrese, thanks for your post.
I want to clarify one point of Dr. Calabrese’s statement. Boeing did not drop Regence (of WA state). Boeing’s “home office” is in Illinois (for tax purposes I believe) and the Blue Card Association finally told Boeing that if the “headquarters” are based in Illinois then their insurance must also be based out of Illinois. Insurances, for the most part, are based out of the same state as the business’ headquarters. So, Boeing obtained Blue Cross Blue Shield of Illinois. In Washington State however, we do not have a Blue Cross Blue Shield. We have Premera Blue Cross and we have Regence Blue Shield. So for Washington residents the Blue Card association decides which company will administer which group’s benefits (so that it is all nice and equatable). In Washington state, Boeing employees are still managed by Regence.
Dr. Calabrese I am glad it worked out for you and your patient. Regence can be very bull-headed about its views and nothing short of a court or the Insurance Commissioner will make them budge.
Case in point, the Insurance Commissioner had to issue a cease and desist order to Regence because they were “no longer accepting applications for individual coverage from applicants under 19 years of age.” This was in violation of statutory law and still it took the Insurance Commissioner taking legal action to get it to change.
For clarification of the confusion surrounding the word “dropped”:
the specific Boeing employee patients in our lawsuit against the Boeing ERISA health care plan managed by Regence Blue Shield in Washington State, were residing in and working for Boeing in New Mexico & Alabama [never WA or ILL]
They were subsequently moved over to a Boeing ERISA plan well managed by BXBS of Illinois, which immediately restored their benefits. But they had no contractual authority to restore the benefits denied illegally for years retroactively. My Boeing patients were never insured by a New Mexico or Alabama Boeing ERISA contractor.
Regence of WA illegally denied reimbursement for medically necessary care and could not have been more abusive and arrogant about it. And Regence repeatedly LIED stating the three patients in the lawsuit were receiving enzyme-potentiated desensitization, when they were not. Regence made other repeatedly false statements blaming a top-notch doctor at Regence for making the denials when she wasn’t even there and had nothing to do with it.
AT BOTTOM, the federal courts cannot be the playground of the rich and well-represented, while everyday Americans suffer and die because their access to appropriate care is illegally denied. It doesn’t matter that federal district court judges have lifetime appointments. We must make them accountable to upholding the law as written.
Dorothy Calabrese, M.D.
Allergy & Immunology San Clemente