Many insurers are increasingly offering incentives for patients to chose physicians deemed as providing lower-cost, and some plans award bonuses to doctors who are deemed “low cost.” Similarly, the health care reform legislation promotes “value-based purchasing,” which would rely on a classification system to analyze physicians’ costs and determine who spends relatively less than their peers while delivering the same quality of care.
According to research, however, many physicians who have been ranked as “lower cost” doctors according to a common formula used by insurance companies are not actually treating patients for any less than physicians with comparable practice patterns. Cost-ranking physician profiles currently in use are not scientifically sound and are poor indicators of the quality of care provided to patients.
TMA believes that neither Congress nor any other institution or company should publicly profile and penalize individual physicians based on faulty methodology. We believe that any standard used to measure physician performance and quality must meet the following:
TMA discourages implementation of any ranking system to evaluate physician performance unless it is based on solid science. Inaccurate information only serves to mislead patients and physicians without improving the quality of care or reducing costs.
That bill passed in the 2009 Texas Legislature. Physicians should use this information in developing their appeal to a health plan if they disagree with their ranking or tiering status.
Basic Steps for Reviewing and Disputing Physician Rankings & Tierings
| Aetna | BlueCross | Cigna | United |
The specialties evaluated include:
Cardiology,Cardiothoracic surgery,Gastroenterology,General surgery,Neurology,Neurosurgery,Obstetrics & gynecology,Orthopedics,Otolaryngology/ENT,Plastic surgery,Urology, andVascular surgery
Blue Cross Blue Shield of Texas Blue Compare
Blue Cross has posted the presentation from the Dec. 22, 2010, webinar about its program. It was the only webinar the company conducted on the program, which rates some 18,000 Texas physicians.
TMA's Payment Advocacy Department staff and an ad hoc committee of physicians have developed a toolkit to guide physicians on how to appeal their ranking.
The specialties evaluated include:
Allergy-immunology,Cardiovascular disease-noninterventional,Cardiovascular disease-interventional,Endocrinology,Family practice,Geriatric medicine,Internal medicine,Nephrology,Neurology,Obstetrics and gynecology,Pediatrics,Pediatric allergy-immunology, Pediatric pulmonary disease, andPulmonary disease.
Cigna Care Designation
Almost 20,000 physicians in Houston, Dallas-Fort Worth, San Antonio, and Austin are being rated.
Specialties evaluated include:
Allergy/Immunology,Cardiology,Cardiothoracic surgery,Colon and rectal surgery,Dermatology,Endocrinology,Family practice,Gastroenterology,General surgery,Hematology,Internal medicine,Nephrology,Neurology,Neurosurgery,Obstetrics/Gynecology,Oncology,Ophthalmology,Orthopedic surgery,Otolaryngology,Pediatrics,Pulmonology,Rheumatology, and Urology.
UnitedHealth Premium® Designation
The UnitedHealth Premium® designation program evaluates doctors in 20 specialties, including:
Cardiology,Internal medicine,Obstetrics/Gynecology,Orthopaedic surgery,Pediatrics, andPrimary care
Quality and efficiency are key components of The Patient Protection and Affordable Care Act. While the specifics of these programs are still in development, two themes remain consistent: a continued focus on performance reporting to drive improvement, and an emphasis on new payment approaches to ensure quality while curbing costs.
View the online course, Efficiency, Accountability, Transparency: Are You Ready?, and take the time to learn whether your practice is ready to face the demands of public and private payers as they push forward value-based purchasing programs.
Refer to these portions of the TMA website:
Deadlines for Doctors Continuing Medical EducationHITTMA Practice ConsultingPayment AdvocacyPhysician Oncology Education Program (POEP)
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