• Physician Ranking (Physician Tiering, Clinical Effectiveness)

    • TMA Develops Toolkit to Help You Challenge Unfair Rankings

       Physician ranking (also known as physician tiering) has traditionally been a profiling methodology used by private insurance companies to steer patients toward lower-cost physicians. 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 some classification system to analyze physicians’ costs and determine who spends relatively less than their peers while delivering the same quality of care.

      TMA staff has developed the following two page guide to appealing a health plan ranking or tiering based off HB 1888 which passed in the 2009 Texas Legislative Session. Physicians should use this information in developing their appeal to a health plan if they disagree with their ranking or tiering status.
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  • What is physician ranking?

    • Physician ranking has traditionally been a profiling methodology used by private insurance companies to steer patients toward lower-cost physicians.

        

      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:

      • The criteria used to evaluate a physician must be evidence-based, fair and accurate, and truly evaluate quality and efficient care, not just cost.
      • The criteria or performance standards must be disclosed to the physician prior to the evaluation period, and include adjustments based upon regional variations in population and health status.
      • The data used to establish the ratings or tiering must be made available to the affected physician prior to publication.
      • The system must allow for a due process for the physician to correct inaccuracies in the data prior to the publication of any ranking or tiering decision.

       

      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.  

  • How do I dispute my unfair or inaccurate rankings?

  • Which health insurers are currently ranking physicians?

    • Aetna, Blue Cross Blue Shield of Texas, Cigna, and UnitedHealth are among the plans currently ranking Texas physicians on cost and/or quality of care.

        

      | Aetna | BlueCross | Cigna | United |

        

      Aetna Aexcel

      The specialties evaluated include:

      Cardiology,
      Cardiothoracic surgery,
      Gastroenterology,
      General surgery,
      Neurology,
      Neurosurgery,
      Obstetrics & gynecology,
      Orthopedics,
      Otolaryngology/ENT,
      Plastic surgery,
      Urology, and
      Vascular 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, and
      Pulmonary 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, and
      Primary care 

  • Whom do I contact if I have more questions?