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.  

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 |

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 

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 Education
HIT
TMA Practice Consulting
Payment Advocacy
Physician Oncology Education Program  (POEP)  

Or Contact the TMA Knowledge Center:
(800) 880-7955
knowledge@texmed.org
Ask TMA 

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