TMA Supports HB 1392: Greater Transparency In Health Benefit Plan Ranking
Texas Medical Association: Testimony House Public Health
House Bill 1392 by Representative Leibowitz
March 17, 2009
By: Josie R. Williams, MD, MMM, CPE
Good morning. My name is Dr. Josie Williams. I am a gastroenterologist and the president of the Texas Medical Association. Today, I stand before you representing nearly 44,000 physicians and medical student members. Currently, I am an associate professor in the Department of Internal Medicine at Texas A&M University System Health Science Center College of Medicine, and director of the Rural and Community Health Institute and the Institute for Health Care Evaluation at Texas A&M, where I specialize in quality and patient safety initiatives.
I would like to thank madam chair and the committee members for the opportunity to testify in support of House Bill 1392 as it relates to physician rating and classification programs used by health plans and insurers. TMA strongly supports HB 1392 for its fundamental goal of greater transparency in health benefit plan ranking systems. This legislation will ensure patients have reliable information upon which to base their health care decisions.
Background on Current Physician Rankings Systems
Health plans in Texas have created or are creating rating, tiering, and ranking systems that attempt to assess a physician's professional performance against his or her peers or an objective measurement. Currently, the objective measurement and performance standards are not disclosed to the physician prior to the evaluation period, leaving the physician without the ability to modify his or her practice to meet the new standards. The results of the evaluation, which are often imprecise or incorrect, are then made available to the public through a rating or ranking published on a Web site or through the inclusion/exclusion of that physician in a "preferred tier" of the health plan network. The preferred tier to which the physician is assigned is also published.
Physicians' professional reputations can suffer harm when incorrect ratings, rankings, tiering, or comparisons are made public. Patients also are misled because the rankings are portrayed as a "quality" ranking when in actuality, the ranking is a cost-efficiency ranking that is beneficial to the health plan. Patients who rely on incorrect ratings, rankings, or tiering information may have their medical care interrupted if they change their choice of physician based on this erroneous information.
Interim Activity (2006-08)
When Blue Cross and Blue Shield of Texas (BCBSTX) began the so-called practice of ranking physicians based on their quality attributes, it was quickly found that the information used had nothing to do with quality but everything to do with cost. As a result of numerous complaints, TMA appointed an ad hoc committee to analyze the details of the BlueChoice Solutions/Risk-Adjusted Cost Index (RACI) that was used to rank physicians. TMA found that the criteria used was based solely on claims data. Quality of care and better patient outcomes were not part of the analysis. For quality to be part of the rating equation, BCBSTX would have had to validate its patient sample by reviewing actual patient charts. It should provide the tools necessary for the physician to improve outcomes in the future. None of these activities are part of the process.
TMA strongly believes that any ranking system used by any health plan must at the very least include the basic tenets of HB 1392. We believe this legislation would make physician-ranking programs more reasonable, honest, and transparent to patients, employers, and physicians. TMA also strongly believes that if all health plans are held to the requirements of this bill, they could significantly improve their ranking programs in the future for Texas patients.
The Importance of HB 1392 Framework
- Provides that any objective measurements or performance standards be disclosed to the physician prior to the evaluation period.
- Requires that the data used to establish the ratings or tiering be made available to the affected physician prior to publication.
- Provides for a due process/fair hearing between the physician and health plan.
- Requires the health plan to prominently display in the publication a symbol that indicates the physician disputes the rating, tiering, or ranking, if the physician and health plan continue to disagree over the rating or tiering decision.
This legislation ensures patients have reliable information upon which to base their health care decisions.
Problem: Health Plan Ranking Systems Are Based on Cost Not Quality
Many health plans have not instituted any controls or audit functions to ensure the underlying data utilized is accurate. As with any complex system, data corruption takes place, yet there is no effort to ensure the rating of a physician is accurate.
Health plans base physician ranking systems on cost, using claims data. This information has nothing to do with physician quality. Health plans represent to patients that the ratings systems assess a physician's "quality" of practice and whether the physician is "efficient" or "affordable." These terms are inaccurate and deceptive. Health plans do not measure "quality" but merely compare claims data to certain medical interventions they have decided are important. Health plans do not measure efficiency - which would require an evaluation of results. Instead, they assign incurred medical costs by one physician back to the primary care physician. Oftentimes, the primary care physician has no knowledge of the patient accessing another physician or hospital and has no control of those costs. Nonetheless, the health plan dings the physician for them when determining the tier or rank.
HB 1392 Solution
Any standard used to measure physician performance and quality must be evidence-based and at a minimum recognized by the National Quality Forum, Agency for Health Care Research and Quality, and Centers for Medicare & Medicaid Services. Ideally, these measures should be those developed by the American Medical Association-led Physician Consortium for Performance Improvement.
You will hear from the health plans that they prefer to look to the outside entity, the National Committee of Quality Assurance (NCQA) for ranking standards. However, these ranking standards were developed to evaluate the performance of large groups, such as large health plans or large groups of physicians working in the same environment to evaluate data against. You cannot use these same standards to evaluate individual physician practices. Individual physician practices see too few patients with any one disease to adequately evaluate their performance without some sort of risk adjustment. Even then, it is difficult because one small variation in the data, such as a death can skew it. Another method must be developed to evaluate individual physicians. Unfortunately, that system does not exist today. So, in essence what NCQA promotes don't institute any accountability in the market place.
Problem: Physicians Aren't Aware of Their Ratings Until They Are Made Public
Physicians are not made aware of the standards against which they are measured until after the tiered network review period. Thus, a physician has no chance to modify his or her practice to conform to the "standards" imposed by the health plan.
Texas physicians have offered repeated examples of how the input data from claims-based systems are flawed, and how the "assignment" of costs to a given physician is arbitrary. Such systems have been studied and reported in peer-reviewed publications, and conclusions have been drawn that these methods cannot reliably and appropriately assign costs to a given physician.
- Example #1: Dr. B reports in a December 2007 letter that when he asked the health plan representative for specific details on patients, dates of service, and codes used to establish the insurance carrier rating, he was informed the information was not available and could not be obtained.
- Example #2: Dr. S, like many of her colleagues, received a poor rating based on a sample of patients that she did not even treat, or in some cases, were never patients in her practice.
In fact, TMA collects complaints such as those above from physicians each time a health plan publishes its physician rankings. More than 50 complaints were received for one health plan alone on the inaccuracies of the patient sample used to apply the physician rank.
In spite of this lack of validation, health plans are marketing these rating systems to employers and the general public as a way to identify physicians who provide high-quality care cheaply. Health plans also continue to post physician rankings publicly, even when the physicians notify them right away that their data are error-ridden. Health plans, when challenged, have not been able to demonstrate that such systems are reliable, nor that they result in higher quality care at lower cost. This marketing practice is, at best, misleading and deceptive to patients and employers.
HB 1392 Solution
HB 1392 ensures that physicians have the information they need to evaluate the rating system and its effect on their practices prior to the health plan posting it on their public Web site.
Problem: No Formal Due Process to Challenge Health Plan Rankings
Prior to a physicians' public ranking, health plans offer no meaningful way to challenge the ranking, thus allowing the physician to protect their reputation. Most health plans do not inform physicians of the availability of its process to challenge their rating. Moreover, if the health plan does offer an internal appeals process, oftentimes it is one-sided and overseen by the health plan's medical director, and the outcome usually favors the health plan.
HB 1392 Solution
HB 1392 strengthens the health plans' internal appeals process. In addition to having health plan representatives present at the hearing, the bill also requires that three physicians who practice the same or similar medical specialty as the affected physician be part of the process. This approach ensures that the grievance brought forth by the physician will be evaluated and considered fairly. The decision of the hearing panel is binding. If the decision favors the health plan - the health plan may post/publish the physician's ranking or tier. However, if the decision favors the physician, the health plan must modify the ranking or tier before publication. Lastly, if the physician continues to disagree with the rank or tier, the health plan must prominently display a symbol that the physician disagreed with the finding.
Closing
Madam chair and members of the committee, these ranking systems cannot reliably assign costs to a given physician and most assuredly cannot assign quality - but this horse has already left the stable. Even though physicians have pointed out time and again that the data used by health plans is seriously flawed and inaccurate and has no basis in quality, it is something employers say they want to see offered. The best you can do is to support HB 1392 to ensure that employers and patients are making health care decisions about their physicians based on accurate physician data. We also want to stress that the measurement standards used should be reliable, evidence-based, and used consistently across health plans in the market. This is the only way employers and patients can begin to make good health care choices. Thank you again for the opportunity to testify. I will be happy to answer any questions.