Quality or Cost Control?

Texas Physicians Concerned About UnitedHealthcare Initiative


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Medical Economics Feature - September 2005  


By  Ken Ortolon
Senior Editor  

Is UnitedHealthcare's new Premium Designation Program an effort to improve both the quality and efficiency of care delivered by physicians in the United network, or is it merely another attempt at cost control and economic credentialing of doctors? Houston and Dallas physicians who attended presentations on the program are skeptical that it can provide any true measure of quality.

But whatever it is, one thing is certain: Despite what some physicians say United is telling them, the Texas Medical Association doesn't endorse it.

United officials unveiled the Premium Designation Program for TMA leaders during a July 12 meeting in Austin, and subsequently outlined it for physicians in the Houston, Dallas-Fort Worth, and San Antonio areas.

The company describes the program as "an initiative that identifies and recognizes network physicians whose UnitedHealthcare claims or survey data demonstrate their clinical practice is consistent with evidence and consensus-based standards as well as cost effective."

The purpose of the program, the company says, is to augment information resources that help patients make informed choices in selecting physicians and hospitals and that support physicians in the practice of better quality and more cost-efficient care.

"We look at it as an important empowerment issue for consumers and an important process to work in collaboration with physicians," said Mark Lindsay, United's vice president for public communications and strategy. "The marriage of those two, we think, is going to add up to a good process."

Physicians will be evaluated on quality of care for patients treated for chronic illnesses, such as asthma and diabetes, as well as several surgical procedures, including coronary bypass, major joint repair and replacement, and spinal procedures. Eligible specialties include allergy, cardiology, cardiothoracic surgery, endocrinology, family medicine, infectious disease, internal medicine, nephrology, neurology, neurosurgery, orthopedic surgery, oncology, pulmonology, and rheumatology.

Specialties excluded include colorectal surgery, dermatology, gastroenterology, general surgery, hematology, neonatology, nuclear medicine, obstetrics-gynecology, ophthalmology, otolaryngology, pediatrics, plastic surgery, rehabilitation medicine, therapeutic radiology, urology, and vascular surgery.

Physicians who meet either the quality standards or efficiency standards will be designated with one star in the company's printed and online network directories. Those who meet both standards will get two stars. Those whose specialties are excluded or for whom there is insufficient data to analyze will be designated with a triangle. 

Where ' s the Quality?  

As of late July, TMA was analyzing the program. But on first blush, TMA leaders say they have numerous concerns, foremost of which is the manner in which United proposes to measure quality.

San Antonio pathologist William Hinchey, MD, chair of the TMA Board of Trustees, says United bases its review under the Premium Designation Program entirely on claims data.

"I'm very leery," he said. "The way they're collecting the data is all by claims information and no review of medical records."

Wichita Falls pathologist Susan Strate, MD, chair of the TMA Council on Socioeconomics, says the sole reliance on claims data is a fatal flaw.

"It's not at all clear that the quality data is based on good evidence-based medicine," Dr. Strate said. "They are basing their quality designation totally on claims data. Claims data is the easiest and cheapest way to get at any kind of information but it is not accurate.   You cannot get good, solid, quality information based on claims data. You must do a medical record review."

Webster pediatrician Angelina Farella, MD, attended the presentation for Houston-area physicians and has a large number of United patients. She says claims data cannot tell United reviewers whether an asthma patient, for example, has a mild, moderate, persistent, or severe condition.

"It's all based on their claims," she said. "Well, I don't write that I did a peak flow meter on my claims, so how do they know?"

Mr. Lindsay, however, says there are practical concerns about how information from medical records could be transmitted "in a de-identified, standard way across the country" for use in physician evaluation.

Even though United officials say the program won't initially be used to punish or reward physicians monetarily, Dr. Farella says it could have a tremendously negative impact on physicians who don't receive the designation because patients will be encouraged to see doctors who do. 

Getting at the Truth  

Meanwhile, TMA has received several complaints from physicians who attended the Houston and Dallas-Fort Worth meetings that United officials claimed TMA endorsed or supported the Premium Designation Program.

In an e-mail to some 13,000 TMA members, TMA President Robert T. Gunby Jr., MD, emphatically denied TMA had endorsed the program or plans by United to create a Texas physician advisory committee.

Dr. Gunby said he left the July 12 meeting with "numerous questions about this new 'quality initiative.' I don't find it to be 'transparent.' On first blush I find it to be yet another antipatient, antiphysician attack from managed care. I am incensed -- but not surprised -- that United has twisted the facts to imply TMA's support."

In a July 21 letter to United attorney Michael Ile, TMA General Counsel Donald P. Wilcox, JD, asked the company to stop claiming that TMA had endorsed the designation program.

"As you may recall, we had the same problem with United in years past saying that TMA endorsed its managed care contracts after meeting with United on our concerns with respect to those contracts," Mr. Wilcox wrote. "We respectfully request that United correct what appears to be a culture of deceptive conduct on the part of its employees, its misstatement of the facts, and cease and desist this activity."

Mr. Ile denied any misrepresentations. He says United presenters merely mentioned that United had met with TMA, Harris County Medical Society, and others to discuss the program.

"We view this type of outreach to be a critically important component of our communication efforts with physicians, and we think it appropriate to mention these efforts in meetings of the type you described," he said.

Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at  Ken Ortolon.  

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