Once you know your practice is being evaluated by payers, monitor yourself using the same metrics to stay on top of your game.
Last year, the California Medical Association and a pair of physicians filed suit against Blue Shield of California dubbing its "Blue Ribbon" program to rate in-network doctors "deeply flawed."
The legal action is the latest in a long line of displeasure with "physician profiling," programs created by insurers like Blue Cross/Blue Shield to rank physicians based on administrative data. Whether through a "ribbon," number of stars, or some other indicator, insurers highlight preferred providers on Web sites, provider booklets, and other outlets based on what their data says about a physician's performance - mostly how efficient they are with care when it comes to healthcare costs.
Research by the RAND Corporation found that payer profiles can be incorrect as much as two-thirds of the time for some specialties, while also misclassifying as many as a quarter of all physicians being evaluated.
J. James Rohack, the immediate past president of the AMA, says the association's two biggest issues with current profiling practices are that the methodology is "flawed and yields inaccurate results," and that "efficiency" refers to measuring costs, without looking at health outcomes.
"Quality-of-care factors are not considered in the cost efficiency measurement process," says Rohack. "Thus, a physician who provides preventive services, like a screening colonoscopy, to his patients may receive a negative rating due to the increased costs of providing those preventive services."
The AMA, like many other physician groups, is promoting pilot programs using alternative methods, but in the meantime, physician profiling doesn't appear to be going anywhere.
Do you know what it takes to be a "preferred" provider for your payers? If not, the result could be more than not seeing a star next to your name. It could be less money coming into your practice.
Trash to treasure
Nearly a decade ago, family practitioner Thomas L. Selznick had a very special place for the profiling reports received from his payers: the wastepaper basket.
Now, Selznick, the managing physician at Livonia Family Physicians in Livonia, Mich., has turned trash into treasure, embracing the information major insurers such as Aetna, Cigna, and UnitedHealthcare send to his office.
"I used to say we had no time for this, but finally, a light bulb went off in our heads and we said, 'wait a minute, [these insurers] are giving us information we don't have access to'…and telling us where we were deficient," he says. "So now, we use that as a positive to help build our practice."
So you may not like physician profiling, but there are ways to use it to your advantage.
John Freedman, a practicing primary-care physician and geriatrician for more than a decade, says it is important physicians protect themselves from any data that is incorrect, miscalculated, or misleading to patients.
But Freedman also notes that finding out about deficiencies in your practice through accurate physician profiling is not ideal. "The last thing you want is for you not to understand that you are actually doing a not-so-good job with a certain category of your patients and then have that show up in a health plan's report card, or even a statewide report card or an employer coalition report card," he says. "That's not the way to find this out."
Delve into the data
As manager of Livonia Family Practice, Selznick says it is "my responsibility" to be sure all the insurance companies he works with have the right information about his office before making their judgment of his efficiency. The last thing you may need is another responsibility, but it can pay off, he says.
"I need to make sure [the data] is accurate," he says, "and I also need to understand that just because I'm the doctor doesn't mean I know everything. We've bettered our practice by utilizing a lot of the reports from insurers on what patients are missing and what they need."
Selznick notes, for example, that payer reports highlighted which diabetic patients needed recommended eye exams, foot exams, and LDL screenings; his practice used that data to call patients to schedule required exams. The result, he says, was improved care to patients and improved pay-for-performance rewards for his practice. The family practice also hired a full-time employee to manage its disease-management program, paid for through insurer incentives.
Selznick's biggest piece of advice to peers: Don't buck the system.
"The system is bigger than you are and if you think you'll be able to win, you'll be one unhappy doctor and you won't enjoy going to work," he says.
So how can you make the best out of physician profiling? Here's some advice.
Know your rights/know the system. Rohack advises practices to sit down and review all their payer contracts and know which insurers have the right to profile physicians. Once you know who is profiling you, learn how they are doing it. Ask for the specific metrics and measurements being used to rate you. Rohack adds that you should inquire how the data will be collected, how evaluations are conducted, and perhaps more importantly, how you can appeal a rating you disagree with.
If quality measures are included in your payer's profiling program, physicians should ask for a complete list of these measures. If there is any concern with the appropriateness of these measures or statistical validity, raise the issue immediately with your insurer.
Check your profile. Don't just check to see what your published profile says, according to our experts, but also request a complete copy from your payers and know when in fact that report becomes public. Rohack says if a physician feels there is an inaccurate ranking, "immediately" request an in-person or over-the-phone meeting with someone at the insurer who has the authority to discuss profiling reports and can change any inaccuracies that come to light.
Measure thyself. Freedman says that once practices know how they are being evaluated by payers, they can monitor themselves using the same parameters. "You need to figure out what is important in the care of your patients and start measuring it," he says. From knowing your percentage of follow-up exams to incorporating patient satisfaction surveys, there are items practices need to know or "that information might come out and prove embarrassing to you, or blindside you by telling you something you did not know," he says.
Educate patients, staff. Rohack says no matter how you feel about physician profiling, take the time to explain it to patients in terms of why there are or are not stars next to your profile, what the stars mean, and how you are looking internally at your practice. The same goes for staff, he adds.
"Practice staff can also play a valuable role in building and maintaining the infrastructure necessary to assess the validity of insurer profiles," he says. "Staff can assist in the development of patient registries and the review of patient records to verify profiling results."
Keith L. Martin is associate editor at Physicians Practice. He can be reached at email@example.com.
This article originally appeared in the March 2011 issue of Physicians Practice.