Physician Profiling

Last year Attorney General Cuomo announced landmark settlements with insurers operating in New York over the issue of physician profiling. Resulting from these settlements, the insurers are now required to submit the rating criteria they use to place physicians in tiered networks, in which members pay lower co-pays or receive discounts for seeing favored physicians. Before this ruling, physicians were unable to learn how they were rated, what criteria were used, how data was collected and really had no way of refuting the results.

Since then, members of the Consumer-Purchaser Disclosure Project adopted The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs. Under this voluntary agreement, health insurers will follow a set of standards, hire an independent entity to audit their programs to ensure they use valid measures to rate physicians, and work toward pooling their data.

The AMA contends all physician-profiling programs must follow standards that require valid methodologies, promote transparency at all levels and assure accurate results and to encourage legislation on physician profiling programs, the AMA developed a model bill, which mandates profiling programs:

Adhere to a set of standards
Use valid quality standards
Properly adjust for risk
Use sufficient sample sizes
Correctly attribute episodes of care

In addition, insurers must fully disclose the methodology used to profile physicians and its limitations and they must profile physicians at the group level, establish a reconsideration or appeal process, and hire an independent third party to oversee the program.

Since New York took this step, Colorado Gov. Bill Ritter has signed legislation aimed at regulating the physician rating systems used by many of his state’s health insurers.
Although there is no perfect system, these regulations and documents such are essential to help ensure the physician performance information health insurers provide patients is both reliable and meaningful. They establish processes that temper some of the inherent risks that can result from physician profiling.

Incorrect and misleading information can tarnish a physician’s reputation and it is unfair to patients who may consider it when choosing a physician. Erroneous information can erode patient confidence and trust in physicians, and can disrupt patients’ longstanding relationships with doctors who know them and have cared for them for years.

Reliable, accurate information that is reproducible and transparent with mechanisms in place for rectifying mistakes will go a long way to help everyone utilizing healthcare.