AMA challenges insurer doctor ratings

By Bruce Japsen
Posted July 21, 2010 at 7:40 a.m.

The nation’s largest doctor group and state medical societies across the country are calling on health insurance giants to improve the accuracy of how they rate physicians for health plan enrollees and consumers.

Insurance companies say they rate physicians on quality and efficiency measures that allow consumers and health plan enrollees to then choose such a doctor for the price of a lower co-payment. A higher co-payment or deductible might be charged for a less efficient or lower quality physician, insurers and employers that are increasingly turning to such ratings, say.

But the American Medical Association and 47 state medical groups including the Illinois State Medical Society say consumers may be choosing doctors merely based on economic reasoning and inaccurate information of the health plan rather than the quality of care the physician provides.

Therefore, the physician groups are calling on health plans to “submit their physician cost profiling programs for external review by unbiased, qualified experts to publicly document misclassification rates of physicians,” the AMA said in a statement to the Tribune.

The doctor groups cite a recent study by the Rand Corp. that showed such ratings are inaccurate more than 20 percent of the time.

Insurers assign physicians into the wrong “profiling” tier more than one out of every five times and even when they use a two-tiered system, the Rand data shows.

“Patients are being encouraged, and often incentivized, to leave longstanding relationships with physicians they trust,” the AMA and other doctors groups’ letter to more than 40 health plans said. “Physicians reputations are being unfairly tarnished using unscientific methodologies and calculations.

The AMA wrote its letter, signed by 47 medical societies, to health insurers that included the nation’s largest health plans such as Aetna, Inc.; Wellpoint Inc.; UnitedHealth Group, Humana Inc. Health Care Service Corp.,parent of Blue Cross and Blue Shield of Illinois.

Insurers say their programs are independent and subject to input by a variety of parties, including doctors.

“Employers and consumers appropriately demand assessments of the performance and cost of a physician, and our Premium Designation provides that with rigorous, accurate, evidence-based information that is subject to external review, including by the rated physicians themselves,” said Tyler Mason, spokesman for UnitedHealth Group.

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