Stanley Feld M.D.,FACP,MACE
Medical organizations have tried to standardize the diagnosis and treatment of various chronic diseases by creating clinical guidelines as a template for medical care. I was the chairman of the AACE guidelines for Diabetes Mellitus in 1995 and 2002. I have also been the guidelines co-chairman for Thyroid Disease, Thyroid Cancer and Thyroid Nodules for AACE.
The guidelines were based on the best contemporary evidence based medicine available. They were meant to be educational and not used as a weapon against physicians for not following the guidelines. The clinical guidelines were not supposed to act as algorithms to commoditize medical care. The goal was not to develop systems mechanically treat people or evaluate physician care. Quality Medical Care is a complex combination of many processes. Clinical judgment and the patient physician relationship is a key factor in quality medical care.
One of the problems with the guideline phenomenon, in my view, is there are many guidelines on the same subject by various medical and disease specialty organizations. Some guidelines are more detailed than others. The guidelines were meant to be educational guidelines only. The guidelines are also fluid and always changing. The insurance industry is making a grave misstep in creating faulty data points and penalizing physicians for not following its created data points.
The Washington Post article of July 24, 2007 goes on to describe much of the conflict between the insurance industry and physicians. This article is important to review because it touches on a problem that must be solved for any progress to be made in the repair of the healthcare system.
“The trend, ( using quality measurement guidelines) which parallels a push by President Bush to promote consumer access to information about health-care quality and cost, has spurred a lawsuit in Seattle, a physician revolt in St. Louis and a demand by a state attorney general that one insurer halt its planned program.”
The guideline trend does not parallel the push by President Bush. It does not empowering the patient to make an educated free choice of physician. It is empowering the insurance industry to penalize physicians. It is giving the insurance industry a tool to lower reimbursement without due process.
In my view, the lawsuit by physicians in Seattle and the physician revolt in St Louis with a state attorney general exercising his power to stop these programs is warranted. I would say it is about time someone has some guts to say this is not the way to Repair the Healthcare System.
“Analysts assess cost efficiency by looking at factors such as how many and what types of exams were conducted. Was a breast mass biopsy done in a hospital with an overnight stay or in an out-patient clinic? Was a generic or brand-name pain medication prescribed?”
Isn’t this the insurance industry telling physicians how to practice medicine? Isn’t this meddling in medical care?
“A doctor who performs well might be awarded stars, a smiley face or a Tier 1 rating. An inferior doctor’s patients might require paying higher co-payments, or the physician might be shut out of an insurer’s preferred network.”
Isn’t this bizarre? Is this giving patients a free choice? It looks as if the insurance industry wants to solidify its power over patients, physicians and the healthcare system?
“In the Washington metropolitan area, UnitedHealthcare has been gathering and evaluating data on physicians and in January rolled out a Web site that ranks physicians with zero, one or two stars. Officials at the District of Columbia Medical Society said they were told that the goal of the Premium Designation program was to encourage physicians to refer patients to two-star doctors and for patients to seek out two-star physicians.”
“We were shocked that they would be profiling physicians for the past 18 months and not tell anyone,” said Peter Lavine, chairman of the board of the medical society, which met with UnitedHealthcare officials last fall.”
This was a unilateral decision by United Healthcare to use criteria to profile physicians using information that might not be accurate?
“Officials with UnitedHealthcare, the nation’s second-largest health insurer and a unit of UnitedHealth Group of Minnetonka, Minn., said the goal is merely to provide information to consumers and to help doctors improve their performance”.
United Healthcare acted without consulting with physicians or physicians’ organization about what they were doing.
“Our focus is really on transparency,” said Lewis Sandy, UnitedHealth Group senior vice president for clinical advancement.”
The use of the word transparency is an insult to medicine and the healthcare system; United Health has done everything in its power to avoid revealing its true costs and its true payments to hospitals and physicians to the consumer. United Healthcare with its high paid administration (1.8 billion over 8 years for its CEO) has been the villain before many times in the past.
“UnitedHealthcare announced it would delay launching its program in New York, New Jersey and Connecticut after doctors complained and after New York Attorney General Andrew Cuomo threatened legal action.”
United Healthcare is gracious enough to delay launching the program in other places. It did not do anything to right the wrong in Washington D.C.
I think physicians should boycott United Healthcare. Another insurance company would get the point and step up and take business away from United Healthcare.
“One doctor fighting ratings systems is Seattle internist Michael Schiesser, who said his rating plummeted from excellent to the 12th percentile within a few months. He said initially Regence BlueShield, an insurer in the Northwest, ranked him in its top 90th percentile of doctors and awarded him a $5,000 check.”
“Later, when Regence cut him from its network and patients had to pay out-of-pocket to see him or go elsewhere, he pressed to see his report. He said he discovered that he had been penalized because of errors in data-gathering.”
“I couldn’t believe the extent to which they had botched the data,” he said.
“He said Regence faulted him for failing to control diabetes in patients who did not have the disease. He said he was docked points for not performing a Pap smear on a woman who had a hysterectomy. He added that his colleague was faulted for not performing a mammogram on a woman who had undergone a double mastectomy.”
This is not unusual. First of all, where is the due process? Has the State Board of insurance given this insurance company the authority to do this? This is where the State Board of Insurance must exercise its power. It is the government agency that grants insurance companies the license to sell insurance in the state and judge its tactics.
Last fall, Schiesser joined five other doctors and the Washington State Medical Association in suing Regence BlueShield, claiming defamation and deceptive business practices after the health plan told participating members that they no longer had access to about 500 doctors because the doctors did not meet the insurer’s quality and efficiency standards”.
Bravo to these physicians. Patients and employers should be right behind them in protesting.
“Regence spokesman Charlie Fleet said that because of the lawsuit, the company could not comment on the data issue. He did say, however, that the data were “provided from the physicians themselves.”
In my opinion this is typical babble from an insurance company spokesperson. The insurance company has overstepped the line and should have its license to sell insurance in the state rescinded.
“In December, Regence abandoned its plan.”
Essentially Regence admitted its error. Where is the State Board of insurance examiners penalty?
“Doctors critical of ratings systems say they are held accountable for whether patients exercise, take their medications or follow their prescribed regimens.”
Here in lies the charade and exposes the faulty evaluation system. Quality measurements were adopted because they are easier to measure than clinical outcomes. Quality measurements may be sensitive in picking up differences between physicians. Many studies show an overall poor correlation between such measurements and clinical outcomes. It is probable that the weak association is due to an inability and unwillingness to measure the many processes involved in medical care such as patient compliance and the physician patient relationships. These processes may have a positive or negative effect on the clinical outcome.
The criteria the insurance companies are using are faulty. Patients and physicians must demand a stop to this faulty profiling.
“Berkenwald, the Massachusetts internist, said he was pushed from Health New England’s top 10 percent of physicians into its second tier because several of his female patients did not get the mammograms or Pap smears he prescribed.”
“But Berkenwald received a top-tier rating by several other insurers participating in the state’s Clinical Performance Improvement Initiative because the health plans use different cut-points for determining who falls into which tier.”
“Disparate ratings can confuse patients and cause turbulence in group practices.”
The disparate ratings also cause anxiety and anger in both patients and physicians toward the insurance industry.
“Despite its flaws, proponents say the systems encourage much-needed quality and cost control.
Dolores Mitchell, executive director of the Massachusetts Group Insurance Commission, which launched its physician-rating program four years ago, said she’s heard doctors’ complaints about errors. But at $1 billion in annual spending on health care, she said, improving performance and efficiency is crucial.”
Someone should tell Dolores Mitchell this is not the way to do improve performance and efficiency.
“The data may not be perfect,” she said. “But they’re better than any data that we’ve had before.”
This kind of thinking will not repair a dysfunctional healthcare system.
It will only create more dysfunction while increasing the insurance industry’s bottom line.