by Delbert Chumley, MD
BCMS President 2007
Not long after my installation as BCMS president, I received a phone call from a disgruntled member about being excluded from a health plan’s network. This was soon followed by “attacks” from other members in the doctors’ lounge, hospital hall-ways, parking lots, and even once while I was working out at the gym — all regarding the same issue: tiered networks.
All of them had one complaint in common: “they dropped me because I charged more than my colleagues.” Of course, some of their comments weren’t this benign. These physicians were frustrated and angry that they had undergone “economic profiling” without their prior knowledge and that the health plan’s evaluation didn't include any recognized parameters to measure quality of care. I personally know a lot of these doctors and highly respect their clinical skills and judgment. I too was a little miffed at how these physicians could be excluded from any health plan. On the contrary, I would have expected that insurance companies would be knocking down their doors trying to get them on board…wrong again.
This problem is not unique to our city. All major health plans in Texas have, or are in the process of, implementing tiered physician networks based on how physicians rank against the insurers’ criteria. Based on the results of these rankings, published in the plan's network directory, patients and employers are left with the mistaken impression that the tiered network physicians provide better quality of care than their counterparts.
Furthermore, health plans use these tiered networks as an incentive to restrict their enrollees’ choice of medical care by charging a higher co-pay to use out-of-network physicians. Of course, patients think they're getting a great deal by staying in network — “quality care for less”…yeah, right.
Unfortunately, the criteria used by health plans are based solely on bill and claims data. Quality of care, efficiency and patient outcomes are not part of the insurers’ analysis. Cheaper health care doesn’t necessarily correlate with quality. Although cost-effective care is important, it should be measured against other parameters evaluating outcomes and quality and not just savings.
In fact, the medical literature clearly documents that claims data alone is not sufficient to do quality determination. For example, claims data doesn’t reflect variation in patient demographics; deal with multiple physicians caring for the same patient; address aggregate ranking in group practices; adjust for intensity of services, severity of illness, or co-morbidities; and provides only a limited over-view of a physician’s clinical practice.
In today's environment of spiraling insurance premiums, employers demanding accountability for their healthcare investment, and healthcare being the number one topic on our federal government's to-do-list; it's no wonder that health plans are scurrying around trying to come up with innovative ways to improve efficiency.
Too bad they didn't ask the medical community first. I believe the majority of us would work to make healthcare more affordable and effective for everyone. Furthermore, we by nature are a competitive breed and are not afraid of being evaluated as to how we compare to our peers, particularly when it comes to delivery of care. In a way, we've been doing this since college.
What we don't want is to be graded by some arbitrary scheme lacking evidence based criteria which otherwise, if structured correctly, could actually help improve efficiency and effectiveness of patient care rather than merely increase the profit margin of some insurance company.
Your TMA and BCMS continue the battle against this type of profiling through ongoing discussions with insurance carriers and education of our membership. In addition, we will also continue to monitor future practice performance indicators, trying to ensure they are evidence based, clinically relevant, easily reportable and not a financial burden on our membership.
It’s a slow, agonizing process but one which we all must support— not only for the benefit of our profession, but also of our patients.
