Doctors Eye Rating Plan with Caution
Friday, July 04, 2008
Robin J. Moody; Portland Business Journal
http://company.angieslist.com/Visitor/News/PressDetail.aspx?i=1183
Many Portland-area doctors are casting a wary eye on a new Providence Health Plan system that rates their performance. Providence is rolling out a system that monitors how well its doctors are meeting the standard of care for 12 measures, including asthma, diabetes and heart disease. Results will ultimately be used, along with other factors, to determine payment amounts for medical groups that do business with the health plan.
When complete, the program will touch at least 1,500 doctors, and will likely save employers money by discouraging wasteful procedures and emphasizing prevention. "Employers have been demanding this of us for years," said Dr. Kevin Keck, chief medical officer for Providence Health Plans, who spearheaded the initiative.
Provider profiling is not new, but many experts say Providence's program is unique locally and years ahead of what other regional health plans have created. Implementing a provider profiling program can be a delicate matter. The Regence Group learned that the hard way in 2006 after it dropped 500 doctors from its Select Network Insurance Plan based on the findings from its own profiling program.
The Washington State Medical Association sued Regence, which ultimately dropped the program and apologized. Providers complained that Regence's methodology was opaque and that the plan didn't give providers ample opportunity to challenge or correct their scores. Providence learned from Regence's mistakes. They brought the Oregon Medical Association and other providers in early to talk extensively about its plans and sought input from doctors. The program also encourages doctors to report discrepancies, which will be corrected. Providence officials have pledged to work with providers with low quality scores, and not to ban providers from its network based on the data.
"Providence has contacted us and asked about our concerns," said Joy Conklin, director of socio-economic affairs for the Oregon Medical Association, a trade group that represents 7,300 physicians, medical students and physician assistants. "They have listened and corrected inaccuracies." However, the medical association and many providers voiced concerns about statistical validity. To be rated, a provider must treat only a minimum of four patients. Others cited problems inherent with using claims data to make inferences about quality.
"The extrapolation of claims-based data to infer whether physicians are managing or preventing diseases is short-sighted, presumptive and inappropriate," said Jeff Baird, administrator for the Broadway Medical Clinic LLP of Portland who previously worked on profiling for the health insurance industry. Baird recommended that administrators and providers keep a close eye on their data, as he has found errors. One provider at his clinic scored poorly on member retention, for example, but when Baird drilled down into data he found 10 of that provider's patients had never set foot in the clinic and were not officially patients there.
Providence officials say their data are "90-plus percent accurate," and point out that using claims data allows them to update scores four times a year. Many providers have accepted the inevitability of the rating system, however.
"Even Angie's List is doing this now," said Dr. Dana Nason, a pediatrician at Hillsboro Pediatric Clinic LLC. "A positive for Providence is that they've been doing data collection for a long time. I have more confidence in them."
When it comes to contracting with providers for payment rates, Providence will use data that's aggregated for an entire medical group, rather than singling out individual providers. Providence will use its "vascular cluster" -- a trio of quality measures for patients with diabetes and vascular disease -- to help it determine pay raises for medical practices, starting in 2010. "If we can show inarguable measures and put money on them, we get better behavior change," said Keck.
Providence Health Plan's provider profiling effort has been launched ahead of a similar effort to collect quality data for medical practices in the Willamette Valley. The initiative, led by the nonprofit Oregon Health Care Quality Corp., will combine claims data for all of the state's major health plans, but data about individual providers will not be provided to the public. Data for that program isn't expected for several years.
Providence Health Plan, a subsidiary of Seattle-based Providence Health & Services, had 265,116 members as of June. While the health plan suffered an underwriting loss in the first quarter of 2008, it has stood apart from its competitors in recent years for strong financial and membership gains. It ended 2007 with the strongest margins in the Oregon market.
The following is a sample of the data measured by Providence Health Plan's new physician profiling system. Not all these measures will be used to rate physicians or to determine reimbursement rates.
- Measures the portion of women between 50 and 70 who have had mammograms within the past two years.
- Measures whether physicians waited a prudent amount of time to do diagnostic imaging for patients with back pain.
- Addressing depression: Measures whether depressed patients under a physician's care receive and fill prescriptions for 6 months worth of psychotropic drugs, the minimum for effective treatment.
- Measures how doctors manage medications for patients with asthma and emphysema in an effort to prevent medical emergencies that lead to costly hospitalization.
- Cardiac care: Looks at how well doctors correct management of bad cholesterol in diabetics patients with heart disease or history of stroke.
- Diabetes: Measures how well providers help patients manage their blood sugar to prevent complications like blindness, renal failure and heart attacks.
- Member retention: Looks at how many patients stay with a provider as an indication of patient satisfaction.
- Emergency department use: Portion of members who access emergency department care during business hours, when they might have been able to see their primary care doctor instead.