Ranking Doctors Using Claims Data Legal

I’ve never liked the idea of health plans using claims data to steer members to doctors. I don't think you can use data to judge human interaction in the patient-physician setting, what actions followed, or the quality of the physician.

But the use of claims data by health plans to steer patients to "quality" doctors is happening more and more , and you ought to be aware of what’s going on out there. Health plans are mining claims data with sophisticated algorithms to rank doctors for quality and economic performance. Doctors in New York State, Washington State, and Connecticut have objected, and have filed law suits, saying rankings focus primarily on cost, not quality.

To address the doctor backlash, George Washington University School of Public Health and the Robert Wood Johnson Foundation did a legal analysis. The analysis indicated rankings are legal under state laws. Their experts maintain physician rankings are critical to a broader movement to measure and publicly report on physician and hospital performance and to help improve the quality and value of health care (Source: Study Underscores Legality of Physician Ranking and Public Reporting Systems When Used to Improve Care Quality, Oct 9, 2007 - Washington, D.C.)

More health plans are rating physicians on quality and efficiency measures and are designing insurance products classifying physicians in tiers. Plans are given incentives to members to select certain high performing physicians. The GW legal analysis concludes transparency is critical when designing a tiering process.

The process should include physicians in the rating process and should be open and visible to physicians and allow their input. Classifying doctors based on the quality and efficiency of services is legal, and so is publishing information regarding health care quality. But undertaking these efforts in the dark could and should lead to physician backlash. Proprietary software should be open to inspection.

Standards should be developed by state insurance regulators in the case of insured plans, the Centers for Medicare and Medicaid Services in the case of Medicare and Medicaid plans, and by the U.S. Department of Labor in the case of ERISA-governed plans.

To me, much of this comes down to who do you trust – hard data from health plans, state and federal government, or subjective opinions of physicians. We shall see if these quality-directed efforts result in better or less costly care – or if they simply justify the economic existence of health plans and add to the bureaucratic red tape already strangling medical practices, or if published data alters the physician-patient relationship.

For doctors, avoiding judgments on quality based on data mining is likely a losing proposition To health plan executives and federal bureaucrats, this aphorism still holds, “In God we trust. All others use data.”
Summary
This is for your information. Your comments are invited.
The George Washington School of Public Health and the Robert Wood foundation have released an analysis saying that health plans can legally use sophisticated algorithms to mine claims data to steer health plan members to physicians whom the data indicates practice quality and economic medicine. The GW and RWJ experts maintain physician rankings are critical to a broader movement to measure and publicly report on physician and hospital performance and to help improve the quality and value of health care. The process, the analysis adds, should be transparent and should invite physician input.
For full story, see www.medinnovationblog.blogspot.com