Thursday, November 22, 2007

Physicians and Health Plans - The Physician-Health Plan Tango

“Tango – A highly stylized dance of Latin American origin in 2/4 time in which the steps are punctuated by glides and sudden pauses.”

Encarta World English Dictionary, 1999

In And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Index Medicus, 1988), I described a tango between HMOs and doctors addressing who should control patient care.

I forecast physicians would rebel against HMO micromanagement. They did. But in the meantime HMOs have picked up the tango tempo by implementing pay-from-performance and physician ranking programs to control costs in the name of quality.

In recent weeks, the tango has reached a new level of intensity.

· In Minneapolis on November 19, The Star Tribune announced the Minnesota Medical Association, representing 11,000 doctors, 60% of the state’s practicing physicians, had issued a report complaining the state’s nine different insurers, using different criteria in their pay-for-performance (P4P) programs, had created unnecessary administrative and cost burdens for doctors. The title of the article was “Minnesota Doctors Turn Tables by Ranking Insurers.” The doctors ranked Minnesota’s nine insurers all of whom had implemented P4P programs. The programs give bonuses to doctors who met certain goals, such as ordering mammograms or checking eyes of diabetics. The doctors say bonuses flowing from P4P weren’t large or dependable enough to justify the expense of tracking compliance or effective in making system changes.

Across the U.S, 150 P4P programs exist with bonuses in the 3% to 20% range. Doctor David Sabin, a University of Minnesota family physician and an expert on P4P, commented, “ I worry about raising a generation of future doctors who do what they do because they follow guidelines. Why? Because they follow the money!” Why, some critics complain, should doctors be rewarded for what they should be doing already.

· In New York City on November 20, New York Attorney General Andrew Cuomo announced UnitedHealth Group Inc. (UNH), Group Health Inc. and HIP Health Plan of New York had agreed to adopt a model for physician-ranking programs.

UnitedHealth said it would apply the model nationwide and planned to launch a doctor-ranking program known as UnitedHealth Premium in New York. The agreement also covered Oxford Health Plans Inc.

"We are witnessing the insurance market correcting itself," Cuomo said, "The three largest insurers in the country have now all said they will apply the principles of our model for doctor rankings nationwide. Leaders in the insurance industry are setting the standard for rating doctors by using a model that was created with the input of physicians and consumers."

The model requires companies to ensure their rankings for doctors aren't based solely on cost, to use established national standards to measure quality of care, and to disclose to consumers how their programs are designed and how doctors are ranked.

Wellpoint Inc. (WLP), Cigna Inc. (CI) and Aetna Inc. (AET) recently have agreed to make similar changes to their physician-ranking programs nationwide.

Empire Blue Cross Blue Shield, a subsidiary of Wellpoint, will adopt Cuomo's model for any future program it adopts in New York state.

And so the tango continues across the health care dance floor– with moves and countermoves, rankings and counter-ranking, forward steps and sidesteps, glides and slides, pirouettes and pauses.

Where will the dance partners be when the music stops?

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