By Christopher Guadagnino, Ph.D.

Anthony Aquilina, D.O., MBA

Published April 2008

• React to this article in the Discussion Forum.

Physician "report cards" – ratings of physician quality and efficiency made publicly available by health plans and other entities – are undergoing major transformation, as key developments are spurring improvements in substantive validity and methodological transparency.

Many physicians have viewed attempts by health plans to publicly profile the quality of their care as an assault on their reputations using crude measures of cost masquerading as valid measures of quality. In Dec. 2006, for example, Regence BlueShield agreed to drop a new "performance-based network" after a lawsuit by the Washington State Medical Association claimed that the health plan defamed physicians when it told thousands of patients that their doctors did not meet the quality and efficiency standards to be included in the new network, which the association said were based on inaccurate information gleaned from outdated claims data.

Last October, a settlement agreement between Cigna Corp. and New York Attorney General Andrew Cuomo sent ripples throughout the industry and raised expectations for physician report cards nationwide, holding them accountable to greater accuracy, transparency and oversight. Cuomo’s industry-wide investigation stemmed from consumer protection concerns, and the settlement wrote that "any initiatives to measure quality and cost-efficiency of physicians, such as the Cigna Care Network, have the potential to cause confusion if not conducted and communicated appropriately."

Under the settlement, Cigna agreed to:

· Ensure that rankings for doctors are not based solely on cost and clearly identify the degree to which any ranking is based on cost.

· Use established national standards to measure quality, including measures endorsed by the National Quality Forum (NQF) and other generally accepted national standards.

· Employ measures to foster more accurate physician comparisons, including risk adjustment and valid sampling.

· Disclose to consumers how the program is designed and how doctors are ranked, and provide a consumer complaint and physician appeals process.

· Nominate and pay for an independent ratings examiner, who must be a national standard-setting organization, to oversee compliance with all aspects of the new ranking model. Cigna and Aetna have selected the NCQA as their ratings examiner.

In a noteworthy passage, the settlement stipulated that Cigna will disclose to consumers "that physician performance ratings are only a guide to choosing a physician, that consumers should confer with their existing physicians before making a decision, and that such ratings have a risk of error and should not be the sole basis for selecting a doctor."

Cuomo had also sent letters to Aetna and UnitedHealthcare and other insurers, warning that their physician ranking programs were likely to confuse consumers, while Aetna in mid-November agreed to adopt the standards of the Cigna settlement, and other insurers are following suit.

Just last month the National Committee on Quality Assurance (NCQA) proposed new requirements, fleshing out many of the principles in the Cuomo settlement, for the physician component of its Physician and Hospital Quality Program – a certification of physician measurement program credibility – with the goal of improving the substance and transparency of physician report card systems.

Notwithstanding the promise of physician report card improvement spurred by the Cigna settlement and NCQA’s proposed new guidelines, some physicians, researchers, and even health plans, continue to express reservations that the limits of existing quality measurement resources inevitably constrain the validity and fairness of report cards, and they note that:

· Collecting quality information from administrative (claims or billing) data is far less precise than collecting it from patient chart review, which may be cost-prohibitive.

· There are areas of clinical care that lack evidence-based measures, particularly for interventional procedures.

· Physicians may not have an adequate number of patients covered by a particular insurer to assess their performance on a given measure with statistical validity.

· Risk-adjustment methodologies for scoring physicians on patient outcomes largely remain black boxes, despite their pivotal role in rendering valid and fair comparative ratings.

· Report cards typically rely on a small number of performance measures accounting for a fraction of a physician’s clinical activity, and represent them as a proxy for the entirety of a physician’s clinical competence. High performance scores are not necessarily a sufficient indicator of good care, nor are low scores reliably indicative of poor care.

· There is considerable variation of measures and methodology across health plans, so a physician may receive different scores by different insurers.

· Performance measure scores often depend on factors beyond a physician’s control, such as patient compliance.

Health plans have already begun to address what the Center for Studying Health System Change (CSHSC) identifies as the most common complaint by physicians about report cards: lack of communication about their designations and how their performance is assessed. Many insurers are now proactively providing physicians the opportunity to vet data before it is published in a report card, including the opportunity to provide patient chart-level information to correct perceived inaccuracies.

As health plans wrestle with the other reservations in an attempt to win physician buy-in for the report cards, they face competition by consumer-driven Web sites with no such quality improvement agenda. There are perhaps dozens of commercial Web sites that rate physicians on the basis of online satisfaction surveys. These Web sites often display written comments by individual raters about physicians, and aggregate satisfaction scores, although they do not verify the identities of the raters, or even whether they were patients of the physician they are rating. The Web sites also tout their immunity from defamation lawsuits.

Health plans have a stake in the credibility and utility of their physician rating systems, and regard physician report cards as part of their transparency initiatives to drive informed consumer choice. According to the CSHSC, the purposes for which insurance companies publicly profile physician quality and efficiency include:

· Offering tiered benefit options to consumers and purchasers, allowing different co-pays and coinsurance for using physicians with different quality/efficiency designations.

· Offering pay-for-performance rewards to physicians.

· Inviting patients to consider the quality and efficiency ratings when choosing physicians.

· Spurring quality and efficiency improvement among physicians through public accountability and/or patient steerage.

Basing physician report card scores on meaningful data is a key goal of all stakeholders, and several efforts are underway to produce valid measures, although incorporating them into health plans’ physician profiling systems faces considerable challenges.

"I have yet to see a process report card from a payor that I would take seriously," says public reporting expert David Dranove, Ph.D., professor of management and strategy, Northwestern University Kellogg School of Management. Physician report cards fall far short of hospital report cards, he says, as they rely much more heavily on process measures and on much smaller numbers. There are virtually no guidelines for a physician’s diagnostic skills, which would require following patients’ care and outcomes much more closely than is possible through claims data, e.g., using patient questionnaires to measure whether pain level was reduced, or when they were able to return to work, adds Dranove. Without a better, integrated system for collecting data on clinical and outcome measures that capture more patient idiosyncrasies, says Dranove, "We are far from having a meaningful public report card for physicians."

Reporting meaningful scores is important, as research on report cards demonstrates that consumers do respond to bad news, with hospitals and health plans losing 10 to 15 percent of their market share after scoring in the bottom of the rankings, while report cards appear to have no market impact on the best performers, says Dranove. No similar research has yet been conducted for physician report cards, and Dranove says it is not known whether they would drive consumer choice of physicians, given that such a choice is much more personal in nature, and often is driven by word-of-mouth recommendations. Regardless, health plans want to advertise their networks and will use physician report cards to pitch high-quality physicians, and in some cases offer tiered benefit products, Dranove adds.

Meaningful data must be made available to consumers in a convenient manner that minimizes complexity, so it is justified to aggregate scores to cut to the chase, according to Dranove.

"Currently, the best way to find the best physicians is to ask other physicians," while "finding some way to harness their knowledge could go farther than any third-party report cards could," says Dranove.

Basing physician performance profiles on claims data, as health insurers typically do, is "like judging a restaurant by the bill," says William W. Hinchey, M.D., president of the Texas Medical Association (TMA), which is encouraging health plans instead to base physician performance on samples of patients’ medical records. In Dec. 2006, Blue Cross Blue Cross and Blue Shield of Texas agreed to delay the launch of an online physician report card after the TMA objected to the reliance on billing information and found errors in the proposed rankings – for example, downgrading an orthopedic surgeon because billing data that showed two knee operations on a patient (implying that the first operation was unsuccessful) failed to reveal that the second operation was performed on the patient’s second knee, weeks later, by a different surgeon, notes Hinchey. "Physicians have a right to know what they’re being judged on, and there needs to be an appeals process," he adds.

Just last month, Blue Cross Blue Shield of Tennessee delayed rollout of its physician profiling consumer Web site by request of the Tennessee Medical Association, which said it found missing and incorrect data.

The American Medical Association recognizes that "claims data is where everyone is starting," and that there are inaccuracies in claims data, but also that it is extremely expensive to collect data from medical records, according to AMA President-elect Nancy H. Nielsen, M.D., Ph.D., who notes that there needs to be the opportunity for physicians to correct inaccurate data. "We are not all enemies, and quality has to be the primary goal. We hope insurers will also give physicians information on how they can do a better job, including the names of noncompliant patients, so that we can improve care," Nielsen notes. "If their goal is cost-reduction, patients need to know that," she adds.

"We have national agreement on what needs to be measured," says Nielsen, pointing to the development of physician quality measures by the AMA-convened Physician Consortium for Performance Improvement (PCPI), validation of the measures by the NQF, and implementation of the measures by the AQA Alliance – a collaborative of physicians, consumers, purchasers and health insurance plans.

"Health plans are at the table with the AQA, although physicians are concerned that different plans select different measures for different clinical conditions" for their physician ratings, while the alliance is trying to reduce that variation, according to Michael Barr, M.D., MBA, a member of the AQA Alliance and vice president of practice advocacy and improvement, division of governmental affairs and public policy of the American College of Physicians. "It is still relatively unknown how well the current measure sets are working, who is using them, and how burdensome they are to collect," adds Barr.

"Physicians are very used to being reported on, but the underlying ‘angst’ is: are we getting measured on valid measures of patient safety and quality, and on things that we can control," says Pennsylvania Medical Society President Peter Lund, M.D., who sits on the PCPI, which is developing evidence- and consensus-based physician quality measures across several specialties. The consortium includes representatives from more than 70 national and specialty medical societies, the NCQA, the Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality and the Joint Commission. CMS has awarded a contract to the PCPI, the NCQA and data collection firm Mathematica to develop measures of physician quality to guide the federal Physician Quality Reporting Initiative.

When developing quality measures, the PCPI uses several criteria, says Lund, including that they:

· Be reliable, valid and based on sound scientific evidence.

· Affect a significant number of patients.

· Have a significant impact on patient outcome improvement.

· Reflect processes of care that physicians can influence or impact.

· Be evaluated in relation to cost of care.

· Reflect a spectrum rather than a single dimension of care (e.g., prevention and health promotion, chronic illness, acute care and procedures).

· Balance completeness and measurement burden.

The PCPI acknowledges that health plan claims data are the logical starting point for implementation of measures, while it recommends moving beyond claims and other administrative data to electronic health records as soon as is practicable. Lund notes that CMS’s Physician Quality Reporting Initiative is also exploring the use of patient satisfaction surveys to include as one of its metrics. The CMS initiative currently offers financial incentives to physicians to offset their data reporting burden, as an additional set of "G-codes" which include clinical data extracted from patient charts must be entered on Medicare claims to transmit the additional quality information to CMS. But Lund concedes that the current level of financial incentive has not yet induced widespread physician participation, calling into question whether a similar approach would work for physician report cards offered by commercial health plans.

To avoid "economic pressure to pollute the data," health plans should separate physicians’ quality ratings from their efficiency ratings, and chart review has to be part of a quality review, says Richard Scott, M.D., president of the Medical Society of New Jersey (MSNJ). "Claims data are only meaningful if health plans go the extra mile," for example, when assessing how often patients are referred for colonoscopies and mammograms, the measurement should be restricted to patients over 50 years old and should not rely exclusively on whether a physician billed for those tests – which could make some referrals invisible. Claims-based measurement "requires insurance companies to go beyond ‘Did they pay for a test,’ which is their first stab at the data, and must factor in patient compliance," says Scott. When judging mortality statistics for a specialist, "they’re going to have to hire coders to do chart review to test their case mix algorithm" and ensure an accurate account of patient severity, Scott maintains.

Insurers’ efficiency rating criteria are not transparent enough for physicians to know their expectations, says Scott. "It’s still a black box that is defining where they draw the line for a physician to earn their star," he says.

Last month, the MSNJ’s board adopted a policy statement laying out a set of minimum standards that all physician ranking programs must meet:

· Assessments must be based on accurate, current and adequate data that can be validated; is risk-, severity- and outcomes-adjusted; is based on statistically significant sample sizes; and includes chart review to verify and support administrative claims data.

· Quality assessments must be based on nationally recognized quality standards, such as those established by the NQF, using evidence-based medicine. The methodology for determining cost-efficiency must be clearly disclosed and should identify the extent to which it is based on costs outside the control of the particular physician – including pharmaceuticals, referrals and facility costs.

· Data and methodologies used for ratings should be transparent to physicians and all stakeholders, and quality and cost-efficiency should be determined separately, or the allocation of each in a combined rating should be disclosed. The rating system should be explained in plain language, which also makes clear to consumers that no negative inference should be drawn about a physician who is not ranked.

· The rating program must allow adequate time for review and correction of incorrect data, and should include an independent appeals process. Physicians should be free to opt-out of an assessment, either before or after it takes place. All rating programs should be reviewed by an independent body to assure that it meets minimum standards.

Many of those principles were part of New York Attorney General Andrew Cuomo’s agreement with Cigna, as well as NCQA’s proposed update to its physician performance program certification program for health plans.

There is still considerable variation of physician rating system methodology and content across health plans, according to Phyllis Torda, NCQA’s senior executive for strategic initiatives. NCQA’s proposed changes to its physician performance program certification would hold health plans accountable to higher standards of clinical detail and transparency and, while some 40 percent of health plans now earn the NCQA’s distinction for their physician performance programs, Torda anticipates that a larger percentage will seek NCQA designation under its new standards. Many insurers are proactively modifying their programs according to the provisions of the Cigna settlement, she notes. "Health plans want to satisfy purchasers and consumers, want to let physicians know they have a ‘good housekeeping seal,’ and also want to avoid legal and regulatory actions," says Torda.

Under NCQA’s old standards (revisions are expected to be finalized this July) health plans could report only efficiency measures if there were no evidence- or consensus-based quality measures for a given physician’s specialties, and major insurers were not being transparent about the measures or methodologies they used for their physician ratings, says Torda. The past two years have seen development of a wide range of measures by organizations such as the PCPI and the NCQA, which has developed a version of Health plan Employer Data and Information Set (HEDIS) for physicians. The NCQA’s proposed updates to its physician quality program certification respond to rising expectations by providers, consumers, purchasers and regulators for greater accuracy, fairness and utility of physician ratings, Torda adds.

Among the proposed changes is specifying key requirements that health plans must pass, with a score 50 percent or higher on each "must pass" element, to achieve NCQA certification. Among those "must pass" criteria are: that statistical validity be achieved by using a sample size of at least 30 observations for individual performance measures; that the method for attributing patients to physicians is disclosed; that at least 50 percent of the plan’s measures be national, standardized measures; that case-mix adjustment be used in calculating cost measures; that quality be considered in conjunction with cost measures, and the relative weight of each be disclosed; and that a thorough process for working with physicians is demonstrated, including giving physicians at least 45 days notice before making ratings public and having a process for physicians to request corrections or changes.

Many health plans are already implementing the latest validity and transparency principles in their physician report card systems, while acknowledging the limitations of existing quality measurement resources.

Under Cigna HealthCare’s quality and cost-efficiency profiles, a physician can earn up to three stars in quality either for earning the NCQA Physician Recognition Award (offered for diabetes care, cardiac and stroke care, spine care, and care coordination/information system implementation); or for being in the top third of their peer group in adherence to evidence-based measures derived from those endorsed by the AQA Alliance, NQF and HEDIS, according to Jim Nastri, Cigna’s vice president of product development and product management for consumer-driven products. A one-star rating is given to physicians in the bottom 2.5 percent of adherence to the guidelines, and two stars are displayed for board-certified physicians, he adds. Cost-efficiency stars reflect a specialist’s cost-efficiency relative to market peers using an episode treatment group methodology, which looks at medical costs (including inpatient, outpatient, laboratory, radiology and pharmacy) for an episode of care, and includes case-mix adjustment to account for differences in the severity of patients’ illness, says Nastri.

Cigna’s initial rating system, launched in 2005, had assigned a "Cigna Care" designation to physicians based on a roll-up of quality and efficiency into one score for each of 21 specialties, while quality had been based solely on the NCQA and board certification criteria, Nastri notes. Cigna now separates quality and cost-efficiency ratings, and bases the quality ratings of 11 specialties on evidence-based measures, while the other specialties continue to be rated based on board certification and NCQA recognition, says Nastri. A total of about 40 measures are used across the 11 specialties, averaging three or four measures per specialty, which Nastri says represents those that are agreed upon by the NQF and the AQA Alliance as valid.

"We don’t have access to physicians’ patient charts, or whether a patient complies with a physician’s recommended care, so we take an ‘outlier approach’ that differentiates the top and bottom of the quality ratings. In the middle range, it is difficult to tell if it’s a practice pattern behavior or a patient compliance issue," Nastri says. While Cigna relies on claims data for its scoring system, Nastri doesn’t think a physician is materially affected by the limitations of that approach "if the physician is always or never meeting the guideline requirements." Cigna would consider using chart review "if it becomes administratively feasible," he says. The quality ratings are updated twice a year, and Cigna offers physicians access to the data on demand, Nastri adds, noting that the profiles are offered to members in select markets, including the Philadelphia and Pittsburgh regions, as well as in northern and southern New Jersey.

The ratings display includes the qualifier that the profiles reflect a partial assessment of quality and cost efficiency, that they should not be used as the sole basis for decision-making, and that Cigna encourages members to consult with their treating physician as they select a specialist for their care.

Cigna tracks the monthly hit rates of its online physician profiles, which Nastri says are still fairly low, with perhaps one to two percent of Cigna’s roughly 10 million members viewing the profiles. There is generally high interest in a handful of specialties, he notes, particularly ob/gyn, cardiology and dermatology. Cigna’s online provider directory is heavily used, with about 15 million hits per month, and Cigna offers the physician profiles within the directory that members are accessing for other purposes, Nastri adds.

Aetna, in 33 of its markets including Pittsburgh and northern New Jersey, touts a "performance network" of specialists by assigning an "Aexcel" designation to physicians in 12 specialties – such as cardiology, gastroenterology, ob/gyn, and urology – who meet both clinical performance and efficiency standards. Aetna focuses its physician profiling on specialty care because that is where medical technology and care costs are rising, while it believes that ranking primary care physicians might be too disruptive to the patient-physician relationship, according to Don Liss, M.D., Aetna’s medical director for the mid-Atlantic region. "An intelligent, engaged consumer can discuss with their primary care physician where to go for specialty care," he adds.

Aetna’s Aexcel Web site informs members that, depending on their Aetna health plan, they may pay more out-of-pocket for care from specialists who are not part of the Aexcel-designated network. The Web site also includes extensive qualifiers about the designation system, including that the patient should consult with their existing doctor before choosing a specialist, that "all ratings have a risk of error and, therefore, should not be the sole basis for selecting a doctor," that "a perfect risk-adjustment mechanism that accounts for all variations in patient population still does not exist," and that absence of an Aexcel designation does not mean a physician does not provide quality services, and might mean that they are appealing their designation status or do not present sufficient data for Aetna to evaluate them.

To be considered for the Aexcel network designation, specialists must have managed at least 20 cases within their specialties for Aetna members over the past three years. They are then are evaluated for clinical quality, based on Aetna’s claims data, according to their adherence to evidence-based guidelines from NCQA, AQA, NQF and other sources, says Liss.

The Aexcel Web site lists five clinical performance measures and their sources used to rate ob/gyns for the Aexcel quality designation (i.e., cervical cancer and breast cancer screening rates, appropriate HIV testing for pregnant patients, expected rate of hospital readmission and number of complications for hospitalized patients), and six for cardiologists (i.e., use of beta blocker for patients with history of heart attacks, use of ACE inhibitor or ARB in patients with chronic heart failure, use of statin medications for patients with cardiac disease, how often cardiac patients take appropriate preventive medication, hospital readmission and complication rates).

More precise clinical performance measures are difficult to obtain for the remaining 10 specialties, says Liss, and Aetna relies entirely on hospital readmission and complication rates for their quality designation. Liss acknowledges that using administrative claims records limits the precision of quality data that can be obtained from those specialties, and he says Aetna would like to see more precise, valid measures emerge.

The cost of data extraction makes patient chart audits a "non-starter," he adds. Asking physicians to supply more granular quality data via "G-codes," as for CMS’s quality reporting initiative, is not yet realistic because of the administrative burden, and the number of physicians actually reporting those codes to CMS "is tiny," says Liss. "Payors haven’t coalesced around them, and still need to discover whether payment incentives are the best way" to induce additional coding by physicians, he notes. For health plans to realistically consider looking beyond administrative claims data for a physician quality reporting initiative, says Liss, they must have a significant enough market share to make it worth a physician’s time and effort to report their patients’ quality information, which could be further facilitated by the use of electronic medical records.

In the meantime, Aetna does not use a strict standard to discriminate quality performance, excluding only the outliers from the Aexcel quality designation: about 96 percent of specialists evaluated for Aexcel pass the quality designation criteria, says Liss.

Aetna’s cost-efficiency determination compares all the resources – inpatient, outpatient, diagnostic, laboratory and pharmacy – used to treat a specialist’s patients to those of other specialists in the same specialty and geographic location; specialists in a group are evaluated at the practice level. The threshold for a specialist to meet Aetna’s cost-efficiency designation is set at roughly the 50^th percentile, depending on the market, while Aetna lowers the threshold (but only for specialists who have met the Aexcel network’s quality criteria) if the Aexcel-designated network of specialists in a given location is not broad enough to meet the needs of Aetna’s membership, says Liss. Aetna also allows members to view negotiated reimbursement rates for the 20 most common E&M and procedural services for individual specialists, he adds.

Aetna re-evaluates specialists’ performance every two years for the Aexcel network designation, while it proactively sends physicians a list of patients they’ve treated for whom they are showing a deficit for any of the measures, and encourages physicians to present any additional data from their medical charts that is not available to the insurer through claims data, says Liss.

Geisinger Health Plan, in central Pa., bases its online primary care Physician Quality Summary on board certification and various other measures, including HEDIS preventive health and chronic care measures, patient satisfaction and access, office hours, efficiency of care and emergency room utilization, according to Anthony Aquilina, D.O., MBA, medical director of medical operations, quality and performance. Physicians are benchmarked to their peer group among Geisinger’s participating physicians, and while measurement is done at the physician level, the ratings are displayed on the Web site at the practice level – which Aquilina says is the level at which patients typically choose a physician. Each practice receives one star for meeting Geisinger’s basic standards, two stars for exceeding them, or three stars for exceeding them by a statistically significant amount. Physician practices receive a separate star rating for each measurement category, and ratings are updated twice a year. While Aquilina acknowledges that a sufficient number of measures is needed to present a valid and fair rating of a physician practice’s overall quality, he cautions that, "if you use too many of them, physicians say they want to focus their improvement efforts on the most important areas."

Geisinger’s physician ratings are tied to pay-for-performance incentive bonuses – at the individual physician level – based on a physician’s aggregate score for all of the metrics: the lowest performance tier earns no bonus; the middle tier (65^th percentile or above) earns a bonus of $2 per-member-per-month plus $4 per visit for products (like a PPO) with no assigned primary care physician; and the highest tier (85^th percentile) earns $4 per-member-per-month plus $9 per visit for non-HMO products. Aquilina regards those payment bonuses as essential to motivating physician improvement. "We don’t think it would be anywhere near enough without the pay-for-performance component," he says.

"We haven’t moved into the specialty care rating arena because those quality measures haven’t been tested, and we don’t yet know what constitutes a good measure," adds Aquilina.

About 50 percent of Geisinger’s primary care physicians are not yet eligible for the bonus payments because Geisinger’s geographic expansion has not yet garnered sufficient patient volume for many physicians to render valid data, notes Aquilina.

Geisinger adopts a hybrid approach to collecting the performance data, supplementing claims data with patient chart review using HEDIS sampling methodology, says Aquilina. "Claims data are actually better for some information, for instance when a primary care physician doesn’t know whether a patient received a diabetic eye exam. We know whether it was done," he says. "A combination of chart review and claims data is best," he maintains, noting that claims data will miss some rendered care that is not appropriately billed for, such as giving patients free samples of asthma medication, or combining a well-visit with an acute visit. "That information may only be in the chart, depending on the documentation," says Aquilina.

Within the next year, Geisinger plans to pilot an online "Member Health Alert," allowing its primary care physicians to view a list of their patients who appear to be noncompliant with some of the quality measures, and allowing them to send to Geisinger patient chart data to refine the accuracy of their scores, Aquilina notes.

The key measure of the rating system’s success, according to Aquilina, is the percent of Geisinger’s membership who go to the best-performing physicians. "Originally, we thought the public choice aspect would be as important as the physician improvement component," says Aquilina. "Three years ago, 26 percent of our members were going to physicians at the highest level of performance. Now it is 46 percent, and that is almost entirely because of physician improvement," Aquilina notes, adding that he doesn’t see significant shifts in patients among physician sites. "Patients are not yet using the tool to make decisions about physicians in any large numbers, although that may change," he says.

Performance transparency can drive physician behavior in other ways. In a UnitedHealth Group pilot study using data from its Premium Designation Program one and a half years ago, the insurer shared the names of interventional and noninterventional cardiologists in its "performance network" with primary care physician practices and asked whether they would consider referring their patients to those high performers, says Lewis Sandy, M.D., UnitedHealth’s senior vice president, clinical advancement. The number of referrals to the "premium" cardiologists increased by 6.3 percent across the pilot’s six markets, and increased by 22 percent in one of the markets, Sandy notes. UnitedHealth has since expanded the program to other markets and specialties, Sandy adds.

Over the past year, in some of its markets, UnitedHealth has also begun to offer automatic fee schedule enhancements to physicians in all 21 specialties who have met the quality and efficiency criteria of the Premium Designation Program, says Sandy.

Highmark Blue Cross Blue Shield, in December, enhanced its online "Physician Selection Advisor" for pediatricians, family practice, and internal medicine physicians by supplementing its existing quality measures – board certification and NCQA recognition – with quality measures culled from its physician pay-for-performance program, according to Kim Bellard, Highmark’s vice president of eMarketing and consumer relations management. Those profiling enhancements were made in 29 western Pa. counties and ratings are displayed at the physician practice level.

The quality measures, drawn from HEDIS, are displayed in three clinical categories: pediatric care (recommended well-care visits), women’s health (recommended breast and cervical cancer screenings), and diabetes care (HbA1c testing, kidney function, eye health, and cholesterol testing); while a peer-benchmarked star rating system denotes below-average performance (one star), below but within a 10 percent margin of the specialty average (two stars), and greater than or equal to the specialty average (three stars), says Bellard.

Highmark tested a hybrid data sampling approach, but decided to rely on administrative claims for the physician rating system because chart reviews did not demonstrate a sufficient difference in accuracy, says Bellard. Since Highmark had been using the data for years for its primary care physician pay-for-performance program, physicians continue to have the opportunity to vet it and offer additional data if necessary, he says.

Highmark solicited physician feedback before using the new quality ratings for the public profiles. Some physicians, for example, expressed concern about the insurer’s original plan to roll up the diabetes quality measure’s four clinical indicators (HbA1c testing, cholesterol testing, eye dilation exam and screening for nephropathy) into one main score on the public profile – and said they believed it would be more meaningful to the consumer to show separate scores on each. Based upon that feedback, Highmark decided to separate the four measures of diabetes care in its public reporting, Bellard says.

Highmark requires a sample size of at least ten patients per performance measure, so that it can present data on as many physicians as possible while ensuring that the data are still valid. "Our statisticians say ten is sufficiently credible to provide relatively meaningful data," adds Bellard.

Highmark currently does not display information about physicians’ cost-efficiency, but may do so some time in the future, says Bellard.

Not all health insurers offer physician report card ratings to consumers, and some still believe that current quality measurement science is not yet sufficiently evolved.

"The standards of validity and methodologies of transparency have been shifting greatly over the past years, and even months," says Independence Blue Cross Senior Vice President of Health Services Richard Snyder, M.D., who is also a surveyor for the NCQA. "The problem we have run into is that quality measures at the physician level represent only a small portion of what they do, and we find it hard to characterize a physician as good, or below average, based on that subset of care," says Snyder.

"Virtually no insurer would have enough cases per physician to produce statistically valid ratings. The NCQA said it would like to see at least a denominator of 30 for a given measure during a reporting period – which is typically one year. It is hard to get that number," Snyder says.

Health plans also vary by how they attribute an individual’s care to an individual patient – e.g., whether the higher cost of a cardiologist’s care necessarily means that they, instead of a primary care physician, should be held accountable for a diabetic patient’s lipid control, says Snyder. "That’s where we get into trouble in publishing these reports and getting physician buy-in," he notes. Before it launches a public physician rating system, IBC wants to continue working with its physician community to review national measures and develop a system that both parties are comfortable with, Snyder adds.

Capital BlueCross is also evaluating these issues as it examines different approaches to developing an accurate, reliable and understandable physician rating tool, according to spokesperson Joseph Butera.

Horizon Blue Cross Blue Shield of New Jersey has a physician performance reporting program but shares the information only with hospitals and physicians, not with its members, according to spokeswoman Cathleen Coleman.