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MD online ratings raise concerns

By William H. Maruca, Esq.

Consumers are flocking to the internet for direct access to health information of all kinds. Not only are patients clicking on WebMD, DrKoop.com and similar sites for information about diseases and medications, but increasingly they are looking to the web to help them select and evaluate physicians. Like all information on the web, the quality and accuracy of information about physicians that is available to the general public varies greatly from site to site.

Physician information is posted by both public and private organizations, including the Pennsylvania Board of Medicine, the AMA, some state and county medical societies, many hospitals, consumer groups, commercial rating services and insurers. Often, the information is limited to relatively innocuous details like licensure status, board certification and hospital privileges, but some sites provide “quality” information or ratings.

As far back as 1992, the Pennsylvania Health Care Cost Containment Council (HC4) has released reports on coronary artery bypass graft (CABG) surgery that include physician-specific outcome data. These reports are now available to consumers online.

Additionally, consumer advocates have continuously lobbied Congress to open the National Practitioner Data Bank to the public. The NPDB maintains information on medical malpractice payments, adverse licensure actions, adverse clinical privilege actions, and adverse professional society membership actions. Access is restricted to hospitals, government agencies and entities which perform peer review. The efforts to open the NPDB have been expanded to cover the new Healthcare Integrity and Protection Data Bank that maintains information about health care fraud and other sanctions. One such organization, Public Citizen, publishes its own directory of “questionable doctors” that lists all physicians who have been disciplined by state or federal authorities. Their directory is not currently online, but hard copies may be purchased through their web site. The 2000 edition lists 20,125 doctors who have been sanctioned.

Physicians are rightfully concerned that unfiltered access to much of this information without appropriate safeguards may be detrimental to informed patient decision making, and may have distorting effects on patient access to care. For example, the HC4 data on CABG grafts may show high mortality numbers for a cardiac surgeon who routinely handles the most severe cases. The HC4 numbers are risk-adjusted, but not all surgeons agree with the adjustment methods. The statistics may create incentives for surgeons to turn away the most severe cases for fear that their reported percentages may suffer.

Similarly, the National Practitioner Data Bank includes reports on even the smallest settlements of malpractice claims paid by insurers to settle nuisance claims that would be more expensive to defend, sometimes over the objections of the physician. While hospitals, medical boards and managed care companies have access to the Data Bank, the consumers do not. The AMA and other physician advocates oppose releasing Data Bank reports to the public. U.S. Representative Thomas Bliley of Virginia plans to introduce legislation to open the Data Bank later this year.

One program that has stirred controversy in western Pennsylvania is Highmark Blue Cross Blue Shield’s recent proposal to post certain quality and patient satisfaction ratings on its web site. In July, participating primary care physicians were informed by Highmark of its plans to make available three indicators for each physician: quality and service using its QIPS ratings; patient satisfaction based on Highmark surveys, and preventative care based on Health Plan Employer Data Information Set (HEDIS) standards.

In the July letter, Highmark included each participating primary care physician’s own ratings and the network average for each of the three criteria, and gave each doctor the opportunity to elect to “suppress” the information that was to be reported on its web site. Patients accessing the ratings for those physicians will see the message “suppressed by request of practitioner.”

If Highmark did not receive a request to suppress the information by August 1, 2000, it will be published. Physicians will have the opportunity to elect to suppress the ratings once each quarter. The program had been scheduled to go live on August 1, 2000, but is now expected to begin in early September.

Highmark’s Quality Incentive Payment System (QIPS) scores are based in part on certain quality indicators such as board certification, ongoing CME, availability and access of the physician office hours, but also include utilization and cost data. Satisfaction ratings are based on patient surveys, and preventative care ratings are based on mammography rates, immunization rates, hospital follow-up visits for behavioral health and rates of routine preventative care.

A number of physician groups have raised questions about the validity of the QIPS scores, which were originally developed as an incentive tool to adjust capitation rates based on cost and quality indicators. Highmark delayed the full implementation of the QIPS incentive program several times while problems with the system were addressed. Doctors have also raised concerns that the decision to suppress ratings based on concerns for the accuracy of the data could mislead patients into thinking that the suppressed ratings are unfavorable. They also question Highmark’s use of the loaded term “suppressed” to apply to physicians who elect not to participate in the program.

Physicians have also objected to the short notice they were given to decide whether to participate, and the fact that the notice arrived in the middle of summer vacation season. Further, it has not been demonstrated that Highmark can provide sufficient definitions and background information to the general public to assist them in interpreting the QIPS data and other quality indicators to be posted online.

At this time it is not clear whether Highmark’s timetable for launching the online rating service has been delayed due to technical issues or due to the participation rate among physicians. The only recourse physicians have is to individually decline participation and to raise their concerns through their representatives, including the state and county medical societies, to try to achieve improvements to the plan. One caution: as in all dealings with third-party payors, collective action such as concerted boycotts of Highmark’s disclosure program may be risky under the antitrust laws.

Given consumer pressures for direct access information, it is likely that other Pennsylvania health insurers may implement programs similar to Highmark’s. Physicians have certainly not seen the last of on-line ratings.

Many physicians share the goal of providing accurate and useful quality information to patients in a manner that will allow them to make informed decisions about their care. Release of raw data without appropriate verification of accuracy and without necessary explanation of the relevance of the data could have unintended consequences. It remains to be seen whether Highmark and other organizations providing online physician evaluation information will address these valid physician concerns.

William H. Maruca, Esq., is a director with the Pittsburgh law firm of Kabala & Geeseman.

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