Doctors Rated but Can't Get a Second Opinion
Wednesday, July 25, 2007
After 26 years of a successful medical practice, Alan Berkenwald took for granted that he had a good reputation. But last month he was told he didn't measure up -- by a new computerized rating system.
A patient said an insurance company had added $10 to the cost of seeing Berkenwald instead of other physicians in his western Massachusetts town because the system had demoted him to its Tier 2 for quality.
"Who did you kill?" the man asked sardonically, Berkenwald recalled.
In the quest to control spiraling costs, insurance companies and employers are looking more closely than ever at how physicians perform, using computers, mountains of health claims and billing data and sophisticated software. Such data-driven surveillance offers the prospect of using incentives to steer patients to care that is both effective and sensibly priced.
It also raises questions about the line between responsible oversight and outright meddling in the relationship between caregivers and their patients. And it shows how people such as Berkenwald are at risk of losing control of their reputations as corporations and other organizations mine electronic data to draw conclusions about them and post them online.
The trend is in its infancy, but such programs are already in more than 100 insurance industry markets or regions across the country, from entire states such as Massachusetts to metropolitan areas such as Los Angeles. Supporters say the programs have slowed the rate of growth of insurance premiums by 3 to 6 percent in their first year.
Arnold Milstein, chief physician for Mercer Health and Benefits, a health-care consulting firm based in New York, said that employers and insurers fully expect resistance but that the benefits are undeniable.
"In every industry, consumers have a thirst for performance information," said Milstein, whose firm is analyzing data for the Massachusetts program that ranks physicians. "People don't want to go to a movie or buy a book or buy a car or go to a restaurant without some ability to assess value for dollar. What's taking place here is inevitable."
Physicians who have been profiled, including those with top ratings, say that the data often contain errors and that doctors often lack the ability to correct them. The effort is more about cutting costs than raising quality, some say, adding that doctors could begin to "cherry pick" healthier patients whose problems are less costly to treat. Such systems fail to capture the intangibles of quality, such as a doctor who visits a dying patient at home, critics say.
The trend, which parallels a push by President Bush to promote consumer access to information about health-care quality and cost, has spurred a lawsuit in Seattle, a physician revolt in St. Louis and a demand by a state attorney general that one insurer halt its planned program.
Physician profiling relies on the growing practice of creating electronic medical records. Once kept only on paper, records about patients, doctors, hospitals, pharmacies and other caregivers are increasingly aggregated in giant digital storehouses. In Massachusetts, six health plans pooled their data after stripping away names, and the resulting 120 million claims are crunched by analysts to assess a doctor's performance.
Doctors are rated on standards of quality of care and cost efficiency. An internist, for example, gets higher ratings on quality if he puts his heart attack patients on beta blockers, a medicine that reduces the workload on the heart, or if diabetic patients are tested for blood-sugar control.