Doctors Rated but Can't Get a Second Opinion

Analysts assess cost efficiency by looking at factors such as how many and what types of exams were conducted. Was a breast mass biopsy done in a hospital with an overnight stay or in an out-patient clinic? Was a generic or brand-name pain medication prescribed?

Doctors are then rated against peers in the same community, by type of patient and illness, and against clinical performance guidelines created by specialists such as the American Heart Association.

The systems differ. A doctor who performs well might be awarded stars, a smiley face or a Tier 1 rating. An inferior doctor's patients might receive higher co-payments, or the physician might be shut out of an insurer's preferred network.

In the Washington metropolitan area, UnitedHealthcare has been gathering and evaluating data on physicians and in January rolled out a Web site that ranks physicians with zero, one or two stars. Officials at the District of Columbia Medical Society said they were told that the goal of the Premium Designation program was to encourage physicians to refer patients to two-star doctors and for patients to seek out two-star physicians.

"We were shocked that they would be profiling physicians for the past 18 months and not tell anyone," said Peter Lavine, chairman of the board of the medical society, which met with UnitedHealthcare officials last fall.

Officials with UnitedHealthcare, the nation's second-largest health insurer and a unit of UnitedHealth Group of Minnetonka, Minn., said the goal is merely to provide information to consumers and to help doctors improve their performance.

"Our focus is really on transparency," said Lewis Sandy, UnitedHealth Group senior vice president for clinical advancement.

UnitedHealthcare announced it would delay launching its program in New York, New Jersey and Connecticut after doctors complained and after New York Attorney General Andrew Cuomo threatened legal action.

One doctor fighting ratings systems is Seattle internist Michael Schiesser, who said his rating plummeted from excellent to the 12th percentile within a few months. He said initially Regence BlueShield, an insurer in the Northwest, ranked him in its top 90th percentile of doctors and awarded him a $5,000 check.

Later, when Regence cut him from its network and patients had to pay out-of-pocket to see him or go elsewhere, he pressed to see his report. He said he discovered that he had been penalized because of errors in data-gathering.

"I couldn't believe the extent to which they had botched the data," he said.

He said Regence faulted him for failing to control diabetes in patients who did not have the disease. He said he was docked points for not performing a Pap smear on a woman who had a hysterectomy. He added that his colleague was faulted for not performing a mammogram on a woman who had undergone a double mastectomy.