By Ellen Nakashima
Washington Post Staff Writer
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.
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.
Last fall, Schiesser joined five other doctors and the Washington State Medical Association in suing Regence BlueShield, claiming defamation and deceptive business practices after the health plan told participating members that they no longer had access to about 500 doctors because the doctors did not meet the insurer's quality and efficiency standards.
Regence spokesman Charlie Fleet said that because of the lawsuit, the company could not comment on the data issue. He did say, however, that the data were "provided from the physicians themselves."
In December, Regence abandoned its plan.
Doctors critical of ratings systems say they are held accountable for whether patients exercise, take their medications or follow their prescribed regimens.
Berkenwald, the Massachusetts internist, said he was pushed from Health New England's top 10 percent of physicians into its second tier because several of his female patients did not get the mammograms or Pap smears he prescribed.
But Berkenwald received a top-tier rating by several other insurers participating in the state's Clinical Performance Improvement Initiative because the health plans use different cut-points for determining who falls into which tier.
Disparate ratings can confuse patients and cause turbulence in group practices.
When Elizabeth Trobaugh of Amherst, Mass., had a tick bite last fall and her family doctor was not available, she saw her doctor's partner, who had a lower rating. Trobaugh was upset when she was charged a $10 higher co-pay. "Why should I be penalized for going to this person's partner?"
Despite its flaws, proponents say the systems encourage much-needed quality and cost control.
Dolores Mitchell, executive director of the Massachusetts Group Insurance Commission, which launched its physician-rating program four years ago, said she's heard doctors' complaints about errors. But at $1 billion in annual spending on health care, she said, improving performance and efficiency is crucial.
"The data may not be perfect," she said. "But they're better than any data that we've had before."
Staff researcher Richard Drezen contributed to this report.