Physician Tiering Programs “Not Ready for Prime Time” – RAND, AMA and 47 States Agree

paperworkToday, the American Medical Association, the MMS, and our colleagues in 46 other state medical societies delivered a letter to health insurance plans across the country, calling on them reevaluate the programs they’re using to profile physicians’ performance. We want the insurers to demonstrate that their programs are accurate, valid and reliable.

The letter follows three separate studies by the RAND Corporation that prove, beyond a reasonable doubt, that these programs are flawed to their core.

As you know, we have been operating under one of the most aggressive physician tiering programs in the country, created and managed by the Massachusetts Group Insurance Commission, the agency that buys health insurance for all state employees and those in several municipalities.

From the very beginning of the GIC’s program in 2006, we heard from physicians that the GIC program did not fairly or accurately represent the care they provide:

  • Many physicians said they were assigned costs from patients they didn’t take care of, or for procedures and services they did not provide.
  • Further, when physicians asked for detailed information on their care, the process was cumbersome and not transparent.
  • While there is an appeals period, it is much too brief to give physicians a reasonable time to comb through the data, determine where the problems are, and ask for corrections.

RAND research proves that tiering does not accurately report the cost performance of an individual physician. For example, for internal medicine specialists, cost ratings are accurate only 50% of the time -you would be just as accurate with a coin flip!

This is particularly troubling for our primary care physicians, who already struggle terribly to keep their practices afloat. We worry that profiling programs like these would be the final blow for some practices.

We’re continuing to pursue our litigation against the GIC and two of its health plans. Five physicians have joined us as co-plaintiffs in the complaint. We want the court to order the GIC to do what the agency has refused to do willingly, which is to correct what’s wrong with the program.

We support, and welcome, holding physicians accountable for the cost and quality of their care. It’s the right thing. But as RAND demonstrates, this tiering program simply doesn’t get the job done.

Alice Coombs, MD
President, Massachusetts Medical Society

  1. Mark B. says:

    Agreed. Monitoring physicians performance is important, but if the metrics are all wrong, we can’t forget the old saying GIGO (Garbage in, garbage out).

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