Tiering

Physicians Must Move Quickly to Appeal Their 2009 GIC Tier Designations

Posted in Tiering on February 19th, 2009 by MMS – Comments Off on Physicians Must Move Quickly to Appeal Their 2009 GIC Tier Designations

Health plans that contract with the Group Insurance Commission have
begun to release their tier designations for 2009-2010. So far, we know about three health plans who released their tiering  designations: Unicare, Tufts and Neighborhood Health Plans.

Physicians have
a very limited time period to appeal their tier designations.

The Massachusetts Medical Society has posted a chart listing deadlines and instructions on how to appeal.  This will be updated when information from the three other GIC health plans becomes available.

Download the chart.

CBS News Covers Physician Tiering

Posted in Tiering on December 5th, 2008 by MMS – 1 Comment

CBS News aired a terrific story last night on the problems with physician tiering programs. It articulates many of the concerns the Massachusetts Medical Society has been expressing for years.

(Unfortunately, CBS subjects you to a 15-second or 30-second advertisement at the beginning. The story follows immediately afterwards.)

Mass. Medical Society Files Legal Action Against the Group Insurance Commission

Posted in Health Policy, Tiering on May 21st, 2008 by MMS – Comments Off on Mass. Medical Society Files Legal Action Against the Group Insurance Commission

The Massachusetts Medical
Society announced today that it has filed legal action seeking to
“correct the wrongs” of the physician ranking program
implemented by the Massachusetts Group Insurance Commission (GIC), the
purchaser of health insurance for most Massachusetts state employees and
retirees.

The complaint, filed in Suffolk Superior Court, alleges that patients
have been defrauded and harmed and physicians have been defamed by the
GIC’s Clinical Performance Improvement initiative (CPI), a program
that ranks (or “tiers”) individual physicians in one of
three tiers, using various cost and quality measures. Patients are
charged higher co-payment fees to be treated by physicians assigned to
the lower two tiers, or must try to change physicians to avoid higher
co-payments.

The filing asks the court to either stop the tiering program, or to
require that the CPI adhere to specific standards, including
transparency, fair notice, formal feedback and correction processes,
meaningful physician involvement in the development of the CPI,
demonstrate the program’s accuracy, validity and reliability, and
submit their programs to an independent oversight authority. These are
both requests that the MMS has asked GIC to do voluntarily on several
occasions.

For more, read the full news release on the MMS website.

An Open Letter on Tiering, Physician Ranking and the GIC

Posted in Health Policy, Tiering on November 30th, 2007 by MMS – 1 Comment

This letter was sent on Nov. 28 to leaders in the business, health care, consumer and political communities of Massachusetts by B. Dale Magee, MD, MS, president of the Massachusetts Medical Society.

The rising cost
of health care has become America’s top domestic issue. Each of the
presidential candidates has provided detailed responses to the problem. It is
dominating the editorial pages of our daily newspapers (most recently, The New
York Times in a 2,000-word editorial on Nov. 25). And most seriously for us in
Massachusetts, high costs are challenging the success of Chapter 58. If we do
not act effectively, this great opportunity to extend health care to almost all
our citizens will be severely undermined.

The rising cost of health
care has become America’s top domestic issue. Each of the presidential
candidates has provided detailed responses to the problem. It is dominating the
editorial pages of our daily newspapers (most recently, The New York Times in a
2,000-word editorial on Nov. 25). And most seriously for us in Massachusetts,
high costs are challenging the success of Chapter 58. If we do not act
effectively, this great opportunity to extend health care to almost all our citizens
will be severely undermined.

Addressing the cost of
health care is a high priority for the Massachusetts Medical Society. I know that no single group is capable of
solving this problem. Progress can only occur when those of us who are involved
with health care delivery as well as those who are most affected work together.

The most visible attempt to
address health care costs in our state is the Group Insurance Commission’s
Clinical Performance Improvement initiative. As you know, the Medical Society
has issued a detailed critique of the program – not because we want to stop the
use of data, but because we want to use data that is accurate and will allow
physicians to constructively change. The GIC initiative meets neither standard
– not because of its intent, but because of its execution.

In recent weeks, the
attorney general of New York signed agreements with five health plans to impose
rigorous new standards on health insurers who rank physician performance.

The New York agreements
declare, “Consumers are entitled to receive reliable and accurate information
unclouded by potential conflicts of interest. The independence, integrity, and
verifiable nature of the rating process are paramount.” Four health plans – Aetna, CIGNA, WellPoint and
United Healthcare – will implement these standards nationwide.

The GIC initiative, as implemented, fails to meet
these standards. Physicians are issued reports that they did not understand
based on data that was developed with a closed, proprietary methodology.
Physicians are, understandably, angry. Patients are being faced with the choice
that they will either have to pay more for their care or switch to another
doctor based on an unproven and inaccurate rating system. When asked what the
cost savings have been thus far as a result of this program, the health plans
were unable to tell us. This is not progress; this is a divisive distraction.

We in Massachusetts are accustomed to providing our
people with the best in health care – the best physicians, the best hospitals
and the nation’s best health plans, by many commonly accepted measures. Yet if
we accept the unproven, inaccurate and potentially injurious system now
purveyed by the Group Insurance Commission, our citizens will not be provided
with the same high standards now enjoyed by the people of New York. This cannot
be allowed to stand.

The GIC is to be commended
for drawing everyone’s attention so acutely to the cost and quality issues of
health care. We must now seek better ways to make progress.

In the end, the best
solutions will come through all of us trying even harder to work together. For
health care to achieve its potential for quality and efficiency, data needs to
be shared between the plans and the physicians. Physicians must be able to use
it to better a patient’s care. Ratings, if they are to be accurate and have
value, will be the byproduct of the alignment of physicians, plans and
purchasers, and will reflect how well we work together to maintain the public
health, and care for those who are ill and injured.

Let’s do this now.

Sincerely,
B. Dale Magee, MD, MS
President,
Massachusetts Medical Society

Five Insurers Now Agree to New York Physician Ranking Rules

Posted in Health Policy, Tiering on November 21st, 2007 by MMS – Comments Off on Five Insurers Now Agree to New York Physician Ranking Rules

A total of five health insurance companies — including the top
three in the country — have now agreed to comply with rigorous new
rules for physician ranking plans, setting a benchmark for the
development of a nationwide standard. United Healthcare and the Group
Health Insurance/Health Insurance Plan (GHI/HIP) of Greater New York
this week joined Aetna, CIGNA, and Wellpoint in accepting the principles
developed by New York Attorney General Andrew Cuomo.

Aetna, Cigna, United, and WellPoint will apply the principles
nationwide.

The New York model expands on the principles for physician tiering
programs that the Massachusetts Medical Society adopted earlier this
month. The Massachusetts Group Insurance Commission (GIC) requires its
participating health plans to utilize a proprietary ranking system. The
system affects nearly 300,000 state and municipal employees in
Massachusetts.

“While the GIC has made some changes in its program in response
to physician concerns,” said B. Dale Magee, M.D., president of the
Massachusetts Medical Society, “it has not been able to ensure
accuracy, reliability, or validity. It falls significantly short of the
New York attorney general’s mandate for these principles, as well
as for independent oversight.”

Cuomo’s office drafted its model with input from the Medical
Society of the State of New York, the American Medical Association, and
several consumer advocacy groups. It requires insurers to fully disclose
all aspects of any ranking system and hire an independent “ratings
examiner” to monitor compliance.

The New York settlement agreements declare, “Consumers are
entitled to receive reliable and accurate information unclouded by
potential conflicts of interest. The independence, integrity, and
verifiable nature of the rating process are paramount.”

“GHI and HIP believe that consumers must have access to
accurate and useful information about their physicians,” said
HIP’s executive vice president, Dan Dragalin, M.D.

According to a statement from Cuomo’s office, insurers
will:

  • Ensure that rankings for doctors are not based solely on cost and
    clearly identify the degree to which any ranking is based on cost;
  • Use established national standards to measure quality and cost
    efficiency, including measures endorsed by the National Quality
    Forum  and other generally accepted national standards;
  • Employ several techniques to foster more accurate physician
    comparisons, including risk adjustment and valid sampling;
  • Disclose to consumers how the program is designed and how doctors
    are ranked, and provide a process for consumers to register complaints
    about the system;
  • Disclose to physicians how rankings are designed, and provide a
    process to appeal disputed ratings;
  • Nominate and pay for the ratings examiner, subject to the approval
    of the New York attorney general, who will oversee compliance with all
    aspects of the new ranking model and report to the attorney
    general’s office every six months. The ratings examiner must be a
    “national standard setting organization” and will be
    national in scope, independent, and an Internal Revenue Code §
    501(c)(3) organization.

United Healthcare had been scheduled to start its ranking program in
New York in December. It said it will comply with the agreement before
launching the program. GHI/HIP accepted the agreement prior to designing
its program.

Interim Meeting Update: MMS Approves New Principles for Physician Ranking Programs

Posted in Health Policy, Tiering on November 3rd, 2007 by MMS – Comments Off on Interim Meeting Update: MMS Approves New Principles for Physician Ranking Programs

The House of Delegates today approved a long list of new principles for physician ranking programs. The principles delcare that ranking programs should:

  • Aim to strengthen patient-physician relationships
  • Involve physicians in the design and implementation of all programs
  • Use clinically important and sound performance measures
  • Ensure sample sizes adequate to support meaningful data analysis
  • Rely on meaningful data and analytic techniques
  • Share and review data with physicians or practices prior to public release
  • Ensure transparency of all quality and cost-effectiveness measures
  • Identify and consider practice characteristics that may require special attention in quality and cost-effectiveness monitoring
  • Use uniform reporting formats
  • Minimum unintended harmful consequences
  • Be pre-tested before implementation

In its notes to the House, the committee which reviewed the proposal stated, "This does not in any way endorse tiering by insurance companies."

In a statement on the passage of the resolution, MMS President B. Dale Magee, MD, said, "Physicians are concerned that the current rating system provides potentially deceptive and unreliable information to patients. This encourages a disruption to existing patient-physician relationships, and can result in patients paying more for their health care.”

He added, “Ultimately, the best solutions will come through collaboration. For health care to achieve its potential for quality and efficiency, data needs to be shared between the plans and the physicians so that they can use it to better a patient’s care. The current experiments in rating physicians are a distraction from the best uses for this data. Ratings, if they are to be accurate and have value, will be the byproduct of the alignment of physicians and plans and will reflect how well payers and physicians work together.”

He concluded, "Controlling cost in health care is everybody’s problem and physicians need to work hard to assure that issues surrounding costs are addressed in a manner that assures quality and guards against unintended consequences."

Be Part of the Cost Solution, MMS President Urges

Posted in Health Policy, Tiering on November 2nd, 2007 by MMS – Comments Off on Be Part of the Cost Solution, MMS President Urges

MMS President B. Dale Magee, M.D., M.S., said Friday
that physicians must actively participate in efforts to solve the problem of
rising health care costs. Speaking at the opening session of the Interim
Meeting of the MMS House of Delegates, “
We can’t just
stand outside and say this isn’t going to work. We have to be part of the
solution,” he noted.

Following is the full text of his remarks:

I will take
a little bit of time this morning to tell you what the officers have been doing
over the past six months. We have done a lot. I know that most of you are aware
of some of the issues. 

For
instance, MinuteClinics have been a front-burner item over the past six months.
And Bruce Auerbach, our president-elect, has represented us very well with
regard to this issue. Our Workforce Study was released this summer and was very
well received by the public and the media and is particularly important at this time
with regard to Chapter 58.

There are a
lot of other things I could talk to you about, but I want to focus your attention
on one thing: cost and health care. We have to focus on this more than we ever
have before.

As long as
I have been in medicine, people have been saying that the rate of inflation in
medicine can’t be sustained. When I started in medical school it was 7 percent
of the GDP, and they said this can’t go on. It is now 16. So we’ve insulated
ourselves from this. Medicine has gone on, our patients have done well, and it
has really not been as big an issue for us as it has been for the policy
people.

We have heard
people that have been crying wolf. The issue is, when the wolf comes, will we
know what it looks like?

Right now
we are at a point in Massachusetts where municipalities are turning off their
streetlights at night. They are closing libraries. The schools are cutting down
on their curricula. Manufacturers are having difficulty paying the salaries of
their workers and also maintaining the cost of their health benefits.

This is
what the wolf looks like, and this is why right now we have to pay more attention.

Add to this
the fact that Chapter 58 is mandating health insurance for everyone in this state,
a good thing, something that we support and have to work to make successful.
Yet so many people feel that even now with all the efforts of Chapter 58, health
care insurance is still unaffordable for them. We have to pay attention. Others
are. Others are offering potential solutions of things that they feel will
help.

The Group
Insurance Commission is offering what they refer to as the Clinical Improvement
Program, which is tiering, and which all of you are familiar with and which we
have looked at in great detail. We spend more time on this than any other topic
of health policy at the Medical Society.

We know
that the tiering program is based on inaccurate data. We know that the tiering
program is based on what amounts to an experimental approach to try to rate
doctors and cost shift to patients or disrupt physician/patient relationships. We
are doing everything we can to inform and protect patients and to protect
physicians from unfair treatment.

We have met
with the Attorney General’s office. We have submitted a Senate bill that will
try to stop the tiering as it is right now. We have met with the plans, with
the Group Insurance Commission, with Mercer, its consultant. We’ve brought in
national experts to try to educate everyone that is involved.  

We have put
articles in newspapers. We have educated the membership. We have reached out to
hospital medical staffs. We are looking at everything we can to try to if not
stop this program entirely, at least bring a little more reason to it.

But the
fact is that the people who are paying for health insurance, the employers,
municipalities, they feel that their house is on fire. And right now the only
one running into the building with a hose is the Group Insurance Commission. We
can’t just stand outside and say this isn’t going to work. We have to be part
of the solution. That is what this Medical Society is working for as well.

Two weeks
ago our State of the State conference focused on the cost of health care. The
idea was to bring experts in around the country to give perspectives to our
health policy people, give them a view so they understand what’s going on so
that when consultants come to them with proposals, they can understand the pros
and cons a little bit better and make more intelligent decisions.

Today at
the House of Delegates we are going to have a meeting looking at practical ways
to handle common problems. We want each person to think about them, how they
handle the problems they may see in their offices, and to have a good
discussion with others regarding how others would review the same problems.

This is how
we address the cost of health care at the clinical level by just exchanging
information and knowing more about how others handle the problem. In December
we are bringing experts in from across the country to speak to medical
directors from the IPAs in this state and help to work with them to find out
what data we need and how we can best use it to try to address the issues of
the cost of health care.

In the
spring we are going to have a Public Health Leadership Forum, which is going to
look at the connection between lifestyle and illness, between illness and the
cost of health care. It’s not just about the care that we deliver and how much
we get paid per unit of service. Rather, it’s the demand for health care as
well.

Ron Davis,
the current president of the American Medical Association, says that about a
third of the increase in the cost of health care over the past decade relates
to obesity and the increased morbidity that goes with it. When schools are
cutting out physical activity and people are spending two hours a day commuting
and can’t exercise, in many ways we are designing a community that is going to
demand more health care. It’s going to require more health care, and perhaps we
should look at ways outside of the health care system to improve people’s
health and decrease the demand for services. That has to be addressed as well.

We’re
addressing it not just for our patients but for us. As you walked around this
building today, you saw that we have a lot of exhibits. In your packets we have
materials for your office. You have been given a pedometer by the Alliance. And
all of these things are going to help us.

At 1:30
today we are going to have a walk around the grounds. Symbolic but important,
because if you had time to spare, you should spend that time moving. So we want
all of us to not only talk the talk, but walk the walk. The officers challenge
you. We are going to be there. Meet in the lobby and we will go for that walk.

In summary,
I just want you to know that cost is where we are focusing ourselves today. It
is not an easy question. It’s not going to be easy to solve, but we’ve got to
try. We’ve got to be part of the solution. We have to run into that building
and solve the problem, not just stand on the outside. 

When the
physicians are involved in this issue, patients will feel better. They will
know that they will get solutions that they can trust. They will get solutions
that everyone can live with. That’s what we want. 

Thank you,
Mr. Speaker.