Ethics Forum: Pay for Performance

Posted in Ethics Forum, Health Reform, Interim Meeting 2014, Payment Reform, Tiering on December 5th, 2014 by MMS Communications – 1 Comment

Since its introduction some ten years ago, Pay-for-Performance (P4P) has been the object of much confusion, conversation and scrutiny in the medical industry.

Such programs have raised a host of practical questions: What criteria do you use to objectively judge performance? How do you develop incentives for accomplishment and penalties for falling short? What principles do you use to guide such programs?

Practical considerations aside, the payment system has also raised some important ethical questions, and those were the focus of the Ethics Forum at the 2014 MMS Interim Meeting on Friday, December 5 presented by the Committee on Ethics, Grievances and Professional Standards.

Offering their perspectives on the topic of Ethics of Pay for Performance were Alyna T. Chien, M.D., M.S., a pediatrician at Boston Children’s Hospital and the lead investigator in four different projects focusing on the effectiveness of payment and quality incentives, and Sachin H. Jain, M.D., M.B.A., Chief Medical Information and Innovation Officer at Merck and Lecturer in Health Care Policy at Harvard Medical School.

“We are in a revolution,” said Dr. Chien, “as the entire organization of medicine is changing, progressing to one of integrated health care.” She noted that most incentives move from the payer to the hospital or physician practice, and that most of the data regarding the impact of P4P programs exists at the organizational level. There’s little data on how it works at the individual physician level.

Dr. Chien believes these performance programs can have one of three effects in delivering care: a neutral effect, where the status quo is preserved; a narrowing of care, where more attention is paid to quality and more programs are tailored to patients; or a widening of care, where gaps will occur between rich and poor and physicians will selectively pick their patients.

Dr. Jain acknowledged that the public perception of the profession has changed and that physicians should be at “a point of soul searching and questioning where we are in society.” He offered a scenario of physicians as either “knights” (motivated by altruism and being the ultimate champion of the patient), “knaves” (driven by self-interest and financial gain), or “pawns” (pushed by rewards and penalties of the system in which they operate).”

While he pointed out that such a framework can also be applied to others (for example, patients, health plans, pharmaceutical companies, nurses, and hospital executives), Dr. Jain believes organized medicine has focused too much on reimbursement and that physicians are perceived not to be trusted to do what’s right unless there’s a carrot or stick approach.

“We are losing our more intrinsic value in favor of pay-for-performance,” Dr. Jain says, “and the intrinsic motivation of doing what’s right for the patient must be preserved. It is what differentiates us from other professions. It is what tells others that we will do the right thing whether we get paid or not.”

His prescription is direct: a proper system of reimbursement must offer a reasonable salary, reject incentive contracting, focus on clinically meaningful measures, make it easy for physicians to do the right thing for patients, and find ways to honor and reward the intrinsic motivation of what’s best for the patient that most physicians have.

Presentations at the Ethics Forum may be viewed here.

The President’s Podium: In the Court of Public Opinion

Posted in patient safety, Primary Care, Tiering on August 22nd, 2013 by MMS Communications – Comments Off on The President’s Podium: In the Court of Public Opinion

by Ronald Dunlap, M.D., President, Massachusetts Medical Society

With the constant push for quality, safety, and transparency, the practice of  rating physician performance is becoming as commonplace as the stethoscope in health care.

Insurers have developed tiers; the federal and state governments and private organizations have launched websites. Local and national magazines rate physicians individually and by group practices. Patients can rate their doctors on any number of websites. The focus on ratings has become so widespread that even organizations best known for reviewing restaurants and home services have joined the club.

Some physicians bristle at the notion of such assessments. A few have filed lawsuits in response to negative reviews, and some, in attempting a preventive strategy, have asked patients to sign documents promising not to use any rating websites. This tactic has backfired and not surprisingly, strained the physician-patient relationship.

Like them or not, ratings are here to stay. Some provide useful information; some not so much, merely allowing disaffected patients to vent about the care they think they should have received, how much time they spent in the waiting room, or why they couldn’t talk to the doctor when they wanted. The methodology used by some organizations and the low sample size may also raise questions. Fortunately, most experts will caution patients about such information, advising them to judge the relevance, accuracy, and reliability of the information with extreme care and to use the information as just one of many factors when judging physicians.

To be sure, physician performance is a critically important and complex issue, and MMS has been ahead of the curve. Back in 1999, MMS first developed our Principles for Profiling Physician Performance, which has since been updated. That was followed by a similar document for health plans, and we’ve even provided guidance for patients.

In the end, each patient individually will determine how well his or her doctor is providing care, and that perhaps is the only rating that truly matters. But reasonable patient input and well-constructed surveys can offer a yardstick for measurement, especially with so many changes taking place in health care.

With that in mind, here’s a look at some responses from the MMS’s recent public opinion poll that relate to physician performance:

  • 84% expressed satisfaction with the care they received over the last year. Notably, that’s comparable to the 88% rate of satisfaction in 2004, when we first asked the question. 51% cited quality of care as the biggest reason for their satisfaction.
  • 74% said they have asked their physician for suggestions when deciding where to go for medical care, signaling that the physician remains the most preferred source of information about care.
  • 67% said they would prefer to receive care from a physician; this despite the proliferation of retail clinics and a new state law allowing nurse practitioners and physician assistants to act as primary care providers.

There’s always room for improvement, and while one hundred percent in every category will remain the target, the judgment from our patients again this year is that Massachusetts physicians and health care providers are living up to their reputation for quality care. That’s good news for physicians, and the high level of satisfaction over a decade, in which huge changes have occurred, is especially gratifying. But let’s remember this: the court of public opinion on health care is always in session. And that’s just as it should be.

The President’s Podium is a new feature that appears regularly on the MMS Blog, offering Dr. Dunlap’s commentary on a range of issues in health and medicine.   



GIC Begins Notifying Physicians of Tier Designations

Posted in Tiering on January 6th, 2012 by MMS – Comments Off on GIC Begins Notifying Physicians of Tier Designations

The Group Insurance Commission this week began notifying physicians about their tier designations for the 2012-2013 benefit year.

We encourage physicians to review this information immediately and contact each of the health plans if they have questions or want to appeal their tier designation.

The deadline to file an appeal of your designation is January 24. If you miss the deadline, you won’t be able to appeal for another year. The plans have said they will notify you of the outcome of your appeal by February 14.

Each health plan, in their communications to physicians, has provided information about who to contact and how to appeal. Keep track of your communications with each plan to make follow-up easier. We are also updating our website with this and additional information at www.massmed.org/tiering.

An Update on the MMS Lawsuit Against the Group Insurance Commission

Posted in GIC, Group Insurance Commission, Tiering on September 22nd, 2011 by MMS – Comments Off on An Update on the MMS Lawsuit Against the Group Insurance Commission

By Bruce Auerbach, MD
Past President, Massachusetts Medical Society

Bruce Auerbach, MD, FACEP

In 2008, as I began my one-year term as president of the Massachusetts Medical Society, the MMS and five physicians filed suit against the Massachusetts Group Insurance Commission (GIC), and two health insurers, Tufts Health Plan and Unicare, over the state program that rates (or “tiers”) doctors based on the cost and quality of the care they provide.

The lawsuit sought to “right the wrongs” of the program, in which patients are charged higher or lower co-payments based on their doctors’ cost and quality scores. (The GIC purchases health insurance for employees of the state and several cities and towns.)

The lawsuit stated that the program is grossly inaccurate, and misleads patients and defames doctors. We alleged that the program is an illegal interference in the business relationship between a doctor and a patient, and that it violates the state’s consumer protection laws. We asked for no specific damages, but simply for the court to order the GIC to fix the program.

However, after three years of motions, hearings and counter-motions, a state judge recently dismissed the GIC from the case. She found that physicians do not have a direct commercial relationship with the GIC, rendering the claims of business interference moot. Tufts and Unicare remained as defendants in the case. The judge issued no ruling or comment on the merits of our arguments.

We considered pursuing the case against the two remaining health plans, but even if we succeeded, it would have affected only their customers, not those of the four other health plans in the program. Further, it might have caused even more disruption to our already chaotic health care system, which made us uncomfortable.

So with these rulings, our trustees felt they had little choice but to terminate the litigation. They directed us to continue working to correct the program by other means.

Despite this decision, we believe our litigation did bear some fruit. We have been heartened by the fact that Independent researchers have upheld our fundamental arguments. Last year, RAND issued a series of research papers that were sharply critical of the GIC’s specific methodology. It found that the program misclassified physicians 22 percent of the time. For some specialties, it was much worse: 50 percent of internists and 67 percent of cardiovascular surgeons who were rated as low-cost physicians actually had an average cost profile. In the New England Journal of Medicine, RAND researchers wrote, “Consumers, physicians and purchasers are all at risk of being misled by the results produced by these tools.”

We also believe that because of this research, along with the attention focused on the issue by our litigation, health plans across the country have generally rejected the GIC’s practice of tiering individual physicians, even as limited provider networks and physician tiering have become more prevalent. It is now far more common for health plans around the country to rate physicians as part of practices or groups, where the data and ratings are far more reliable.

Despite these signs of progress, we are left with a program in Massachusetts that has deep flaws. We know of specific instances where patients are still being negatively impacted by this program, which is of paramount concern to our board members and our physician colleagues throughout the state.

So we have a lot of work to do. We will continue to fight vociferously to fix the GIC’s tiering program, though in different venues. We even retain the right to go back to court, particularly if the legal climate changes.

I want to extend a special thanks to the five physicians who agreed to serve as plaintiffs in the case. The entire physician community owes them a debt of gratitude. They performed a great service to the profession, and to patients throughout Massachusetts.

GIC Begins Sending out 2011-2012 Tier Designations: Appeal Information

Posted in Group Insurance Commission, Tiering on January 12th, 2011 by MMS – Comments Off on GIC Begins Sending out 2011-2012 Tier Designations: Appeal Information

Physicians have begun receiving their 2011-2012 tier designations from the six health plans contracting with the state Group Insurance Commission.

The MMS encourages physicians to review this information immediately and to contact health plans promptly if they have questions or want to appeal their tier designation.

The deadline to request an appeal is January 26.

Each health plan provided contact information in their communications to physicians. We are also updating our website with this and additional information at www.massmed.org/tiering. Keep track of your communications with each plan to make follow-up easier.

Be sure to track your contacts with each plan, in order to make it easier for follow up questions.

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

Posted in Tiering on July 19th, 2010 by MMS – 2 Comments

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

Watch Your Mail: New GIC Ratings Expected Early Next Month

Posted in GIC, Group Insurance Commission, Tiering on December 21st, 2009 by MMS – Comments Off on Watch Your Mail: New GIC Ratings Expected Early Next Month

Image by simiezzz, via flickrMassachusetts physicians should watch their mail next month for information from the six health plans that participate in the Group Insurance Commission. We expect that the plans will release next year’s individual tier designations early in January.

Review these mailings right away. They will include general information about your profile and the tiers into which you’ve been designated.

We believe that the appeal period will again be very short. We will share the details on any changes in the plans’ methodologies and measures as soon as we learn them.

What You Should Do:

We want to hear about your concerns and questions. Your experiences will help us advocate with the health plans.  Comment here, or e-mail us at mdfeedback@mms.org

Meanwhile, the Medical Society litigation against the GIC and two of its participating health plans is still before the state Superior Court. The complaint – which was upheld in a ruling earlier this year – states that the GIC program misleads patients and defames physicians by using an inaccurate and faulty rating system.

Jerome Groopman Weighs In On Tiering; Evokes Orwell, Kafka

Posted in Tiering on April 8th, 2009 by MMS – Comments Off on Jerome Groopman Weighs In On Tiering; Evokes Orwell, Kafka

Dr. Jerome Groopman, the Boston physician who has written bestsellers and writes for the New Yorker, writes a scathing indictment with Dr. Pamela Hartzband on the pitfalls of current pay for performance programs in today's edition of the Wall Street Journal. This section of the article on the GIC's tiering program is priceless:

"Too often quality metrics coerce doctors into rigid and ill-advised
procedures. Orwell could have written about how the word "quality"
became zealously defined by regulators, and then redefined with each
change in consensus guidelines. And Kafka could detail the recent
experience of a pediatrician featured in Vital Signs, the member
publication of the Massachusetts Medical Society
. Out of the blue,
according to the article, Dr. Ann T. Nutt received a letter in February
from the Massachusetts Group Insurance Commission on Clinical
Performance Improvement informing her that she was no longer ranked as
Tier 1 but had fallen to Tier 3. (Massachusetts and some private
insurers use a three-tier ranking system to incentivize high-quality
care.) She contacted the regulators and insisted that she be given
details to explain her fall in rating.

"After much effort, she discovered that in 127 opportunities to comply
with quality metrics, she had met the standards 115 times. But the
regulators refused to provide the names of patients who allegedly had
received low quality care, so she had no way to assess their judgment
for herself. The pediatrician fought back and ultimately learned which
guidelines she had failed to follow. Despite her cogent rebuttal, the
regulator denied the appeal and the doctor is still ranked as Tier 3.
She continues to battle the state."

Read the full article in Vital Signs here.

Judge Allows Lawsuit Against the GIC to Proceed

Posted in Tiering on April 2nd, 2009 by MMS – Comments Off on Judge Allows Lawsuit Against the GIC to Proceed

We learned today that a Superior Court judge has upheld six separate claims in the litigation filed by the MMS and five physicians against the Group Insurance Commission's physician tiering program.

The court dismissed four other claims, but two of the most important claims (defamation and consumer protection) were upheld.

The MMS news release on the announcement is available here.
A copy of the ruling is available here.

An Amazing Post on GIC Tiering By a Primary Care Physician

Posted in Health Policy, Health Reform, Tiering on April 1st, 2009 by MMS – 1 Comment

Dr. Sally Ginsburg, pediatrician from Longmeadow, has written an amazing post on the absurdities of the Group Insurance Commission's physician tiering program. It's on WBUR's "CommonHealth" blog. We heartily recommend a close, careful reading of her points.

She agrees that health care must be delivered more efficiently and that quality must be improved. But she cites many examples of where tiering clearly fails the test.

She concludes, "Look at where the BIG health care money is really being spent- high cost, end of
life care and very costly and sometimes futile beginning of life care. Stop
playing this out on the primary care physicians, before there are none of us
left in the state."

The Massachusetts Medical Society has filed suit against the GIC to "correct the wrongs" of the tiering system. We contend that the GIC's tiering system is not only complex, it is impossible to understand. It is
not only unfair, it is inaccurate. It is supposed to save money and
reduce costs, but there is no evidence it does either – and there is a
lot to suggest it actually does the opposite. It is unfair to physicians, and it misleads patients.

In December, a state judge held a hearing on the GIC's contention that the complaints of the MMS and five physician co-plaintiffs were without merit. A ruling on the matter is still pending.

Meanwhile, the GIC's health plans have released the tier designations for program's fourth year, and the inequities and inaccuracies seem as bad as ever, if not worse.

This isn't the way to address cost and quality. It's time to move on to something else.

Bruce Auerbach, MD
President, Massachusetts Medical Society