Physicians

Docs and Insurers Posture on Report Cards, But Is Silence the Real Goal?

Millenson  Report cards are back in the news.

The Washington Post (via Kaiser Health News) is warning about the difficulty of rating individual physicians. Meanwhile, spokesmen for the insurance industry and the doctor industry (a/k/a the American Medical Association) are content with huffing and puffing about the perfidy of any report card that’s about them.

 In late July, for instance, the AMA sent letters to more than 40 health insurance companies requesting they investigate the reliability of their physician rating programs in the wake of RAND studies casting doubt on how low-cost and high-cost doctors are classified and on some quality rankings. That work was partly funded by the AMA and the Massachusetts Medical Society, which is also suing the Massachusetts Group Insurance Commission (GIC) over its physician ranking effort.
 

I'd have more sympathy for the docs except for the fact that the GIC effort has actually been one of the most intensive in the country to take into account quality as well as cost. Moreover, GIC executive director Dolores Mitchell has been a fierce pro-consumer advocate, not a role typically filled by your local medical society. (One local profile called her a “change agent” who “doesn’t take any guff.) And despite the complaints, there has been very little effort by the AMA or most other medical societies to work with insurers to provide the kind of timely clinical data (as opposed to claims data) that would make report cards more useful to patients.  The search for the perfect is too often a deliberate tactic to delay the implementation of the good.


 

But at least when it comes to objecting to cost comparisons of individual physicians, the docs have the facts on their side. The insurers, in contrast, win the chutzpah award for their reaction to the federal government’s healthcare.gov website. In response to the government’s plan to show how often insurers deny claims, America’s Health Insurance Plans (AHIP) sent a letter to the government claiming, in effect, that the report card needed to be risk-adjusted for doctor stupidity.

Join me please, in reading between the lines in this story from the Los Angeles Times : 

“’Providing information about claims denials without providing proper context does not begin to tell the whole story,’ said Robert Zirkelbach, a spokesman for the group, who said claims are often denied because a provider sent a duplicate claim or submitted a claim to the wrong health plan.”

The seeming logic of this objection falls apart completely on closer inspection. The reality is that the same doctors are on the panels of virtually all health plans in most markets. If one plan’s denial rates are higher, the reason is either the physicians (and their staff) are dumber when they fill out only that claim form or that claim form is more difficult to fill out or that health plan's policies actually result in denial of more claims – the latter two possibilities meaning the plan has earned its bad grade. The same holds true if a provider that dominates one market gets a much lower grade than a provider that dominates a different market. Again, it’s either the fault of the insurer or – to paraphrase AHIP– it’s because “my doctors are dumber.”

 The unfortunate reality is that today’s report cards still only scratch the surface of what patients want to know and deserve to know, as St. Louis Post-Dispatch reporter Jeremy Kohler makes clear in an Aug. 1 account, trying to track down the details after being tipped off about a wrong-site surgery at a local hospital. His piece is entitled, “Serious Medical Errors, Little Public Information.” Indeed, patients continue to fight just to see their own medical information , much less information on doctors.
 

When it comes to patient safety and quality, a deadly silence , alas, too often continues.

Livongo’s Post Ad Banner 728*90

Categories: Physicians

13
Leave a Reply

13 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
8 Comment authors
Margalit Gur-ArieDBrad FMichael MillensonTom Leith Recent comment authors
newest oldest most voted
Nate
Guest
Nate

as a note we deny a lot more claims then we use to. In the past we could pend a claim for accident details, third party liability, or medical notes. Now that is now allowed, we have to deny the claim and request it

Nate
Guest
Nate

excellant point Margalit. Not all denials are bad. If I deny a 100 claims for lack of medical necessaity that is far different then me denying 100 claims for accident details or so I can sudit. The data is already there it just needs used.
If someone takes my denial data and starts degrading me though for legit denials I’m going to be unlikly to share it. We deny maybe 5% of claims but 4.5% are for good reasons.

Margalit Gur-Arie
Guest

The vast majority of claims are not filled by anybody. They are created electronically by a practice management system and sent out, as Nate said, to a clearinghouse which then sends them to the appropriate payer. The clearinghouse will not reject any claim as long as it is properly formatted because they have no eligibility information. Payers will reject claims for incorrect information (bad demographics, bad billing information, etc.) – this is the practice’s fault. They fix the claim and send it out again. Payers will deny claims for lack of medical necessity, uncovered services, request for additional medical records,… Read more »

D
Guest
D

I agree that the public needs information about the cost of health care. So do the doctors ordering this care. For plans to pay different providers vastly different fees and keep these contracts secret from the doctors ordering the services while blaming them for variation in the cost of health care shows just how cynical they can be. Tiering is just another gimmick allowing plans to appear to be doing something, while blaming the doctors and shifting costs to patients. At least the AMA and the Massachusetts Medical Society had the decency to have an outside expert perform a study… Read more »

Michael Millenson
Guest
Michael Millenson

Brad, I agree with you completely about the problems with measuring individual physicians dealing with chronic disease and the like. But the kind of work done by the GIC and that has been done with others to try to deal with some rough issues — say, appropriate drug prescribing — has not always been supported by the profession. In other words, you are right on the science. And some medical societies (mostly the FP’s and internists) have been very progressive. Most in-the-trenches docs are less progressive than the progressives at the top of the FPs and ASIM, alas. Good for… Read more »

Nate
Guest
Nate

you can in theroy reject a claim at the cleearing house EDI level, legally you can no longer reject a claim, anything submitted is supposed to be paid or denied and an explanation sent. clearing houses are not very willing to do this though, they want the flow through at .40 per claim rather it is valid or not and if it is the first or fifth time that month it has been submitted. ” are the employees of your plan stupider than the employees of the competitor?” If I am a taft hartley TPA that writes trade skills then… Read more »

Brad F
Guest
Brad F

MIchael I am sorry, that is a non-answer. As societies and thoracic surgery goes, measurement is much easier and to examine and risk adjust CABG’s where registries exist and things of that sort are closely followed, you are talking about an easier task. Medical and chronic conditions are far more difficult, and while medical societies may be somewhat obstructionist–not all, many docs are not afraid of transparency and measurement (grads after the 90s) and there is only so much one can do in fragmented system. I am no shill for medical societies, but it would serve you will to look… Read more »

Michael Millenson
Guest
Michael Millenson

To Brad’s question about non-claims data: the database from the Society of Thoracic Surgeons uses clinical data, very well risk-adjusted. It was hand-collected when the system started and may be automated by now. Although physicians complaining about lack of automation while resisting computerization of offices and hospitals for decades is a bit much. There are flaws with claims and other data. There are now efforts to use data mining techniques, etc., to fix them. To my knowledge, no organized professional societies have been leaders in trying to make data better, although they do work well in a defensive mode (sometimes).… Read more »

Tom Leith
Guest
Tom Leith

Nate, is there a distinction between “rejected” and “denied”?
t

Tim
Guest
Tim

The truth is that you can’t use “claim denial rates” for anything without having a whole lot more information. I look at this data every day.

Nate
Guest
Nate

“The seeming logic of this objection falls apart completely on closer inspection.” This just killed any thought you might understand how claims are filed. If you don’t understand the process why not just say so or leave it alone or ask around before you make your self look bad and impeach the entire post? “The reality is that the same doctors are on the panels of virtually all health plans in most markets.” First error, and a big one, is while a large number, no where close to most, doctors might be on the same panels their concentration of care… Read more »

Brad
Guest
Brad

Michael: “And despite the complaints, there has been very little effort by the AMA or most other medical societies to work with insurers to provide the kind of timely clinical data (as opposed to claims data) that would make report cards more useful to patients.” Outside of claims or administrative data–which is usually available (yes, I know, that is another post), but subject to suboptimal analysis, incompleteness, inability to risk adjust, etc., what other efforts that would not require extensive hand review and submission do you suggest? You are right, the docs can whine quite a bit, but frankly, a… Read more »

Alicia
Guest

Well, maybe our way of thinking is to blame. Too many people want to take advantage and make claims if those cards would be publicly “filled in”. taking them into court as a proof.