Current methods for profiling individual physicians as to whether they provide low-cost or high-cost care are often inaccurate and produce misleading results, according to study findings.
Health plans use cost profiling to limit how many physicians get in-network contracts and to allot bonuses to the physicians whose “resource use” is lower than average. In each case, there must be a method for determining physicians' costs, yet the accuracy of these methods has never been proven, according to John L. Adams, Ph.D., of Rand Corp., Santa Monica, Calif., and his associates.
Dr. Adams and his colleagues assessed the reliability of current methods of cost profiling using claims data from four Massachusetts insurance companies concerning 1.1 million adult patients treated during 2004-2005. A total of 12,789 physicians were included in the study. They were predominantly men who were board certified, had been trained in the United States, and had been in practice for more than 10 years.
The physicians worked in 28 specialties, including cardiology, endocrinology, gastroenterology, and obstetrics and gynecology. Family physicians, general physicians, and internal medicine physicians comprised approximately one-third of the sample.
The investigators estimated the reliability of cost profiles on a scale of 0-1, with 0 representing completely unreliable profiles and 1 representing completely reliable profiles. They then estimated the proportion of physicians in each specialty whose cost performance would be calculated inaccurately.
Overall, only 41% of physicians across all specialties had cost profile scores of 0.70 or greater, a commonly used threshold of acceptable accuracy. Only 47% of internists, 30% of cardiologists, 41% of family or general physicians, 57% of ob.gyns., 59% of gastroenterologists, and 22% of endocrinologists received scores of 0.70.
Overall, only 9% of physicians in the study had scores of 0.90 or greater, indicating optimal accuracy.
The proportion of physicians who were classified as “lower cost” but who were not in fact lower cost ranged from 29% to 67%, depending on the specialty. Fully 39% of family or general physicians were misclassified as “lower-cost” providers when they were not.
These findings indicate that standard methods of cost profiling are highly unreliable, and that many individuals and groups are basing important decisions on inaccuracies (N. Engl. J. Med. 2010;362:1014-21).
The study findings also suggest that using cost profiles that are based on these unreliable methods will not reduce health care spending.
Disclosures: This study was supported by the Department of Labor, the National Institutes of Health, and the Robert Wood Johnson Foundation. The investigators' conflicts of interest included support from the Physicians Advocacy Institute, Commonwealth Fund, and Ingenix Inc.
My Take
Abandon Flawed Evaluations
The RAND Corporation study verifies the American Medical Association's longstanding contention that there are serious flaws in health insurer programs that attempt to rate physicians based on cost-of-care.
The RAND study shows that physician ratings conducted by insurers can be wrong up to two-thirds of the time for some groups of physicians. Inaccurate information can erode patient confidence and trust in caring physicians, and disrupt patients' longstanding relationships with physicians who have cared for them for years.
Patients should always be able to trust that the information they receive on physicians is valid and reliable, especially when the data are used by insurers to influence or restrict patients' choice of physicians.
Given the potential for irreparable damage to the patient-physician relationship, the AMA calls on the health insurance industry to abandon flawed physician evaluation and ranking programs, and join with the AMA to create constructive programs that produce meaningful data for increasing the quality and efficiency of health care.
J. JAMES ROHACK, M.D., president of the American Medical Association, reported having no conflicts of interest.
