The Massachusetts Medical Society has filed suit against a state agency and two insurers to “correct the wrongs” in programs that charge patients copayments based on physicians' performance ratings.
The suit is the latest in a series of broadsides against systems that purport to rank physicians, usually based on cost data extracted from claims. Physician groups have called that method flawed, and complained that often physicians have not been privy to how the ratings are calculated.
The Massachusetts physicians said that the program developed by the Massachusetts Group Insurance Commission (GIC) is seriously flawed. For example, the medical society cites a neurologist who took on multiple sclerosis patients and used a team approach to care, having all of the providers' costs assigned to her, making it appear that she was a very-high-cost provider, the suit alleges.
The commission buys health insurance for about 300,000 state employees through six plans. Tufts Health Plan and the UniCare Life and Health Insurance Co., both of which were also named in the suit, had the most egregious practices, said Frank Fortin, a spokesman for the Massachusetts Medical Society, in an interview. UniCare began using tiers in 2006 and Tufts in 2007.
The suit was filed now because starting this month there will be three tiers instead of just two and more specialists will be subject to tiering, Mr. Fortin said. Primary care has not yet been included.
Mr. Fortin alleged that the distribution among the tiers was partly set by quota. The expansion will affect more patients, and, with the new rankings, “more physicians are in lower tiers because they were assigned costs from patients they did not treat and for procedures they did not perform,” said Dr. Bruce S. Auerbach, president of the Massachusetts Medical Society, in a statement. The society does not oppose rankings, but said that the data are not accurate enough to be used to rate individual physicians.
Tufts wouldn't comment on the litigation. However, in a statement, spokeswoman Patti Embry-Tautenhan said that Tufts “developed physician tiering methodology with guidance from the Massachusetts Medical Society and other interested and affected parties in the health care community.” She added, “Transparency of information regarding cost and quality is in the best interest of our members and health care consumers in general.”
It's not the first time physicians have resorted to litigation. Rating systems instituted by UnitedHealthcare and Cigna Healthcare came under fire in Connecticut; a lawsuit filed in 2007 by the Fairfield County Medical Association is still pending. And, after filing suit in 2006 to block a Regence Blue Shield network, the Washington State Medical Association accepted a settlement last August in which Regence will continue to measure performance, but will engage physicians more directly in the process and make the programs more transparent.
The American Medical Association wants a settlement won in late 2007 by New York Attorney General Andrew Cuomo to serve as a national model. Cigna was the first to enter into the agreement. Aetna followed and said it would apply the agreement nationally. Empire Blue Cross and Blue Shield (a division of WellPoint), United Health, Group Health, and the Health Insurance Plan of Greater New York also agreed to the terms, within New York state.
The agreement was crafted by the attorney general, with the AMA, the Medical Society of the State of New York, and consumer groups such as Consumers Union and the National Partnership for Women and Families. It included a requirement that insurers publicly disclose rating methods and how much of the ratings is based on cost, and retain an independent monitoring board to report on compliance.
In early April, a group of physicians, consumers, employers, and insurers agreed to a voluntary program similar to the New York settlement. The Patient Charter was forged by the Consumer-Purchaser Disclosure Project.
Dr. Nancy Nielsen, AMA incoming president, said in an interview that the Massachusetts suit could have been avoided if the Patient Charter was in place. Rating systems are here to stay, however, she acknowledged, adding that the AMA does not oppose the programs on principle.
She said legislation codifying the voluntary standards would not likely pass Congress, because of insurance industry opposition. But when insurers don't follow the principles backed by physicians and consumers, “we'll go to the attorney general of that state,” Dr. Nielsen said.