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 data from a recent Rand Corp. study.
Health plans use cost profiling to limit how many physicians get in-network contracts and to allot bonuses to those 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 proved, according to John L. Adams, Ph.D., of Rand Corp. and his associates.
The investigators 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. In all, 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.
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.
Only 41% of physicians across all specialties had cost-profile scores of 0.70 or greater, a commonly used threshold of acceptable accuracy (N. Engl. J. Med. 2010;362:1014–21). 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.
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 include support from the Integrated Healthcare Association, American Medical Association, American Board of Medical Specialties, Arkansas Medical Society, American Board of Internal Medicine Foundation, Massachusetts Medical Society, Physicians Advocacy Institute, Commonwealth Fund, and Ingenix Inc.
My Take
Abandon Flawed Evaluation Programs
The Rand 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 study shows that such ratings 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 us to create constructive programs that produce meaningful data for increasing the quality and efficiency of health care.
J. JAMES ROHACK, M.D., is president of the American Medical Association. He reported no conflicts of interest.
