Physician-designation programs that seek to steer patients to certain neurologists are becoming more important as employers increasingly seek to control health care costs.
Through these programs, private insurers identify physicians who meet certain quality and efficiency standards and offer financial incentives to encourage their members to choose them.
The programs are controversial with physicians, some of whom question the ability of health plans to determine a physician's performance using claims data. “I believe they cannot fairly identify physicians — neurologists in particular — that are high-quality and low-cost,” said Marianna V. Spanaki-Varelas, MD, PhD, a neurologist at Henry Ford Health System in Detroit. “I don't think the tools they are using are able to identify those attributes.”
For one thing, the programs have so few neurology-specific quality measures that a neurologist's care is evaluated on factors unrelated to neurology; for another, a study conducted by RAND Corp. suggests that profiling programs do a poor job of accurately classifying physicians as “low cost” relative to their peers.
A member of the AAN Medical Economics Committee, Dr. Spanaki-Varelas wants health plans to change the way they evaluate neurologists.
“We want to be part of the process,” she said. “We are willing to work with insurers to make a difference in the care of our patients.”
WHY IS PROFILING POPULAR?
Health plans — and employers — love the designation programs because they believe they encourage patients to receive superior and lower-cost care than they otherwise would.
Aetna says physicians in its Aexcel designation program are on average 10 percent more efficient than their peers in the same specialty, according to studies of 2008 and 2009 claims. Because the specialties covered in the Aexcel network represent such a large percent of health care costs, that translates into a better bottom line for employers and lower out-of-pocket expenses for members.
“In round figures, it can be as much as a 4 percent savings of total claim costs, which is quite substantial,” said Wayne Gowdy, senior product manager at Aetna, comparing the experience of employers who use the Aexcel physician network to those who do not.
Employers are asking for even more focus on efficiency — or cost savings — from physicians and hospitals, he said. Where they once valued a large selection of providers to give their workers maximum choice, now they want employees to choose physicians who are judged to offer good care at lower cost.
“Efficiency requirements are actually getting ratcheted up, and in 2012 we are going to be reducing the size of those specialty networks to get people to be more focused on the most efficient providers,” Gowdy said.
HISTORY OF THE STARS
Physician-designation programs, which first surfaced about six years ago, were an early step toward the pay-for-value movement that is now taking the health care industry by storm.
The basic idea is that all physicians are not, in fact, equal, and that patients should have some way of telling which ones are best. Thus, health plans promote “best” physicians by placing them at the top of “find a physician” searches or highlighting their names with one or two stars.
Of course, “best” is in the eye of the evaluator. Health plans generally seek to highlight physicians based on the quality and cost of care they provide, but there is no consensus about what measures or thresholds should be used.
Shortly after they emerged more than five years ago, doctor-ranking programs got into hot water with then New York Attorney General (now New York State Governor) Andrew Cuomo, who charged that they were overly focused on cost rather than quality and that their methods for choosing favored physicians were not clear.
In late 2007, major insurers started entering into formal agreements to adhere to a “national model” for physician-ranking programs that was designed to promote fairness and transparency.
Today, many national and regional plans have physician-designation programs, but their scope and selection criteria vary considerably. While many programs do not include neurologists, two of the largest — Aetna's Aexcel and UnitedHealth Premium — do.
Aetna's program, which includes 12 specialties, will grow from 36 markets this year to 40 markets in 2012. Currently, about 64 percent of the 6,256 neurologists in Aetna's networks have achieved the Aexcel designation for their performance on quality and cost measures, earning them a blue star next to their name in Aetna's DocFind online directory.
Since its inception in 2005, UnitedHealth's program has grown to include 21 types of primary care and specialty physicians in 41 states. Of the 7,105 neurologists evaluated for UnitedHealth Premium designation, 40 percent received two stars — signifying that they met the health plan's quality and cost efficiency criteria — and another 6 percent earned a single star for the quality-only designation. The other 54 percent of neurologists contracted with UnitedHealth did not meet the criteria for either “one-star” or “two-star” designation.
QUESTIONS ABOUT ‘PARTICIPANTS’
“I think that neurologists are participating — and I'm using air quotes when I say ‘participating’ — because they don't even know that they are in these programs,” said Katie Kuechenmeister, the AAN senior manager of medical economics.
Although UnitedHealth and Aetna both notify physicians by letter each year to let them know whether they have achieved “star-worthy” designation, the information apparently does not always get through.
Dr. Spanaki-Varelas thinks neurologists pay little attention to the profiling programs because they think patients do not use them to choose physicians. Rather, she believes patients rely on recommendations from primary care physicians, friends, and family and are generally unaware of the insurers' favored physicians.
“Even if they were aware, they wouldn't necessarily choose based on those criteria,” she said. “Their decision might be affected only if there are some incentives, such as lower co-pays, if they go to the physicians who get one- or two-star designations.”
Indeed, the pay-for-value movement is specifically designed to use financial incentives to steer patient choice. Employers design their benefit plans to reflect how much they want to encourage patients to choose certain providers.
For example, a patient might have a $5 copayment for an Aexcel-designated neurologist compared to a $25 copayment — as well as a higher coinsurance responsibility — for an Aetna-contracted neurologist that did not earn the designation, Gowdy said.
UnitedHealth spokesperson Lynne High said that for claims covered by the 21 specialties in the UnitedHealth Premium program, 59 percent of claims dollars were from physicians who were designated for both quality and cost efficiency. Considering that only 40 percent of neurologists contracted with UnitedHealth achieved “two-star” designation, it appears that the health plan is successfully steering patients to its favored doctors.
The Academy first weighed in on the physician-profiling movement in 2008 when it issued a position paper lauding Cuomo's work to force insurers to be more transparent about their ranking systems. Aetna's protocol for evaluating specialists is at http://bit.ly/k4Uimx, and UnitedHealth's method is at http://bit.ly/lt4oYR.
The general concept of evaluating physicians to help consumers choose wisely gets a thumbs-up. “There is a need,” Dr. Spanaki-Varelas said. ”Medical societies are not against programs that use methodologies that identify evidence-based medicine principles and try to rein in health care costs.”
However, the current profiling programs have few neurology-specific measures with which to fairly evaluate neurologists, Kuechenmeister contends. As per Cuomo's “national model,” health plans agree to use measures endorsed by the National Quality Forum (NQF), but the only neurology-related measures endorsed to date are for stroke.
When NQF-endorsed measures are not available, UnitedHealth uses measures developed by other organizations, including the Academy, and expert panels. For example, the quality measures it uses for migraine headache care are from AAN, the Institute for Clinical Systems Improvement and an expert panel.
There are a few other NQF-endorsed measures, such as falls, that can be applied to any physician, including a neurologist. Thus, a neurologist's quality performance is scored on measures that have nothing to do with neurology.
Beyond that, Dr. Spanaki-Varelas contends that analyzing claims data does not allow an insurer to know how the patient fared.
“Claims do not link to the patient's outcome. Only physicians can have outcomes information,” she said. “In order to be meaningful…methodologies need to change.”
Further, the ability of health plans to accurately identify a physician's efficiency in delivering care has come into question. A March 18, 2010, study in The New England Journal of Medicine by RAND Corp. of a mock cost-profiling program using claims from four health plans found that more than 20 percent of physicians were misclassified.
Dr. Spanaki-Varelas encourages all neurologists to learn about physician-designation programs — and to keep the programs in a proper perspective.
“It is not our priority to achieve a one-star or two-star designation — it is our priority to apply the principles of evidence-based medicine for the well-being of our patients,” she said.