Each Patient Counts: Massachusetts Medical Society Weblog

Jerome Groopman Weighs In On Tiering; Evokes Orwell, Kafka

Dr. Jerome Groopman, the Boston physician who has written bestsellers and writes for the New Yorker, writes a scathing indictment with Dr. Pamela Hartzband on the pitfalls of current pay for performance programs in today's edition of the Wall Street Journal. This section of the article on the GIC's tiering program is priceless:

"Too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word "quality" became zealously defined by regulators, and then redefined with each change in consensus guidelines. And Kafka could detail the recent experience of a pediatrician featured in Vital Signs, the member publication of the Massachusetts Medical Society. Out of the blue, according to the article, Dr. Ann T. Nutt received a letter in February from the Massachusetts Group Insurance Commission on Clinical Performance Improvement informing her that she was no longer ranked as Tier 1 but had fallen to Tier 3. (Massachusetts and some private insurers use a three-tier ranking system to incentivize high-quality care.) She contacted the regulators and insisted that she be given details to explain her fall in rating.

"After much effort, she discovered that in 127 opportunities to comply with quality metrics, she had met the standards 115 times. But the regulators refused to provide the names of patients who allegedly had received low quality care, so she had no way to assess their judgment for herself. The pediatrician fought back and ultimately learned which guidelines she had failed to follow. Despite her cogent rebuttal, the regulator denied the appeal and the doctor is still ranked as Tier 3. She continues to battle the state."

Read the full article in Vital Signs here.

Judge Allows Lawsuit Against the GIC to Proceed

We learned today that a Superior Court judge has upheld six separate claims in the litigation filed by the MMS and five physicians against the Group Insurance Commission's physician tiering program.

The court dismissed four other claims, but two of the most important claims (defamation and consumer protection) were upheld.

The MMS news release on the announcement is available here.
A copy of the ruling is available here.

An Amazing Post on GIC Tiering By a Primary Care Physician

Dr. Sally Ginsburg, pediatrician from Longmeadow, has written an amazing post on the absurdities of the Group Insurance Commission's physician tiering program. It's on WBUR's "CommonHealth" blog. We heartily recommend a close, careful reading of her points.

She agrees that health care must be delivered more efficiently and that quality must be improved. But she cites many examples of where tiering clearly fails the test.

She concludes, "Look at where the BIG health care money is really being spent- high cost, end of life care and very costly and sometimes futile beginning of life care. Stop playing this out on the primary care physicians, before there are none of us left in the state."

The Massachusetts Medical Society has filed suit against the GIC to "correct the wrongs" of the tiering system. We contend that the GIC's tiering system is not only complex, it is impossible to understand. It is not only unfair, it is inaccurate. It is supposed to save money and reduce costs, but there is no evidence it does either - and there is a lot to suggest it actually does the opposite. It is unfair to physicians, and it misleads patients.

In December, a state judge held a hearing on the GIC's contention that the complaints of the MMS and five physician co-plaintiffs were without merit. A ruling on the matter is still pending.

Meanwhile, the GIC's health plans have released the tier designations for program's fourth year, and the inequities and inaccuracies seem as bad as ever, if not worse.

This isn't the way to address cost and quality. It's time to move on to something else.

Bruce Auerbach, MD
President, Massachusetts Medical Society

Physicians Must Move Quickly to Appeal Their 2009 GIC Tier Designations

Health plans that contract with the Group Insurance Commission have begun to release their tier designations for 2009-2010. So far, we know about three health plans who released their tiering  designations: Unicare, Tufts and Neighborhood Health Plans.

Physicians have a very limited time period to appeal their tier designations.

The Massachusetts Medical Society has posted a chart listing deadlines and instructions on how to appeal.  This will be updated when information from the three other GIC health plans becomes available.

Download the chart.

CBS News Covers Physician Tiering

CBS News aired a terrific story last night on the problems with physician tiering programs. It articulates many of the concerns the Massachusetts Medical Society has been expressing for years.

(Unfortunately, CBS subjects you to a 15-second or 30-second advertisement at the beginning. The story follows immediately afterwards.)

Mass. Medical Society Files Legal Action Against the Group Insurance Commission

The Massachusetts Medical Society announced today that it has filed legal action seeking to “correct the wrongs” of the physician ranking program implemented by the Massachusetts Group Insurance Commission (GIC), the purchaser of health insurance for most Massachusetts state employees and retirees.

The complaint, filed in Suffolk Superior Court, alleges that patients have been defrauded and harmed and physicians have been defamed by the GIC’s Clinical Performance Improvement initiative (CPI), a program that ranks (or “tiers”) individual physicians in one of three tiers, using various cost and quality measures. Patients are charged higher co-payment fees to be treated by physicians assigned to the lower two tiers, or must try to change physicians to avoid higher co-payments.

The filing asks the court to either stop the tiering program, or to require that the CPI adhere to specific standards, including transparency, fair notice, formal feedback and correction processes, meaningful physician involvement in the development of the CPI, demonstrate the program’s accuracy, validity and reliability, and submit their programs to an independent oversight authority. These are both requests that the MMS has asked GIC to do voluntarily on several occasions.

For more, read the full news release on the MMS website.

An Open Letter on Tiering, Physician Ranking and the GIC

This letter was sent on Nov. 28 to leaders in the business, health care, consumer and political communities of Massachusetts by B. Dale Magee, MD, MS, president of the Massachusetts Medical Society.

The rising cost of health care has become America’s top domestic issue. Each of the presidential candidates has provided detailed responses to the problem. It is dominating the editorial pages of our daily newspapers (most recently, The New York Times in a 2,000-word editorial on Nov. 25). And most seriously for us in Massachusetts, high costs are challenging the success of Chapter 58. If we do not act effectively, this great opportunity to extend health care to almost all our citizens will be severely undermined.

The rising cost of health care has become America’s top domestic issue. Each of the presidential candidates has provided detailed responses to the problem. It is dominating the editorial pages of our daily newspapers (most recently, The New York Times in a 2,000-word editorial on Nov. 25). And most seriously for us in Massachusetts, high costs are challenging the success of Chapter 58. If we do not act effectively, this great opportunity to extend health care to almost all our citizens will be severely undermined.

Addressing the cost of health care is a high priority for the Massachusetts Medical Society. I know that no single group is capable of solving this problem. Progress can only occur when those of us who are involved with health care delivery as well as those who are most affected work together.

The most visible attempt to address health care costs in our state is the Group Insurance Commission’s Clinical Performance Improvement initiative. As you know, the Medical Society has issued a detailed critique of the program – not because we want to stop the use of data, but because we want to use data that is accurate and will allow physicians to constructively change. The GIC initiative meets neither standard – not because of its intent, but because of its execution.

In recent weeks, the attorney general of New York signed agreements with five health plans to impose rigorous new standards on health insurers who rank physician performance.

The New York agreements declare, “Consumers are entitled to receive reliable and accurate information unclouded by potential conflicts of interest. The independence, integrity, and verifiable nature of the rating process are paramount.” Four health plans – Aetna, CIGNA, WellPoint and United Healthcare – will implement these standards nationwide.

The GIC initiative, as implemented, fails to meet these standards. Physicians are issued reports that they did not understand based on data that was developed with a closed, proprietary methodology. Physicians are, understandably, angry. Patients are being faced with the choice that they will either have to pay more for their care or switch to another doctor based on an unproven and inaccurate rating system. When asked what the cost savings have been thus far as a result of this program, the health plans were unable to tell us. This is not progress; this is a divisive distraction.

We in Massachusetts are accustomed to providing our people with the best in health care – the best physicians, the best hospitals and the nation’s best health plans, by many commonly accepted measures. Yet if we accept the unproven, inaccurate and potentially injurious system now purveyed by the Group Insurance Commission, our citizens will not be provided with the same high standards now enjoyed by the people of New York. This cannot be allowed to stand.

The GIC is to be commended for drawing everyone’s attention so acutely to the cost and quality issues of health care. We must now seek better ways to make progress.

In the end, the best solutions will come through all of us trying even harder to work together. For health care to achieve its potential for quality and efficiency, data needs to be shared between the plans and the physicians. Physicians must be able to use it to better a patient’s care. Ratings, if they are to be accurate and have value, will be the byproduct of the alignment of physicians, plans and purchasers, and will reflect how well we work together to maintain the public health, and care for those who are ill and injured.

Let’s do this now.

Sincerely,
B. Dale Magee, MD, MS
President, Massachusetts Medical Society

Five Insurers Now Agree to New York Physician Ranking Rules

A total of five health insurance companies -- including the top three in the country -- have now agreed to comply with rigorous new rules for physician ranking plans, setting a benchmark for the development of a nationwide standard. United Healthcare and the Group Health Insurance/Health Insurance Plan (GHI/HIP) of Greater New York this week joined Aetna, CIGNA, and Wellpoint in accepting the principles developed by New York Attorney General Andrew Cuomo.

Aetna, Cigna, United, and WellPoint will apply the principles nationwide.

The New York model expands on the principles for physician tiering programs that the Massachusetts Medical Society adopted earlier this month. The Massachusetts Group Insurance Commission (GIC) requires its participating health plans to utilize a proprietary ranking system. The system affects nearly 300,000 state and municipal employees in Massachusetts.

“While the GIC has made some changes in its program in response to physician concerns,” said B. Dale Magee, M.D., president of the Massachusetts Medical Society, “it has not been able to ensure accuracy, reliability, or validity. It falls significantly short of the New York attorney general’s mandate for these principles, as well as for independent oversight.”

Cuomo’s office drafted its model with input from the Medical Society of the State of New York, the American Medical Association, and several consumer advocacy groups. It requires insurers to fully disclose all aspects of any ranking system and hire an independent “ratings examiner” to monitor compliance.

The New York settlement agreements declare, “Consumers are entitled to receive reliable and accurate information unclouded by potential conflicts of interest. The independence, integrity, and verifiable nature of the rating process are paramount.”

“GHI and HIP believe that consumers must have access to accurate and useful information about their physicians,” said HIP’s executive vice president, Dan Dragalin, M.D.

According to a statement from Cuomo’s office, insurers will:

• Ensure that rankings for doctors are not based solely on cost and clearly identify the degree to which any ranking is based on cost;
• Use established national standards to measure quality and cost efficiency, including measures endorsed by the National Quality Forum  and other generally accepted national standards;
• Employ several techniques to foster more accurate physician comparisons, including risk adjustment and valid sampling;
• Disclose to consumers how the program is designed and how doctors are ranked, and provide a process for consumers to register complaints about the system;
• Disclose to physicians how rankings are designed, and provide a process to appeal disputed ratings;
• Nominate and pay for the ratings examiner, subject to the approval of the New York attorney general, who will oversee compliance with all aspects of the new ranking model and report to the attorney general’s office every six months. The ratings examiner must be a “national standard setting organization” and will be national in scope, independent, and an Internal Revenue Code § 501(c)(3) organization.

United Healthcare had been scheduled to start its ranking program in New York in December. It said it will comply with the agreement before launching the program. GHI/HIP accepted the agreement prior to designing its program.

Interim Meeting Update: MMS Approves New Principles for Physician Ranking Programs

The House of Delegates today approved a long list of new principles for physician ranking programs. The principles delcare that ranking programs should:

• Aim to strengthen patient-physician relationships
• Involve physicians in the design and implementation of all programs
• Use clinically important and sound performance measures
• Ensure sample sizes adequate to support meaningful data analysis
• Rely on meaningful data and analytic techniques
• Share and review data with physicians or practices prior to public release
• Ensure transparency of all quality and cost-effectiveness measures
• Identify and consider practice characteristics that may require special attention in quality and cost-effectiveness monitoring
• Use uniform reporting formats
• Minimum unintended harmful consequences
• Be pre-tested before implementation

In its notes to the House, the committee which reviewed the proposal stated, "This does not in any way endorse tiering by insurance companies."

In a statement on the passage of the resolution, MMS President B. Dale Magee, MD, said, "Physicians are concerned that the current rating system provides potentially deceptive and unreliable information to patients. This encourages a disruption to existing patient-physician relationships, and can result in patients paying more for their health care.”

He added, “Ultimately, the best solutions will come through collaboration. For health care to achieve its potential for quality and efficiency, data needs to be shared between the plans and the physicians so that they can use it to better a patient’s care. The current experiments in rating physicians are a distraction from the best uses for this data. Ratings, if they are to be accurate and have value, will be the byproduct of the alignment of physicians and plans and will reflect how well payers and physicians work together.”

He concluded, "Controlling cost in health care is everybody’s problem and physicians need to work hard to assure that issues surrounding costs are addressed in a manner that assures quality and guards against unintended consequences."

Be Part of the Cost Solution, MMS President Urges

MMS President B. Dale Magee, M.D., M.S., said Friday that physicians must actively participate in efforts to solve the problem of rising health care costs. Speaking at the opening session of the Interim Meeting of the MMS House of Delegates, “We can't just stand outside and say this isn't going to work. We have to be part of the solution,” he noted.

Following is the full text of his remarks:

I will take a little bit of time this morning to tell you what the officers have been doing over the past six months. We have done a lot. I know that most of you are aware of some of the issues. 

For instance, MinuteClinics have been a front-burner item over the past six months. And Bruce Auerbach, our president-elect, has represented us very well with regard to this issue. Our Workforce Study was released this summer and was very well received by the public and the media and is particularly important at this time with regard to Chapter 58.

There are a lot of other things I could talk to you about, but I want to focus your attention on one thing: cost and health care. We have to focus on this more than we ever have before.

As long as I have been in medicine, people have been saying that the rate of inflation in medicine can't be sustained. When I started in medical school it was 7 percent of the GDP, and they said this can't go on. It is now 16. So we've insulated ourselves from this. Medicine has gone on, our patients have done well, and it has really not been as big an issue for us as it has been for the policy people.

We have heard people that have been crying wolf. The issue is, when the wolf comes, will we know what it looks like?

Right now we are at a point in Massachusetts where municipalities are turning off their streetlights at night. They are closing libraries. The schools are cutting down on their curricula. Manufacturers are having difficulty paying the salaries of their workers and also maintaining the cost of their health benefits.

This is what the wolf looks like, and this is why right now we have to pay more attention.

Add to this the fact that Chapter 58 is mandating health insurance for everyone in this state, a good thing, something that we support and have to work to make successful. Yet so many people feel that even now with all the efforts of Chapter 58, health care insurance is still unaffordable for them. We have to pay attention. Others are. Others are offering potential solutions of things that they feel will help.

The Group Insurance Commission is offering what they refer to as the Clinical Improvement Program, which is tiering, and which all of you are familiar with and which we have looked at in great detail. We spend more time on this than any other topic of health policy at the Medical Society.

We know that the tiering program is based on inaccurate data. We know that the tiering program is based on what amounts to an experimental approach to try to rate doctors and cost shift to patients or disrupt physician/patient relationships. We are doing everything we can to inform and protect patients and to protect physicians from unfair treatment.

We have met with the Attorney General's office. We have submitted a Senate bill that will try to stop the tiering as it is right now. We have met with the plans, with the Group Insurance Commission, with Mercer, its consultant. We've brought in national experts to try to educate everyone that is involved.  

We have put articles in newspapers. We have educated the membership. We have reached out to hospital medical staffs. We are looking at everything we can to try to if not stop this program entirely, at least bring a little more reason to it.

But the fact is that the people who are paying for health insurance, the employers, municipalities, they feel that their house is on fire. And right now the only one running into the building with a hose is the Group Insurance Commission. We can't just stand outside and say this isn't going to work. We have to be part of the solution. That is what this Medical Society is working for as well.

Two weeks ago our State of the State conference focused on the cost of health care. The idea was to bring experts in around the country to give perspectives to our health policy people, give them a view so they understand what's going on so that when consultants come to them with proposals, they can understand the pros and cons a little bit better and make more intelligent decisions.

Today at the House of Delegates we are going to have a meeting looking at practical ways to handle common problems. We want each person to think about them, how they handle the problems they may see in their offices, and to have a good discussion with others regarding how others would review the same problems.

This is how we address the cost of health care at the clinical level by just exchanging information and knowing more about how others handle the problem. In December we are bringing experts in from across the country to speak to medical directors from the IPAs in this state and help to work with them to find out what data we need and how we can best use it to try to address the issues of the cost of health care.

In the spring we are going to have a Public Health Leadership Forum, which is going to look at the connection between lifestyle and illness, between illness and the cost of health care. It's not just about the care that we deliver and how much we get paid per unit of service. Rather, it's the demand for health care as well.

Ron Davis, the current president of the American Medical Association, says that about a third of the increase in the cost of health care over the past decade relates to obesity and the increased morbidity that goes with it. When schools are cutting out physical activity and people are spending two hours a day commuting and can't exercise, in many ways we are designing a community that is going to demand more health care. It's going to require more health care, and perhaps we should look at ways outside of the health care system to improve people's health and decrease the demand for services. That has to be addressed as well.

We're addressing it not just for our patients but for us. As you walked around this building today, you saw that we have a lot of exhibits. In your packets we have materials for your office. You have been given a pedometer by the Alliance. And all of these things are going to help us.

At 1:30 today we are going to have a walk around the grounds. Symbolic but important, because if you had time to spare, you should spend that time moving. So we want all of us to not only talk the talk, but walk the walk. The officers challenge you. We are going to be there. Meet in the lobby and we will go for that walk.

In summary, I just want you to know that cost is where we are focusing ourselves today. It is not an easy question. It's not going to be easy to solve, but we've got to try. We've got to be part of the solution. We have to run into that building and solve the problem, not just stand on the outside. 

When the physicians are involved in this issue, patients will feel better. They will know that they will get solutions that they can trust. They will get solutions that everyone can live with. That's what we want. 

Thank you, Mr. Speaker.