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Fam Pract Manag. 2005 May;12(5):32-38.

Doctors protest insurer's rating program

The AMA, AAFP and others are speaking out against a new program from United Healthcare that seeks to identify physicians within its network who provide high-quality, low-cost care and encourages patients to select those physicians. The Performance Designation Program is currently in place in 13 states. About a quarter of physicians who contract with United Healthcare in those areas are on the list, reports the March 29 Wall Street Journal.

Physicians are awarded the preferred designation based on claims data from 2002 and 2003. They are identified in the insurer's provider directory with a gold star by their name. Patients who choose these physicians may receive financial incentives, such as lower co-payments.

United Healthcare says the program helps consumers make informed choices when selecting a physician.

But physicians believe the program has little to do with quality and is largely a cost-cutting measure. A key concern is that the program does not use nationally agreed-upon quality performance measures.

In an April 5 letter to the insurer's CEO, AAFP Board Chair Michael Fleming, MD, wrote, “We have serious concerns about the statistical validity of the program's quality assessment element given the purpose to which the results are being applied, public profiling of physicians. The efficiency measure is both difficult to understand and arbitrary in its application. The program appears to be less about providing legitimate information to inform patient decision-making and more about directing patients to low-cost physicians using questionable information and methodology.”

The insurer has said it is listening to physicians' criticism of the program and intends to improve it.

How to report complaints against insurers

Physicians who experience problems in their dealings with health plans, such as delayed claims or unfair payment practices, have several avenues available:

  1. File a complaint with your state's insurance commissioner. To locate the commissioner for your state, go to http://www.naic.org/state_contacts/sid_websites.htm and click on your state.

  2. Inform your local and state medical societies. They may ask you to complete a complaint form.

  3. Complete the AMA's online Health Plan Complaint Form. This form is available at http://www.ama-assn.org/ama/noindex/category/11149.html. Data collected will be used by the AMA to identify trends and to facilitate discussions with national health insurers.

Study shows how simple interventions can increase colorectal cancer screening

A recent study showed real-world potential for improving colorectal cancer screening by instituting simple office systems, such as flow-sheets, manual tracking systems and patient education brochures.

Office systems have been shown to be effective with a variety of preventive services, such as cardiovascular disease prevention, well-child care and immunizations. Researchers at Brigham and Women's Hospital and the Harvard School of Public Health wanted to find out whether the same could be true for colorectal cancer screening, which presents physicians with a more complex set of recommended tests and strategies.

For their study, the results of which are published in the March 28 issue of the Archives of Internal Medicine, the researchers connected staff from the American Cancer Society (ACS) with 127 primary care physicians in New England to identify areas for improvement. Over 29 months, the ACS facilitators made at least four visits or phone calls to participating practices. During that time, researchers observed significant improvements in two areas: educating patients about colorectal cancer screening through the use of posters and brochures and monitoring compliance with fecal occult blood tests using manual tracking systems. Of 551 patient records reviewed, the percentage of patients up-to-date with screening recommendations increased from 38.7 percent to 56.1 percent.

Patients could pay more for unhealthy lifestyles

Along with paying taxes and observing the speed limit, some Washington state residents will have to add “staying healthy” to their list of government responsibilities.

Under an agreement between officials in King County and labor unions, county employees will have higher deductibles, co-payments and insurance rates unless they adopt healthy lifestyle habits.

Workers will complete confidential health surveys and earn points for leading healthier lives and managing their diseases. Employees who refuse or do not earn enough points will pay more than $1,000 annually in out-of-pocket health care expenses.

While this policy won't take effect until 2007, some consumers are speaking out against the program. Caroline Whalen, a deputy administrative officer for King County defended the controversial policy, saying, “We wanted employees to take ownership of their health.”

Lending support for the concept, former U.S. Secretary of Health and Human Services Tommy Thompson was in Detroit in April urging the Big Three automakers – General Motors, Ford and DaimlerChrysler – and other domestic corporations to convince their employees to adopt healthier lifestyles if they wanted to see health-care costs dramatically reduced.

Consumers willing to trade more options for lower costs

Americans would rather pay lower out-of-pocket medical costs than have a wider selection of physicians and hospitals in their health plan, according to a March 2005 study by the Center for Studying Health System Change. In 2003, 59 percent of those surveyed were willing to trade provider choice for lower premiums, deductibles and co-pays, compared to 55 percent in 2001.

Though the study confirms Americans' concerns about increasing health care expenses, 40 percent of respondents still preferred to have access to a wider variety of providers, illustrating that the issue remains divisive.

Respondents with lower incomes were more likely to favor lower costs over more choices, with two-thirds of consumers with incomes below $36,800 willing to accept restricted options. Even so, 54 percent of respondents making at least $73,600 also said they were willing to sacrifice choice for lower costs.

The survey found that in 2003, 56 percent of Americans with chronic health conditions were willing to make the trade-off for lower costs. This was an increase of 5 percent from 2001, when out-of-pocket costs were not as high.

Consumer attitudes about choice versus cost were relatively stagnant between 1997 and 2001, due in part to the managed care backlash that called for a broader choice of health care providers. However, in 2002, many employers began to increase cost-sharing with their employees, creating concerns about affordability.

Job satisfaction falls for U.S. workers

If you suspect that your employees or colleagues aren't fully engaged in their work but are simply showing up for a paycheck, you may be right. U.S. workers are growing increasingly unhappy with their jobs, according to a new survey based on 5,000 households from The Conference Board. The dissatisfaction is widespread among workers of all ages and across all income brackets.

Half of all Americans say they are satisfied with their jobs, down from nearly 60 percent in 1995. Of this group, only 14 percent report being “very satisfied.”

“Rapid technological changes, rising productivity demands and changing employee expectations have all contributed to the decline in job satisfaction,” said Lynn Franco, director of The Conference Board's Consumer Research Center.

The survey found that employees are least satisfied with their company's bonus plan, promotion policy, health plan and pension. Two out of every three workers do not identify with or feel motivated to pursue their employer's business goals and objectives.

Physicians offer pay-for-performance guidelines

Three out of four physicians believe the quality of medical care would improve if doctors could get extra pay for superior performance, according to a survey of attendees at a recent summit sponsored by Johns Hopkins University and American Healthways. Following the summit, attendees released a report outlining key principles for making pay-for-performance (P4P) programs effective. The following were among their recommendations:

  • Programs should reward groups and individuals. Although payments may be distributed to physician organizations, practices should direct funds to individual physicians based on their performance within the group. This will hold both physician organizations and individual physicians accountable for patient outcomes.

  • Programs should use true bonus payments. The alternative is using quality withholds, in which a portion of the physician's income is set aside pending performance on quality targets. “Negative financial incentives should be avoided,” the report states. “In the early phases of P4P programs, developing adequate levels of provider buy-in to the process will be critical to program success. Negative incentives would discourage providers from participating. In addition, loss of income associated with negative incentives can create serious gaps in the flow of practice revenue.”

  • Programs should be public – to a point. The report encourages public disclosure of the names of those physician organizations that meet quality and outcome targets. However, it notes that programs should not publicly rank all participating physician organizations “because of unreliability inherent in conventional statistical methods and the resultant risk of falsely identifying outliers.”

  • Programs should include a variety of metrics. To provide a balanced view of physician performance, programs must include a sufficient number of metrics across a spectrum of health promotion activities and disease states. The metrics should be evaluated periodically to determine whether they are having the intended impact on access, costs, quality, health outcomes, physician satisfaction and patient satisfaction.

  • Programs should be fair. The report recommends that data should be collected using adequate sample sizes and should be adjusted for differences in patient mix. This will prevent physicians who care for sick or needy populations from being penalized.

Concerns about care coordination

Fears about liability have caused some physicians to resist taking on expanded care coordination responsibilities for patients with multiple chronic diseases, on multiple drugs and seeing multiple specialists. Such responsibilities include maintaining a comprehensive treatment plan for the patient and recommending additional referrals or changes in specialist management. But a study in the March/April 2005 Annals of Family Medicine suggests such fears about liability are unfounded. Instead, care coordination may actually lower liability risks if it is done well, with the assistance of best practice guidelines, integrated electronic medical records and computerized reminders.

Health care courts

Legislation that would authorize funding for states to create special health care courts on a pilot project basis was recently introduced in the House of Representatives by Mac Thornberry of Texas. Under the Medical Liability Procedural Reform Act of 2005, states would be able to set up courts staffed with full-time judges who have health care expertise and whose sole focus would be medical malpractice cases, which would bring expertise and consistency to these cases. The idea has been championed by Common Good, a bipartisan legal reform coalition.

Creating culturally competent docs

New Jersey has become the first state to require mandatory training in cultural competency for its physicians. Sparked by studies that show racial and sexual biases in medical care, the law enacted on March 24 requires each medical college in the state to offer instruction on race and gender-based disparities in health care. Students must complete the training to receive their diplomas. Physicians not trained on these issues in medical school must do so within three years of the law's inception in order to renew their licenses. The legislation, S144, can be found online at http://www.njleg.state.nj.us/.

Medicare payment cuts likely

If Congress fails to prevent a 4.3-percent cut in Medicare payments to physicians next year and a 26-percent cut over the next six years, beneficiaries' access to care could suffer, according to a recent survey of physicians from the AMA. Some 38 percent of respondents said they would reduce the number of new Medicare patients they accept, 34 percent said they would discontinue seeing patients in nursing homes and more than half said they would defer the purchase of medical equipment or information technology. The cuts are the result of a flawed physician reimbursement formula, which Congress has chosen to correct for the past three years, replacing the cuts with small increases. A similar outcome seems unlikely this year, as Congress is seeking to trim Medicare spending. Any increases for physicians could necessitate raising beneficiaries' premiums, which saw double-digit increases this year.

Insurers dominate many markets

Competition among insurers is lacking in many U.S. markets, according to the American Medical Association's 2004 Competition in Health Insurance study. The most recent study analyzed 92 metropolitan areas in 21 states. It also looked at 28 states where reliable metro-area data were not available. It found that the HMO/PPO market in 93 percent of the cities and states would be considered “highly concentrated” according to Justice Department guidelines. Such market domination makes it difficult for physicians to have any negotiating leverage.

Controversial hospital food

Bellevue Hospital Center in New York City placed itself at the vanguard of alternative medicine when it was announced it had become one of the first locations in the city to test Tasty Fries french fry vending machines. The hospital will host two machines, one of which will be in the main lobby, but only for a limited time. The fried potato dispensers were installed in mid-April “to test market demand and reaction.”


 

Copyright © 2005 by the American Academy of Family Physicians.
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