"We're not opposed to quality. We encourage quality. This is not quality," AAFP President-elect Larry Fields, M.D., of Ashland, Ky., said recently about a UnitedHealthcare performance program. It has fueled physician anxiety in some states, and AAFP News Now interviewed Fields and others about the topic.
The UnitedHealth PerformanceSM Program was rolled out as a pilot program in 13 states last fall. As of Jan. 1, the company had signed contracts for clients in Missouri and Louisiana. "This program is designed to provide information to our customers that enables them to make informed decisions regarding their care," said Jordan Ginsburg, M.D., medical director of UnitedHealthcare of the Midwest.
Academy Blasts Insurer's Performance Program
By Sheri Porter
4/5/2005
Patients' information sheets say network physicians who meet the UHC program's quality and efficiency criteria receive the UnitedHealth Performance designation. The patient resource also says, "Many physicians will not be eligible for designation simply because of insufficient claims data."
What patients see, as they go about the task of choosing a physician from the list of names provided, are stars by some physicians' names. What patients may incorrectly infer, said Missouri AFP Vice President David Campbell, M.D., of St. Louis, is that physicians listed without stars "are providing some lower standard of care." Campbell called the concept of a performance- or quality-based program "laudable," adding that the problem comes in establishing appropriate and fair criteria. "The UHC program, as rolled out, does not have such criteria and hence is very unfair to some physicians," he said.
Patients who choose a "starred" physician may be rewarded with financial incentives such as lower co-pays. And that doesn't set well with the AAFP. Fields called the program "a ploy by UnitedHealthcare to encourage people to see doctors who spend less money on patients." More important, continuity of care -- a critical component of providing quality care -- is lost in the process, said Fields.
Ginsburg asserted the program is designed to enhance patient care by evaluating physicians on quality and efficiency based on national evidence-based medical standards, clinical guidelines and market-based resource utilization comparisons.
Fields said the data pulled to evaluate physicians were old (2002 - 2003), and many physicians didn't qualify simply because data on them were missing. The absence of practicing physician input in developing the program is also disconcerting, he said.
The Academy is certainly in favor of true pay-for-performance programs that use acceptable quality measures and then pay physicians additional money for meeting those measures, said Fields. The UHC program is not about pay-for-performance, he continued. Instead, it's a "tiered network benefit plan that promotes patients going to certain physicians based on cost without regard to the physician/patient relationship," he said.
Ginsburg said the UHC physician network "remains intact, and enrollees may see any physician in the network." He also said procedures are in place to ensure continuity of care.
UHC will continue to invite comments from physicians and physician groups about the program, said Ginsburg. A series of town meetings in St. Louis provided feedback that helped UHC make adjustments to the program. "We've also convened a group of physician representatives, including representation from organized medicine, to serve as an advisory panel," he said. It was not clear at the time of publication whether the Academy will participate in that panel.
Stay tuned. This issue isn't likely to go away. The Academy will continue a dialogue with UHC about the performance program, said Fields. "Currently, the number of physicians affected is relatively small. But if this program is expanded, or if other companies start to look at this model more closely, then we've got a bigger problem."
Visit the Wall Street Journal Web site for a story on this topic: "Doctors Criticize Health Insurer Over Provider Ratings Program."
What patients see, as they go about the task of choosing a physician from the list of names provided, are stars by some physicians' names. What patients may incorrectly infer, said Missouri AFP Vice President David Campbell, M.D., of St. Louis, is that physicians listed without stars "are providing some lower standard of care." Campbell called the concept of a performance- or quality-based program "laudable," adding that the problem comes in establishing appropriate and fair criteria. "The UHC program, as rolled out, does not have such criteria and hence is very unfair to some physicians," he said.
Patients who choose a "starred" physician may be rewarded with financial incentives such as lower co-pays. And that doesn't set well with the AAFP. Fields called the program "a ploy by UnitedHealthcare to encourage people to see doctors who spend less money on patients." More important, continuity of care -- a critical component of providing quality care -- is lost in the process, said Fields.
Ginsburg asserted the program is designed to enhance patient care by evaluating physicians on quality and efficiency based on national evidence-based medical standards, clinical guidelines and market-based resource utilization comparisons.
Fields said the data pulled to evaluate physicians were old (2002 - 2003), and many physicians didn't qualify simply because data on them were missing. The absence of practicing physician input in developing the program is also disconcerting, he said.
The Academy is certainly in favor of true pay-for-performance programs that use acceptable quality measures and then pay physicians additional money for meeting those measures, said Fields. The UHC program is not about pay-for-performance, he continued. Instead, it's a "tiered network benefit plan that promotes patients going to certain physicians based on cost without regard to the physician/patient relationship," he said.
Ginsburg said the UHC physician network "remains intact, and enrollees may see any physician in the network." He also said procedures are in place to ensure continuity of care.
UHC will continue to invite comments from physicians and physician groups about the program, said Ginsburg. A series of town meetings in St. Louis provided feedback that helped UHC make adjustments to the program. "We've also convened a group of physician representatives, including representation from organized medicine, to serve as an advisory panel," he said. It was not clear at the time of publication whether the Academy will participate in that panel.
Stay tuned. This issue isn't likely to go away. The Academy will continue a dialogue with UHC about the performance program, said Fields. "Currently, the number of physicians affected is relatively small. But if this program is expanded, or if other companies start to look at this model more closely, then we've got a bigger problem."
Visit the Wall Street Journal Web site for a story on this topic: "Doctors Criticize Health Insurer Over Provider Ratings Program."
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