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Two of the nation’s largest managed care organizations are focusing on physician ratings. At least one MCO has made this information public, which could prompt many more payers to jump on the bandwagon.
Cypress, CA-based PacifiCare Health Systems Inc. recently launched its physician group practice quality index program, which gives its HMO members a score card of how physicians rate on a variety of clinical and patient satisfaction measures.
United HealthCare Corp. of Minneapolis also has a new physician report the company plans to make public within a few years.
Managed Care Strategies spoke with the medical directors of both companies, and asked them to explain how their programs work and where they’re heading with these report cards.
• Sam Ho, MD, is vice president and corporate medical director of PacifiCare in Santa Ana, CA. PacifiCare of California, an HMO subsidiary of PacifiCare Health Systems Inc., serves more than 2.1 million members in its commercial and Medicare risk health plans.
• Lee N. Newcomer, MD, is an oncologist and the chief medical officer of United HealthCare Corp., which, as one of the nation’s biggest managed care companies, has 200,000 doctors in its nationwide network.
Here’s what they say:
MCS: Why did PacifiCare and United HealthCare start these physician reports?
Newcomer: [United HealthCare] calls it a clinical performance report. We didn’t want to use "report cards" or "grade cards" because it seemed a little too punitive.
We started it because we had done some early work with our data bases; experimenting with how well we could profile care, and learning how well we could do it. And as we verified performance levels, it became clear that the [physicians’] performance wasn’t at the level we would like and that physicians would like.
No matter what we measured — whether it was diabetes or cardiac care or hypertension — we found that physicians were complying with the standard of care only half of the time. My thought was that I practiced medicine for 12 years; and no one ever gave me any information on how well I was practicing medicine, so I practiced under the assumption I was doing it right. If someone had given me this [kind of] information I could say that I’d go back and learn how to improve it. So our thought was to give the physicians these reports.
Ho: [PacifiCare’s] first reason was to provide credible and relevant information to consumers so when they select provider groups they have the information they need at the point of selection. The second objective is to give physicians information so they can continue to improve peformance.
In combining those two objectives, we basically use the marketplace as a driver for innovation and quality, allowing consumers to vote with their feet.
MCS: How did you start the reports?
Ho: We’ve done a lot of market research, and we saw that quality means different things to different people. We purposely devised a quality index with 50% clinical measures and 50% service measures. To some patients, it might be really important to choose what the mammography screening rate is, and others may want to know the patient satisfaction rate of a provider.
This is just the beginning; we’ll update these reports twice a year, and learn more about what’s important to consumers, and also learn more about what data is more credible to providers.
Newcomer: We did a pilot project last year in four cities — Columbus, OH; Greensboro, NC; Denver; and Dallas. That was our first attempt with cardiologists and internists. We sent the information out and did a formal survey on these physicians to see if we had any errors. The feedback was very positive.
We did our second wave of reports in October, with 21,000 reports covering 238,000 patients in 23 health plan markets. This is still for internists and cardiologists, and we added family practitioners.
MCS: How will public reporting work?
Ho: When the consumer receives a provider directory from PacifiCare, it no longer lists just addresses. It’s a blue star directory and represents medical groups in the top 10% of all of these indices. (See an explanation of PacifiCare’s quality index, below.)
In order to maintain it, we’re going to update this report twice a year. We know how doctors respond to competition. So in order to maintain a blue star ranking, they’ll have to continually improve service. For example, if the top medical groups close their practices to new patients, they’ll lose their blue star ranking. Instead, they will have to extend hours or hire nurse practitioners to take care of the more routine clinical issues, or hire more doctors. It taps into their innovative spirit.
The people in the top 10% will have to work very hard to maintain that 10% ranking. The others will have to work to gain a top 10% ranking.
Newcomer: We will not release the physician reports to the public for at least two years. It’s simple fairness. The physicians have seen this data for the first time ever in October; since they never have received any evaluation of clinical work before I think they deserve some time to improve it. We might publish those with extremely good scores so those who are doing very well will receive some kind of reward. (See United HealthCare’s indicators, p. 146.)
MCS: Will PacifiCare and United HealthCare also begin to issue reports on hospitals?
Newcomer: The big limitation for us with hospitals is the claims data we get from them. Our hospital contracts are either DRGs or per diem, so we can’t tell from the claim record what went on while the patient was hospitalized. We have to go to the nursing review records, and you can’t pull out that data as easily.
Also, most of the hospitals already do [their own clinical reports.] Quite a few participate with vendors who help them understand their morbidity and mortality against risk-adjusted normals. But hospitals don’t release that information. I think in the future, you will see us asking for that data — a lot of information on how they perform for pneumonia, heart attacks, and common [procedures] against normals.
But to get that data is very difficult. They’re reluctant to share it publicly. I think some day it will be part of the contracting process. We’re already doing it in four cities in cardiac disease — surveying hospitals for cardiac information. In the first round, what we’ll do with the information is list in the member directory those hospitals that meet certain standards. If the members want the information, they can see this center got good grades on these points we look at for cardiac care.
Ho: We haven’t gone to hospitals yet. We will explore the possibility of looking at hospital report cards as well. The advantages would be that consumers are as interested in their hospital care as in their physician care. The disadvantage is that number one, you still have problems with data submitted by hospitals; and number two, hospitals take care of one segment of the population, so a report doesn’t capture the full spectrum of care. Only 3% of the population uses hospitals in a given year.
Sam Ho, MD, Vice President, Corporate Medical Director, PacifiCare, 3100 Lake Center Drive, Santa Ana, CA 92704. Telephone: (714) 825-5175. Fax: (714) 825-5033.
Lee N. Newcomer, MD, Oncologist and Chief Medical Officer, United HealthCare Corp., Mail Route MN008-W310, 9900 Bren Road E, Min-netonka, MN 55343. Telephone: (612) 936-7212 or (612) 992-6000. Fax: (612) 936-7290.