Sunday, March 27, 2005
Some plans, like Premera and Blue Cross of California, are comparing doctors' relative cost-effectiveness. Others, including Aetna and PacifiCare, are also factoring in clinical quality. But even when they do that, cost remains king.
PacifiCare, for example, culls the most efficient physicians for its Value Network before it evaluates their clinical performance. 'We need to be able to offer it on a discount basis compared to a standard network,' explains FP Sam Ho, PacifiCare's chief medical officer. 'If you're not going to be cost efficient, there won't be much attraction for this product.'
Ho observes that some doctors who score high on quality are less cost-efficient than other physicians. 'If consumers want those providers, they can select them in the standard tier, but they have to pay more. For instance, they have to pay 30 percent coinsurance instead of 10 percent. Or, in the standard network, maybe they'll have to pay 10 to 15 percent more in premiums than they would in the Value Network.
'What we're trying to do is find the highest-quality, lowest-cost providers. If consumers want to choose other providers, one of the attractions of this program is that they can still choose them.'
Similarly, Aetna's approach to tiering focuses on cost, tempered by the reality that consumers still prefer broad networks. According to internist Don Liss, senior medical director of Aetna, the big insurer decided to tier specialists rather than all physicians because it saw that 'specialty care is the cost driver.'
And how do they decide who rates for the favored program? Not by reviewing their charts or patient outcomes, but by looking at the money the insurance company spent paying claims:
To evaluate the physicians' cost-effectiveness, Aetna, like many other plans, uses a claims analysis program known as the "episode treatment grouper" or ETG. The software totals all of the medical, surgical, and pharmacy claims for a particular episode of care and compares that to the total for claims when other doctors in the same specialty manage a similar case.
As an example, Liss cites an orthopedist treating an upper arm fracture. "The software looks at the cost of the ER, the X-ray, the orthopedist's consultation, pain medication, follow-up visits, and so on." The analysis includes all cases of that type that Aetna has claims for.
The problem with claims data is that it's highly inaccurate. For example, one of the insurance companies in our area sends me periodic reports that list my patient who haven't had a pap or mammogram according to their claims records. At least, not a pap or mammogram that I billed them for. Most of the patients on their list are women who go to a gynecologist for paps and mammograms. The insurance company has claims for them, but they don't bother to look those up. They just look at claims with my tax identificaiton number on them. It's an imperfect system for monitoring quality of care, to say the least. Especially when you consider that with a little extra effort, they could do better.
And as far as these tiered networks go, is the cheapest doctor necessarily the best doctor?
posted by Sydney on 3/27/2005 08:05:00 PM 2 comments
Hi, cool blog. Is this your only one? I have a couple of my own. Keep up the blogging, enjoy.
By 3:01 AM, at
Hi there. You have a nice blog here. Just out blogging, thought I'd leave a comment.