Two of our finest docs were recently down-graded from premium status by a major insurer for providing sub-par care. Specifically, the insurer claimed that not enough patients seen by these docs got routine screenings with pap smears and mammograms.
I was asked to help review the data that led to this down-grade in designation for these docs. Here’s what we found –
Of the 209 instances where the insurer claims that patients did not receive either paps or mammograms according to recommended screening guidelines –
This, my friends, is how insurers measure quality.
Lemme guess–United Healthcare maybe? I got a nice little letter from them about being a “quality” doctor but not an efficient one–been meaning to blog about it so I better get with it. Same story–erroneous data and a stupid comparison, but I figure I might make other docs look good according to their analysis, so I’m OK with that!
This is the kind of trash that drove me out of practice. Why primary care doctors continue to contract with these insurers is beyond me. What is going to take for enough to lean out their windows and yell “I’m mad as hell, and I’m not going to take your plan anymore”?
power through paperwork. when all you have is a hammer, everything looks like a nail. what an unholy bunch of crap. i hope the docs sue the shit out of the insurer, but docs generally don’t roll that way.
So let me see, an insurance company publicly “downrates” a participating provider giving its reasons as specific non-performance where the records of those patients used to make that allegation actually bear written evidence to the contrary? And they then publicly “downgrade” that doctor on the same false allegations?
At what point does that become libel and defamation?
I have spent alot of spare time studying quality improvement. This reaction(question the data) is universally the physicians response to these measurements. And indeed, as in this case, the data are flawed. As they have been many times when I deal with insurers. But do we apply that skepticism to the data on the new cholesterol med? I think physicians often use a “question the data” defense when they don’t want to face problems…
Sorry, a little self promotion.http://poemd.blogspot.com/2007/03/quality.html
ddx:dx –
I think we do apply skepticism to new drugs. The data on drugs are subjected to FDA scrutiny and oversight, and articles are peer reviewed in the medical literature. True, the process didn’t catch the VIOXX problem soon enoght, and that means we need to tighten the process.
There is no such oversight on insurer’s data collection or interpretation.
As far as not wanting to face problems, that’s an interesting idea, but I’m not sure how it relates to this issue. These are docs who clearly met the standards but were being penalized wrongly. If our data review had shown otherwise, we would be dealing with that issue.
Jane marie – Is supect being efficient means running a well-oiled mill at low rates. I would love someone to do an analysis to see how doc ratings compare with contracted rates with insurers – I would not be surprised to find out that those with the lowest contracted fees have the highest ratings. That way, insures have one more way to drive consumers towards the cheaper docs, thus saving them money.
anonymous and 911- I don’t think individual docs suing is going to help, but large organizations can do so. And large medical systems can fight the good fight because insurers want them in their network.