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Physicians group files suit over rankings

Insurance panel uses flawed data to calculate cost of care, doctors say

Email|Print|Single Page| Text size + By Jeffrey Krasner
Globe Staff / May 22, 2008

The Massachusetts Medical Society yesterday sought to derail a two-year-old plan under which physicians are ranked for cost and quality measures by health plans associated with the Group Insurance Commission, the agency that oversees health insurance for thousands of public employees at state and local levels.

In a lawsuit filed in Suffolk Superior Court, the society - which represents the state's doctors - alleges the commission's plan hurts physicians and patients.

The suit claims doctors capriciously ranked lower have been defamed, and that patients who have to pay higher copayments based on their doctor's ranking have been defrauded.

Dr. Bruce S. Auerbach, president of the powerful medical society, said efforts to improve the tiering program, part of the insurance commission's Clinical Performance Improvement initiative, have failed.

"There is a right way to do this, and a wrong way - and the Clinical Performance Improvement initiative is definitely not the right way," said Auerbach in a statement.

"We have worked with the GIC for four years to improve its program, and the agency has made changes in some limited areas. However, the GIC has refused to correct the CPI's most glaring problem, which is its ranking of individual physicians using inaccurate, unreliable, and invalid tools and data."

Tiering has become a widespread technique for controlling healthcare costs. For example, many insurers have adopted tiered pharmacy benefits, with higher copayments for name-brand drugs serving as an inducement for patients to choose generics. Such structuring is credited with controlling spiraling drug costs.

But the tiering of physicians has proceeded more slowly. Doctors have fought the cost-control methods, particularly tiering plans that seek to rank individual doctors, as opposed to physician practices.

The Massachusetts Medical Society long ago signaled its displeasure with the insurance commission's efforts, and its willingness to take its case to the courts.

Earlier this year, it undertook a massive review of all documents related to the tiering program, which it obtained from the commission through Freedom of Information laws. Three weeks ago, the society said its board of trustees had given the go-ahead for a lawsuit.

Dolores L. Mitchell, executive director for the Group Insurance Commission, called the doctors' actions "regrettable."

"It's a shame that in this time of stress in both costs and quality in the healthcare system, the Massachusetts Medical Society has decided to stop cooperating with us to make this a better product, and instead has taken this confrontational approach," she said. "The attorney general will represent us in court."

Mitchell said she had invited the medical society to join its physician advisory committee, which met periodically to work through problems with physician tiering.

"We agreed to a lot of the suggestions they made," said Mitchell, "but not all of them. They apparently wanted us to agree with all of them."

The physician rankings were first used in mid-2006. To compile them, the insurance commission uses a database of claims from six insurance companies, and applies computer analytic tools to compare the performance of physicians to one another.

But the medical society said the methodology was flawed.

In the complaint, it said Dr. Linda Buchwald, chief of neurology at Mount Auburn Hospital in Cambridge, uses an interdisciplinary approach to treat patients with advanced symptoms of multiple sclerosis, which can be expensive. "Her ranking was negatively affected by her willingness to treat these seriously ill patients," the medical society said.

Another doctor looked through all medical claims related to him that were submitted by health plans for the rankings. He found that more than half the patients were not actually treated by him, although he may have read their charts or interpreted their test results. As a result, the claims didn't accurately reflect the doctor's cost of providing care, the society said.

The lawsuit also names Tufts Health Plan and UniCare Life and Health Insurance Co., two companies that offer health plans that use tiering for insurance commission members.

Patti Embry-Tautenhan, a spokeswoman for Tufts, said, "We developed physician tiering methodology with guidance from the Massachusetts Medical Society and other interested and affected parties in the healthcare community. It is our belief that transparency of information regarding cost and quality is in the best interests of our members and other healthcare consumers."

Jeffrey Krasner can be reached at krasner@globe.com.

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