NOT WHAT THE DOCTOR ORDERED

Doctors decry insurance ratings based on economics

Dr. James Wang of Springfield, Mass., says it s hard for those outside the exam room to determine quality of care.

Part of a series.

Dolores Mitchell heads the Massachusetts Group Insurance Commission, which uses tiering.

BOSTON -- In the rush to contain health-care costs, insurers are increasingly ranking doctors into groups based on their clinical treatment decisions.

Known as 'tiering,' the groupings are of dire concern to many doctors who contend insurers' rankings deceptively cause patients to question their physicians' performance and create wrong incentives for physicians to cut down on prescribing expensive drugs and tests.

The reason for tiering is for insurers to save money with patients of the worst-rated physicians forced to either pay higher co-pays or switch doctors. Tiering is most commonly used in major cities on the East and West coasts, although it has been tested in Ohio.

During the past five years, the Massachusetts Group Insurance Commission, which purchases insurance for nearly 300,000 state employees and retirees, has implemented a plan that tiers physicians.

READ THE SERIES: Not What The Doctor Ordered

To offset the rising costs of health care, Dolores Mitchell, the executive director of the commission, said it has increased co-pays, encouraged the use of generic drugs, and implemented managed-care programs. She said the commission turned to tiering physicians in an effort to improve health-care quality and contain costs.

Dr. Dale Magee, an obstetrician- gynecologist in Shrewsbury, Mass., says doctors are going crazy over this.

Patients of Tier 1 'preferred providers' have the lowest co-pays for office visits, but patients of physicians in other tiers will pay $10 to $20 more per visit to see their doctors.

'A great deal of care has been taken to be fair,' said Ms. Mitchell, adding that the standards are designed by physicians. 'Are they perfect? Of course not. Is this process perfect? Of course not. It is evolutionary.'

The Massachusetts Group Insurance Commission expects patients to use the tiering system to select quality and cost-conscious doctors.

Doctors say the measurements are not fair because they fail to take into account extenuating circumstances of patients and because they are based on insurance claims data.

'The doctors are going crazy over this because they feel like somebody is grading them using a secret standard, and when they ask for their information, they repeatedly find errors,' said Dr. Dale Magee, an obstetrician and gynecologist in Shrewsbury, Mass.

'One or two patients can sway someone from one tier to another,' added the immediate past president of the Massachusetts Medical Society.

Don Pirc of Medical Mutual of Ohio says his company contemplated a tiering system but backed off.

The Massachusetts Medical Society recently sued the Massachusetts Group Insurance Commission, claiming that patients have been defrauded and physicians defamed by the tiering system. Massachusetts isn't alone. Ranking systems in New York, Connecticut, and Washington state also have faced legal challenges.

Medical Mutual of Ohio considered using a tiering system several years ago, but doctors in the network advised against it. Quality is hard to measure, and there is a question about whether enough data on each doctor exists to determine cost effectiveness, physicians said.

The Cleveland insurance company does share quality and other data with doctors but does not make it public as tiering systems do, said Don Pirc, Medical Mutual's director of network management in northwest Ohio.

'We backed off on it,' he said. 'That's really when we decided the best way to go is to work cooperatively with them, and we have ever since.'

Dr. James Wang, a obstetrician and gynecologist in Springfield, Mass., said it is difficult for observers outside the exam room to determine the quality of care provided by a doctor.

'Medicine was traditionally an art because we didn't know a lot about the science of medicine,' Dr. Wang said. 'The focus is now on science, but there's still an art to medicine. You need to have some sense of what's happening, and to some degree, you need to have a gut instinct about what to do with patients.'

Dr. James Wang of Springfield, Mass., says it s hard for those outside the exam room to determine quality of care.

Dr. Wang believes that initiatives such as tiering are part of a silent campaign to take the human aspect out of practicing medicine, make doctors appear interchangeable, and undermine their patients' confidence in them.

The result is that physicians like Dr. Wang feel as if they've become 'technicians' for the health-care industry as they work within increasingly stringent protocols to treat their patients.

With the rules tightening, doctors wonder aloud, half-jokingly, if physicians eventually will be replaced by computers, with patients inputting symptoms and machines spitting out treatment plans.

'They are eroding the patient-physician relationship by taking away the ability of physicians to be people,' Dr. Wang said.

Blade staff writer Julie M. McKinnon contributed to this report.

Contact Steve Eder at: seder@theblade.com or 419-304-1680.