APMA News - July/August 2013 - (Page 28)

Reimbursement Economic Credentialing Economic credentialing is the practice of determining a physician’s qualifications to participate in a health-plan network based in whole or in part on utilization of health-care services and lower cost of care without regard to the appropriateness of the care furnished. Economic credentialing (also known as economic profiling) may be used to assign physicians to tiers in a network, or it may be used to make decisions to wholly exclude a physician from a health plan’s participating provider panel. APMA issued a public position statement against economic credentialing in 2005 that stated, in part, “organizations that perform economic credentialing do not ensure that their members receive the highest quality of care, inappropriately interfere with the relationships between physicians and their patients, and provide incentives for physicians to underutilize care and under-treat their patients.” While there had been a few prior lawsuits regarding the use of economic credentialing to rank physicians, in 2007, the New York Office of Attorney General (NYAG) brought the issue to the forefront. The NYAG requested that UnitedHealthcare refrain from introducing its “Premium Designation” physician ranking program. The NYAG’s office expressed three principal concerns about the program: 1. Consumers may be steered to doctors based on faulty data and criteria. 2. Consumers may be encouraged to choose doctors because they are cheap rather than because they are good. This could undermine the integrity of the doctor–patient relationship. 3. UnitedHealthcare’s profit motive may affect the accuracy of its quality ratings because high-quality doctors may cost UnitedHealthcare more money. This is a conflict of interest.i The NYAG’s office sent similar letters to five other health plans and ultimately announced that the office had entered into formal agreements with CIGNA, Aetna, United, Group Health Inc./Health Insurance Plan of New York, and Wellpoint that define the transparency standards under which the plans would engage in any physician performance measurement, reporting, and/or tiering programs. CIGNA, Aetna, United, and Wellpoint announced they would go beyond the terms of the settlement by applying nationally the model standards set forth in the settlement agreement. The agreements prohibit plans from conducting rankings solely on the basis of cost of care and require transparency in informing consumers regarding the portion of measures that are based on cost. Under the agreements, cost-efficiency measures may only be used in conjunction with quality measures. If a plan uses a combined cost/quality score, it must disclose the specific measures and relative weights used in determining the i Letter to Thomas J. McGuire, Esq., of UnitedHealthcare from Linda Lacewell, Counsel for Economic and Social Justice, State of New York Office of the Attorney General (July 13, 2007). 28 APMA News July/August 2013 score. Cost-efficiency and quality performance measures have to be calculated and disclosed separately in information for consumers and public reporting. Additional elements of the agreements focus on accuracy of data, as well as the transparency and oversight of the process. The agreements were based on model standards drafted in consultation with AMA, the New York medical association, and consumer advocacy groups. Under the agreements, at least 45 days prior to publishing quality or cost evaluations, plans must furnish physicians with the methodology and measures used to assess them, the data used, and an explanation of the physician’s right to make corrections and appeal. If a physician makes a timely appeal, the plan cannot publish the evaluations until the appeal is completed. Subsequent to the New York settlement, several states, including Colorado, Maryland, Texas, and Ohio, enacted laws regarding physician ranking or rating systems that include many of the features of the NYAG settlement agreement. For example, Ohio, Maryland, and Colorado laws prohibit rankings based solely on cost effectiveness. Maryland law requires that the quality and cost components be calculated separately and disclosed and that the proportion of quality measures to cost measures be disclosed. All of these state laws require a health plan to disclose to physicians their ratings in advance of publication and provide a mechanism for a physician to obtain the data underlying his or her rating and to appeal the rating. Ohio and Maryland require that ratings be approved by an independent ratings examiner, and Texas requires that plans follow the endorsed measures, guidelines, and standards of the National Quality Forum or AQA Alliance (formerly the Ambulatory Care Quality Alliance). The previously mentioned state laws all focus on measurements or ranking results that are published. However, it is important to ensure that unpublished economic credentialing, such as terminating providers based on their costs, is also regulated. California and Texas regulate such economic profiling but only require the plan to disclose the methodology and results to the provider. Texas and Ohio also have laws requiring that any economic profiling take into account characteristics of a physician’s or provider’s practice that may account for variations from expected costs. These laws fall short of providing meaningful protection. APMA continues to promote its position on economic credentialing and to monitor the use of economic credentialing and laws regulating it. As set forth in the APMA statement, “any time utilization of health-care services is used as a factor in a network participation decision, it must be measured in a way that reflects whether appropriate care was furnished and identifies underutilization as well as over-utilization. Measures of appropriateness of care can only be made based on well-recognized and accepted standards of care and must give full consideration to the risk status of patients on the physician’s panel.” n Contact the APMA Health Systems Committee at healthsystems.hpp@apma.org.

Table of Contents for the Digital Edition of APMA News - July/August 2013

APMA News - July/August 2013
President's Message
Contents
Destination Hawaii: The National in 2014
Arizona Study Finds Podiatry Saves Lives and Reduces Expenses
Committee Nominations Requested
US Naval Podiatrist Trains Afghan Orthopedists
The Man Behind the Marketing: The New Face of Student Recruitment
The Benefits of Working with Residents
Bylaws Propositions Due
Health Policy and Practice Committees Meet to Tackle Reimbursement Issues
Reimbursement
ICD-10: How to Code a Typical Infection
Federal Advocacy Forum
Cosponsors to the Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians Act
APMAPAC Chair Report
Resolutions Submission Deadlines
Coverage Corner
IT Consultant
Inside APMA’s Social Media
Website Wisdom
On the Road with APMA
Small Business 101
CPME Update
Young Physicians’ Accomplishments
In Short
Worthy of Note
Affiliates Corner
List of Affiliated Organizations
New Members
Death Notices
APMAPAC Update
Development Update
Annual Scientifi c Meeting Sponsors
Classified Advertising
Dates to Remember
Advertising Index
10 Questions
Your APMA

APMA News - July/August 2013