Managed Care - August 2008 - (Page 52) PLAN WATCH ment with leading physician groups and health insurers on principles to guide how health plans measure doctors’ performance and report the information to consumers.” “The national effort to standardize these ratings programs has received buy-in from large employers, but it also has received buyin from national medical associations,” says Fried. Those include the American Medical Association, the American College of Cardiology, the American College of Surgeons, the American College of Physicians, and the American Association of Family Physicians. Aexcel focuses on physicians in 12 specialty categories who meet certain clinical performance and cost-efficiency benchmarks. The specialties are cardiology, cardiothoracic surgery, gastroenterology, general surgery, obstetrics/gynecology, orthopedics, otolaryngology, neurology, neurosurgery, plastic surgery, vascular surgery, and urology. These specialties make up a sizeable piece of the health care cost pie. Fried echoes the desire of most medical directors to use performance ratings to work with doctors to identify opportunities to improve care, rather than to do something drastic, like drop them from the plan’s network. “We’ll do that if there is appropriate information, irrefutable information,” says Fried. “There are other mechanisms that health plans have always had in the past to review quality of care. We do that. Doctors certainly have been eliminated from health plan networks if in fact there are significant qualityof-care concerns, but that’s not what these programs are about. “A part of our provider performance evaluation is a physician reconsideration process. It enables physicians to provide us with additional information that they might have pertaining to their care for Aetna members that might not be captured in claims data. Physicians have this option after they review member-level reports that we provide them in advance of a public display of their status that is based on the data that we have. This is done to ensure that our decisions are made using the most comprehensive set of evidence and that we engage physicians as participants in the process.” Waiting for a consensus “The other challenge is that many of the quality measures are relatively new, and we’re sort of waiting for a consensus among physicians and the other health plans because physicians want credible measures and so do we. And we’re not going to make decisions based on either flawed data or measures that are not credible,” says Fried. An Aetna fact sheet about Aexcel states: Who’s in and who’s not Though more than 700,000 Aetna members in 35 markets have benefit plans that include Aexcel, all the approximately 17 million Aetna members have access to the ranking system. “They can go online and see the ratings systems for who’s in or who’s not in this particular designation,” says Fried. Members whose plan includes performance networks with Aexcel designations are encouraged to see high-performing doctors through a discounted copayment or coinsurance. “Members like it because it gives them a way to make some better decisions regarding choosing specialists,” says Fried. “And employers like it because of the medical cost savings associated with those choices.” But not all Aetna products have regulatory approval for the Aexcel enhancement yet. “These systems are works in progress,” Fried says, “and as we get better identifying and agreeing on appropriate clinical measures, we’ll have that much more information to present to consumers.” ” MC If you know of a health plan that has a promising, innovative program or one that has been recognized as exceptional, and you think that clinical executives and plan management across the country would like to read about it, please contact us at editors@managedcaremag.com. 52 MANAGED CARE / AUGUST 2008
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