Making the Grade

Toward that end, patients, insurance companies and employers have reached a summit agreement of sorts, known as the Patient Charter. Under the new charter, which was announced earlier this month, participating insurance companies agree to provisions that include disclosing how they rate physicians, how they take into account both cost and quality, their steps to stick to a nationally accepted body of standards when measuring quality and to provide doctors the opportunity to challenge rankings before they are made public.

Most importantly perhaps, they will also have their ranking systems vetted by an independent third party known as a ratings examiner. Endorsed by the AMA, Cigna, United Healthcare and the AFL-CIO, the plan is being heralded as a major milestone along the bumpy path toward establishing true standards in health care. "It's voluntary, so we'll be watching it closely," says Nielsen, "But if the big insurers implement the principles we've agreed on, it will be a huge improvement over the existing system."

Although the charter's call for independent third-party monitoring promises to eliminate transparency concerns, other issues maybe less tractable. For example, each plan ranks physicians based only on the information provided in its own claims data. So if a physician has 100 patients, but only 15 of them are on a given plan, then only those 15 patients will contribute to that plan's rating of that doctor. The result: a physician can end up with drastically different rankings from one plan to the next.  

"One insurer gave me their double-star ranking, meaning I am both high quality and low cost. That same month, a second company deselected me from their cost-efficiency network because I didn't meet the standards," says Justin Bartos, a Ft. Worth, Texas-based family physician. "It leaves me with no clear sense of where I am excelling or where I might improve."  (The insurance company involved declined to comment on specific doctors and their rankings.)

And by most counts, room for improvement abounds. Americans spend as much as $300 billion every year on health care that does not improve patient outcomes. According to one RAND Corp. study, U.S. patients receive only about half of the recommended care for any given condition, and as many as 98,000 people die each year from preventable medical errors. Those errors and inefficiency drive up premiums which can force some employers to cut back on their coverage altogether. "We have many small employers, with fewer than 25 employees, who are struggling to provide any type of health insurance," says Blue Cross Blue Sheild's Taylor.

What no one disputes is that doctor rankings are here to stay. One sign of that are the doctor-rating Web sites cropping up in cyberspace. HealthGrades.com, RateMDs.com and Careseek.com, to name a few, allow patients to rate doctors anonymously on measures like punctuality and bedside manner. But experts caution that such sites only provide a fragment of the whole picture. "These vendors don't have any better information than anyone else at this point," says Painter. "While we urgently need reliable measures of quality in health care, the bottom line is that no one has gotten it quite right yet."

© 2008