Friday, August 17, 2007

Physician ranking shenanigans: do insurers steer patients to cheaper doctors rather than the most qualified?

I've written numerous posts expressing serious concern that executives of large healthcare organizations are strangely reluctant to consider informatics-qualified physicians for leadership positions in healthcare IT, such as at "Leadership Position in Health Informatics: MD's Need Not Apply?" and "Hospital IT: Amateurs welcome."

This observation may unfortunately also apply more broadly. In the Philadelphia Inquirer today, a short summary of a Dow Jones story appeared. The Inquirer article puts the "money question" (pun intended) right up front and is rather blunt about it:


Philadelphia Inquirer, Aug. 17, 2007

Aetna Inc. and Cigna Corp., both Philadelphia, may be deceiving patients who rely on the insurer' physician-ranking programs, steering them to cheaper doctors rather than the most qualified, New York Attorney General Andrew Cuomo said.


The Dow Jones story is a little less blunt than the Inquirer short summary, but nonetheless revealing. Here are some excerpts:


UPDATE: NY AG Cuomo Concerned About Physician Rankings

by Chad Bray of DOW JONES NEWSWIRES chad.bray@dowjones.com

Attorney General Andrew Cuomo said Thursday that his office has sent letters to units of insurers Aetna Inc. (AET), Cigna Corp. (CI) and UnitedHealth Group Inc. (UNH), raising concerns about their physician-ranking systems.

In the letters, Cuomo's office said it's concerned the doctor-ranking programs carry "significant risk of causing consumer confusion, if not deception."

"Transparency and accurate information are essential when consumers make health-care decisions," Cuomo said in a statement. "We will ensure that insurance companies are not obscuring important facts at the consumers' expense."

The letters, dated Thursday, were related to Aetna's "Aetna Aexcel" program and Cigna's "Cigna Care Network" system, which have created networks of specialists based on criteria determined by the insurers.

... In both cases, Cuomo's office has raised concerns about the Aetna and the Cigna programs using claims databases to rank physicians - which his office says don't include all relevant clinical data and can be too small to generate reliable rankings.


That's very interesting. The AG is accusing these insurers of very fundamental violations of good medical informatics/information science practices. The article continues:

"We just received the NY AG's letter, and will review the request for information. We will cooperate fully," said Cynthia Michener, an Aetna spokeswoman, in a statement. "Aetna is fully committed to transparency, including publishing the criteria for the selection of specialty physicians on our member and provider web sites.

In the AG's letter, the following is stated:


The attorney general's office also expressed concern that neither the Aetna program nor the Cigna program discloses the data used to rank the doctors, even to the doctors themselves. "As a result, doctors and consumers have no ability to bring errors in the rankings to your attention so that they may be corrected," wrote Linda A. Lacewell, counsel for economic and social justice in Cuomo's office.


As in clinical trials of pharmaceuticals and medical devices, without extremely robust and thorough disclosures of the underlying data and algorithms, there is ample opportunity to "make the data work for you."

Cuomo's concern was met with the following response as cited in the Dow Jones article :


Tyler Mason, a spokesman for the UnitedHealthcare unit, said Thursday that the company responded to the attorney general's request with extensive information and a 25-page cover letter addressing his questions. "The program is designed to raise consumer awareness of differences among health-care practices that can affect both the effectiveness and cost of care and treatment," Mason said. "Understanding how often a physician adheres to evidence-based clinical guidelines, or how well a hospital treats a particular condition, helps consumers select the doctor or facility that best meets their needs." Mason said the program's methodology is based on "rigorous evidence-based guidelines" and has been honed with opinions from UnitedHealthcare network physicians, expert panels and physicians from national and professional organizations.

That all sounds wonderful, but can reflect a veritable information science cesspool that gives meaning to the "lies, damn lies and statistics" refrain if the data content, definitions, collection methods, and algorithms are subject to even slight defects or bias.

I find this situation particularly interesting.

"Who ya gonna believe?"

Here's how I am informed by my own personal experiences:

The Philadelphia-area HQ of Aetna is very close to one of the Merck satellite office sites where I often put in hours, in Blue Bell, PA, and I passed it regularly on the way home, a 15-minute drive. When the Merck 'Equinox' layoffs of 4,400 occurred in late 2003, I naturally applied to several Aetna positions.

A recruiter in the Connecticut HR offices at Aetna wrote this:

In a message dated 11/12/2003 4:32:01 PM Eastern Standard Time, PassarettiB@aetna.com writes:

Hello Scot,

Thank you for your interest in Aetna. Actually there are 3 positions that I feel you are qualified for. Please call me at your convenience to discuss further. Looking forward to speaking to you.

Regards,

Barbara


One position called for this:


Position Applied For: "Senior Clinical Outcomes Researcher 14972BR"

Designs, conducts and manages the production of health services research, health related quality of life program impact, economics research, models and publications for plan sponsors ... Supports multi-disciplinary teams, including outcomes research, clinical research and marketing staff to support women's health marketing, quality outcomes and cost-savings analyses.

What are we looking for? Strong interpersonal, communication, consultative, and presentation skills; the ability to collaborate and work within multidisciplinary teams, the ability to interact with colleagues at varying levels ... The ability to write in a clear, concise and effective manner to achieve the highest impact on a wide variety of audiences. Strong ability to convey complex concepts and to address major strategic challenges in writing and verbally. Ability to conduct health care intervention evaluations using economic modeling/analytic tools. Strong knowledge and ability to research a variety of qualitative and quantitative databases. Strong ability to analyze therapeutic area specific information to identify current trends and to address unmet challenges.

What is required? PhD in health services research, medical informatics or similar health related area or a Master's degree with extensive hands-on analytical experience.


I did not even get in for an interview:


Subj: RE: Thanks
Date: 11/13/2003 12:46:43 PM Eastern Standard Time
From:
PassarettiB@aetna.com
To: ScotSilv@aol.com

Hello Scot, I did hear from one of the hiring managers. Unfortunately, he feels you don't have the statistical background he is looking for. In the meantime, I will keep your resume on file and if I see something that is suitable I'll be in touch. Also, you can always check the
www.aetna.com website for opportunities that may be of interest to you.

Regards,

Barbara

I guess nothing "suitable" was ever found, as I didn't hear back from the recruiter.

Another position I expressed interest in was this:


"Business Information Manager"

What are we looking for? Solid understanding of integrated health care data, advanced analytical skills and outstanding consulting skills. Strong, interpersonal, communication, and presentation skills; the ability to collaborate and work within multidisciplinary teams, the ability to interact with colleagues at varying levels. Must be able to describe complex activities and analyses at both a high level and a detailed level for specialized audiences. The ability to write in a clear, concise and effective manner to achieve the highest impact on a wide variety of audiences. Self-starter, creative, resourceful, high energy and flexible.

What are the job responsibilities? Lead or participate in multi-disciplinary teams of clinicians, business and IT managers, and informatics analysts to develop quality metrics, consumer-focused tools for selecting quality health care facilities and providers, and evaluate Aetna's quality, medical management and member-centric programs.



I initially expressed interest in this role but when I discussed its reporting structure in more detail, it being a low-level manager position, I decided against it. I've discussed the issue of marginalization of medical informatics professionals on numerous occasions (ex. here and here) due to defective organizational structures and stereotyping. The question arises as to why a position such as this was graded so low.

Finally, an email I sent a few months later to Aetna's Senior Vice President and Chief Medical Officer describing my background and how the company might benefit from Medical Informatics expertise went unanswered.

Who do I find more credible regarding possible profit-generating flaws in the insurer physician-ranking programs, the Attorney General or the insurers?

As I'd written before in my posting "US senator says FDA needs independent safety office":


... Insights into process flaws, inadequate leadership skillsets, and perhaps even corruption in high-stakes industries can be gleaned by who they won't hire.

Of course, this is a personal opinion colored by personal experience, which should be taken with a grain of salt.

I report, you decide.

-- SS

3 comments:

Vijay Goel, M.D. said...

I've worked with a number of the insurers through my time at McKinsey, and I didn't share your impression that they were out to consciously exclude doctors from employment.

They do however, see medical expenses as largely uncontrolled and with very high variation, and since they don't know how to differentiate on quality, they differentiate with what they have (and care most about), which is price.

Until doctors start showing how that extra expense generates extra value (and much of Wennberg's work will say that it doesn't and we are on the flat of the curve), then I would say it is reasonable for insurers to steer their customers to the lowest price provider.

My sense is service and satisfaction may be parts of this-- but insurance companies are not going to be incented to raise their payments to suppliers-- so these metrics are likely going to have to come from someone else.

MedInformaticsMD said...

I've worked with a number of the insurers through my time at McKinsey, and I didn't share your impression that they were out to consciously exclude doctors from employment.

I can't comment on physicians in general. I'm mainly referring to medical informatics-trained physicians.

... since [insurers] don't know how to differentiate on quality, they differentiate with what they have (and care most about), which is price ... I would say it is reasonable for insurers to steer their customers to the lowest price provider.

That depends on one's definition of "reasonable", which from a societal perspective is often quite different than from the perspective of actuaries.

MedInformaticsMD said...

In thinking about this again:

... since [insurers] don't know how to differentiate on quality, they differentiate with what they have (and care most about), which is price ... I would say it is reasonable for insurers to steer their customers to the lowest price provider.

If insurers are fuzzy on what's "quality", then the patient-centered approach (as opposed to the highest-proft approach) would be to steer patients to the middle-priced providers, NOT the lowest-priced ones.

Sub par care more likely resides at the extremes.