Physicians Cite Continuing Problems with Fourth Year of GIC Tiering

Physicians Cite Continuing Problems with Fourth Year of GIC Tiering

Vital Signs: April 2009

Ann T. Nutt, M.D., a Dorchester pediatrician, vividly recalls the day this past February when she opened her mail to find that she would no longer be a tier 1 physician after July 1 under the state Group Insurance Commission’s (GIC) Clinical Performance Improvement program (CPI). The health plans under the aegis of the GIC insure about 300,000 state and municipal workers, their families, and retirees.

In fact, Dr. Nutt discovered she was now ranked in tier 3 — which meant, among other things, higher copays for her patients.

“I was irked, discouraged,” she said. “The insurance company’s letter was hard to understand. It took a couple of reads to interpret what the numbers meant.”

Finally, she called the health plan. A representative told her that the “efficiency” part of her record was excellent. “It’s quality that’s killing you,” she was told.

“I care about my efficiency,” Dr. Nutt said. “But I really care about my quality.” The insurer instructed Dr.Nutt to send a letter listing the reasons why her rating should be reconsidered. “What they didn’t do was give me a list of patients linked to the claims so that I could look in the chart, see what was done, and make an effective case for myself,” she said. Eventually she got the insurer to send her detailed information used in her ranking. That data, she said, showed that in 127 opportunities to be “compliant,” she had complied 115 times.

“Then I was really irked,” Dr. Nutt said. Heeding MMS advice that members move quickly to appeal their rankings, she formally appealed within the tight deadlines set down by insurer.

Dr. Nutt finally determined that her fall from the highest to lowest physician rating occurred because, in treating certain adolescent girls, she prescribed birth control pills without requiring chlamydia screening. Dr. Nutt knew that the girls in question were not sexually active and thus did not need to be screened for the sexually transmitted bacterium. Apart from their use as contraceptives, birth control medications, she added, are appropriate treatment for intense menstrual pain, acne, or polycystic ovary syndrome in such patients.

“But in reviewing my record, they just saw the claim for prescribing the medication without also seeing a claim for ordering the screening,” she said.

Despite her clinically sound explanation, the insurer denied Dr. Nutt’s appeal of her tier 3 ranking. “The denial was just a form letter,” she said. “It seemed as though they hadn’t even read my letter explaining everything.” After calling the insurer yet again, Dr. Nutt was told that a letter to pediatricians affected by the chlamydia measure was forthcoming and that her rating would probably be upgraded to tier 2. As this issue of Vital Signs went to press, she had not received the letter nor confirmation of any tier change.

Dr. Nutt is not alone in her frustration with the controversial GIC rankings. As it has every year since the GIC “Select and Save” tiering program began in 2006, the MMS has been inundated with calls from members unhappy with their rankings.

“We’ve gotten reports of physicians who are retired being put in tier 1,” said Bruce S. Auerbach, M.D., the MMS president. “Clearly one has to ask what the basis is for them being tiered.”

In May 2008, the MMS and five individual physicians filed a lawsuit against the GIC and two health plans that take part in the GIC program — Tufts Health Plan and UniCare. The suit claims that the tiering program defrauds consumers and defames physicians. In December, a Superior Court judge heard arguments from the defendants to dismiss the suit. As this issue of Vital Signs went to press, the judge’s decision on whether the suit should proceed had not been handed down.

“News to Us”

In a message to state employees contained in the winter issue of its newsletter, For Your Benefit, the GIC maintained that it “continues to work with physicians in and out of our health plans to refine physician scoring methodology.”

“That would come as news to us,” Dr. Auerbach said. “I haven’t seen anything that indicates any substantial change in the methodology and I haven’t been hearing from physicians that there is a change.”

In the newsletter, the GIC also said that for the 2010 fiscal year, beginning July 1, it “will be using an advanced statistical model developed by a leading biostatistician at Johns Hopkins University that increases the probability that the quality scores are an accurate reflection of physician performance.” Physicians are skeptical that the GIC’s quality rankings next February will be any more accurate than they have been.

No Roadmap for Quality Improvement

Elaine Kirshenbaum, MMS vice president for policy, planning, and member services, said she has heard from many physicians that data used to rank them is difficult to understand and use to improve their quality performance. “If the information doesn’t help physicians to understand what’s going on quality-wise, the usefulness to the practice is limited at best,” she said.

Further, Kirshenbaum said, some specialties now being tiered under the GIC program do not have enough quality measures for statistical reliability, so these doctors are tiered only on efficiency. “If there’s no quality improvement component, these physicians are tiered based only on cost,” Kirshenbaum said.

In addition, last year the GIC mandated that its participating health plans assign no more than 20 percent of doctors to tier 1, 65 percent to tier 2, and 15 percent to tier 3. Kirshenbaum says these arbitrary cutoffs continue to “create a situation that could easily disrupt patient-physician relationships.”

Dr. Nutt feels badly that her new tier ranking will mean higher copayments for her patients at the Neponset Health Center. “They are already straining with the current copay,” she said. “It’s just so discouraging — you work hard to do the right thing. I don’t see anything they’ve done here that will improve my quality or cost.”

Still, Dr. Nutt said, “I love my work. I’m happy with what I do. But this is just wrong. There is no justice. It needs to be fixed.”

– Tom Walsh