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For years, doctors have chafed at new ways insurers are rating them and tying bonus payments to those ratings.

Insurers pay doctors extra to achieve certain health goals -- such as getting patients' blood sugar or cholesterol levels down or making sure they get regular mammograms.

Today, the Minnesota Medical Association is issuing a report complaining that different criteria used by different plans creates a heavy administrative burden. Moreover, the association says, these programs don't reward doctors for investing in information technology and for coordinating care for those with chronic disease.

It's the latest step in a tense tango doctors and insurers have engaged in since pay-for-performance programs took off as insurers tried to overcome a key weakness in how medical payments are structured. Doctors are paid for treating patients when they're sick, not to keep them well.

Now when your doctor nags you to lose weight or to eat better, your payoff could be better health and the doctor could get a small financial boost.

"No one likes to get measured, but I think those of us working in the quality arena know measurement has a benefit if done correctly," said Dr. David Luehr, chair of the Medical Association's quality committee.

"The important thing is to make sure we have valid and meaningful measures," he said.

That's why the association also complained in the report that insurers don't take into account different patient populations, effectively penalizing doctors who treat sicker, poorer patients. The association has 11,000 members, who make up about 60 percent of practicing physicians in the state.

In their most confrontational move yet, the association turned the tables on insurers by ranking nine of the so-called pay-for-performance programs. The Centers for Medicare and Medicaid Services ranked at the top while Bridges to Excellence, a program used by large, self-insured employers, was at the bottom. Programs by Blue Cross Blue Shield of Minnesota, UCare, PreferredOne, HealthPartners and Medica fell somewhere in between.

The Medical Association shared the report with insurers in a meeting Friday. The insurers said they were working with the association to address the concerns, though they didn't necessarily agree with all of them.

"This was not an easy conversation, but it was a good conversation," said Julie Brunner, executive director of the Minnesota Council for Health Plans.

Ratings prompt changes

Although still considered an experimental approach, pay-for-performance plans have become widespread since HealthPartners established the first in 1997.

All major Minnesota health plans now dole out bonuses if doctors achieve goals such as getting their patients to have regular mammograms or regular eye checks for diabetics.

HealthPartners, for example, expects to pay $21 million this year in bonuses. Blue Cross Blue Shield of Minnesota is paying $10 million. It said the number of participating clinics is up, from 67 in 2005 to 106 in 2008.

There are now about 150 payment programs around the country and between three and 20 percent of a physician's reimbursement comes from bonuses, said Dr. David Satin, a family physician with the University of Minnesota and an expert on the trend.

Health plans use a combination of medical claims data and ratings by Minnesota Community Measurement, a group that rates primary and chronic care across the state.

The group, which spun off from the council of health plans, released its latest report last week. While some groups such as Park Nicollet and HealthPartners did better than others, there continued to be a large variation in the quality of care among other clinics.