Doctors turn tables by ranking insurers

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.

Those that do well say such public report cards do drive efforts to improve.

"We all pay a lot of attention to it," said Dr. David Wessner, chief executive of Park Nicollet, which owns Methodist Hospital in St. Louis Park and a chain of Twin Cities clinics. But payments flowing from those measures are neither large enough nor dependable enough to influence investment in systemic changes, he said.

The concept remains hugely controversial among doctors.

While the Medical Association was meeting with health plans Friday, a breakfast meeting was taking place over at United Hospital in St. Paul. The Ramsey Medical Society hosted a talk titled "Ethical Issues in Pay-for-Performance."

The speaker was Satin, who in addition to being a family doctor is also a bioethicist. While acknowledging that the programs often improve patient care, Satin added that the challenge for doctors is figuring out when to follow the guidelines and when to make an exception. "I worry about raising a generation of future doctors who do what they do because they follow the guidelines. Why? Because they follow the money."

One doctor in the audience called the payments a "thinly veiled effort to control physician behavior."

A defense of bonuses

Insurers emphasize that bonus payments remain a work-in-progress.

"Actually, the plans have been working on these things [such as standardizing criteria] and MMA didn't know it," said Dr. Doug Hiza, a medical director at Blue Cross.

One recommendation from the Medical Association -- paying for care coordination -- is already happening at some levels.

At Neighborhood Health Care Network, which has 14 metro-area clinic groups, community health workers coordinate care for patients, making sure they get regular tests and educating them on nutrition. Money to pay these workers comes from public programs such as Medical Assistance.

Partly as a result, 19 percent of diabetic patients now achieve goals for optimal care, compared with 1 percent in 2005, catapulting the group to second best amongst clinics rated by Minnesota Community Measurement for diabetes care.

Chen May Yee • 612-673-7434

Chen May Yee • mychen@startribune.com