UnitedHealth Group has raised the hackles of providers and consumers with a new performance-rating program that critics say snubs as many as three-quarters of the doctors available to patients in some areas.
The American Medical Association, the Medical Group Management Association and a number of regional medical societies have sent letters to UnitedHealth opposing its new Performance Designation Program, designed to improve quality and reduce costs by steering patients to a select group of high-value physicians. And BJC HealthCare, St. Louis' largest health system, is so riled up over the issue that it announced plans to terminate its entire contract with UnitedHealth on Aug. 13 unless the insurer suspends or significantly alters the program.
Under the program, now being piloted in 13 states, network physicians who are determined by UnitedHealth to provide higher-quality, lower-cost care than their peers receive stars next to their names on the company's Web site. The insurer's three partners in the pilot-General Motors Corp., DaimlerChrysler AG and United Parcel Service-then push their employees toward the "stars" by demanding higher copayments for using non-designated doctors. Several thousand employees at the three companies will be affected by the benefit change.
The program is part of a growing effort among insurers and employers to curb rising healthcare costs by identifying doctors and hospitals that, according to some measures, provide the best care at the lowest price (Nov. 24, 2003, p. 14). In recent years, Aetna, PacifiCare Health Systems, Health Net, Blue Cross of California and several other insurers all have launched their own versions of the so-called tiered- or narrow-network concept.
Lewis Sandy, chief clinical officer of UnitedHealth's UnitedHealthcare division, said the program is an information resource designed to help patients make better-informed decisions about where to seek care. "We are trying to create more transparency in the marketplace at a time when consumers are being asked to shoulder a greater and greater share of their healthcare costs," he said.
But critics contend the program emphasizes costs far more than quality and is so rife with design flaws that it is misleading to consumers.
"It's inconceivable to me just how incredibly poorly thought-out and executed the program is," said MGMA President and Chief Executive Officer William Jessee. "UnitedHealth's description of it as a `quality' performance program is a blatant untruth. ... It's a fraud being (perpetrated) on patients."
UnitedHealth originally analyzed claims data from 2002 and 2003 to determine which physicians ad-hered most closely to evidence-based standards of care and/or had the lowest complication rates. Those who scored high on the quality measures were then evaluated on efficiency, or relative treatment costs for a particular illness. To win a star, a doctor's cost score had to be at or below 80% of the market average.
According to Sandy, roughly 40% of doctors weren't eligible for the star designation because they hadn't submitted enough claims during the two-year period to produce a proper analysis. Some other physicians were evaluated solely on cost, because evidence-based standards for their specialties had not been established.
Responding to providers' concerns, UnitedHealth has since adjusted its economic criteria so that doctors who meet average market costs can qualify, Sandy said. It has also started giving stars to physicians who have received National Committee for Quality Assurance recognition in specific areas and will evaluate more specialties as evidence-based standards become available, he said. "A pilot program is intended to be one that evolves over time, and ours is evolving in a very positive way," Sandy said.
But some providers say these efforts are too little too late. "UnitedHealthcare has tinkered at the margins. But this program is so fatally flawed that you can't Band-Aid it. It's moribund," said AMA Secretary John Armstrong.
BJC HealthCare, which operates 10 hospitals in Missouri, argues that the program has so severely restricted patients' access to care that it has forced the system to sever ties with UnitedHealth altogether.
In St. Louis and other areas where the Performance program is in place, an average of just 25% of UnitedHealth's network doctors are on the designated list.
By comparison, Blue Cross of California's narrow network product includes roughly 50% of the physicians that the insurer typically contracts with. And among the hospitals that Blue Shield of California contracts with, as many as 84% are in the preferred tier of its tiered network.
Among BJC's admitting physicians, only 18% met the program's criteria. Moreover, just four of the 1,144 full-time faculty physicians at St. Louis' Washington University-doctors who admit only to BJC facilities-received stars. The problem resulted from the fact that the vast majority of the university's doctors bill in groups; because UnitedHealth was unable to evaluate the doctors based on their individual claims, it excluded entire groups.
"It is wrong for an organization to restrict access to physicians under the guise of `quality' when the underlying criteria is based on questionable and inconsistent methodologies in the rating of physicians," said John Krettek, chief medical officer at BJC's 358-bed Missouri Baptist Medical Center in Town and Country, Mo.
Such standoffs between insurers and providers have become increasingly common as the tiering and performance-rating movements have gathered steam.
Two-hospital NorthBay Healthcare Corp., Fairfield, Calif., canceled its contract with Blue Shield of California in 2002, arguing the insurer's tiering system ignored differences in the quality and breadth of service. The 499-bed University of California, Davis Medical Center in Sacramento also threatened to cut ties with Blue Shield after being relegated to its lower tier but later changed its mind when the insurer agreed to factor in quality criteria and patient-satisfaction scores (June 24, 2000, p. 24).
"Performance measurement is still in its very rudimentary stages," Armstrong said. "There are a number of challenges to measuring quality and efficiency. At this point, it remains very difficult to generate an accurate report card" on providers.