The Doctor Weighs In

Brian Klepper 

Last week the New York Times reported that New York's Attorney General (AG) office threatened UnitedHealthcare (UHC) with a lawsuit if it proceeded with the September release of a physician profiling report. The details were fuzzy, but apparently the AG was responding to charges by different physician groups – the AMA and the St. Louis Metropolitan Medical Society were named  - that UHC's methodology is based purely on cost and does not consider quality. The Times piece includes this snippet:

Linda A. Lacewell, a senior lawyer in the office of Attorney General Andrew M. Cuomo, wrote in the letter that the ranking would apparently be used to steer consumers toward selected doctors. “To compound the situation,” she wrote, “we understand that employers may act on these ‘ratings’ to offer financial inducements such as lower co-payments or deductibles to promote ‘cost-effective’ doctors to their employees.”

Ms. Lacewell said patients might be steered toward doctors based on flawed data and UnitedHealthcare’s “profit motive.” She wrote, “Consumers may be encouraged to choose doctors because they are cheap rather than because they are good.”

Without more information, it is hard to know what's going on here. But UHC and the NY AG's office each have a point and each are suspect. Here's what we know:

Ingenix, a UHC subsidiary, is a health care analytics firm which owns and licenses Episode Treatment Groups (ETGs), a highly-regarded and widely-used health care patient classification system. ETGs are used by many other reputable analytical companies, like MedStat, MedAI, and ProfSoft. One would assume that UHC's analyses of physician performance in New York and elsewhere used this tool, but who knows?

On the other hand, the Ingenix tool violates what I think of as a core rule of transparency, which is that any tool used to achieve transparency must be transparent as well.  Ingenix' ETG algorithm is proprietary, which basically means that the people being evaluated can't find out exactly how the evaluation works. This invariably makes them worry that they're getting shafted.

Let's apply this problem to a real life example. I use this tool to evaluate the performance of all the doctors, by specialty, within a network. I'm going to publicly publish the results – the identification of high, average or low performing physicians – and then tie the results to payment levels.

I approach a low performing physician and show him the results, and he's aghast. “How did you arrive at THAT?” he asks. “I can't tell you,” I say. “It's a secret.”

Now take this problem of a proprietary evaluation methodology, and embed it in a profit-driven company that has been caught in disputes involving money on more than one occasion. It's not impossible to see why the AG's office is skeptical of UHC's intentions or approach.

The AG's Ms. Lacewell is concerned that the UHC analysis might steer patients to doctors based on cost rather than quality. That might be the case if UHC's analytical tool was set up that way. But unless UHC is not using their own tools, it is not likely. ETGs and other contemporary health care analytical tools provide risk-adjusted evaluations of value. That is, they hold outcomes constant and then compare cost. Or they hold cost constant and compare outcomes.

The point here is that we most certainly want to identify better and poorer performers. We want to steer patients to the better ones and give the poorer ones reasons to improve.

We have a crisis in health care in large measure because the performance of doctors, hospitals, health plans, drug companies, device companies and everyone else involved in health care has been hidden. The lack of accountability has resulted in tremendously excessive cost and a tolerance for poor and sometimes dangerous quality. Worse, the lack of transparency has created an opportunistic culture throughout health care. Professionals and companies in every health care sector gild the lily with inappropriate and wasteful products and services, because they're mostly certain that the excesses won't be detected.

Of all the things we can do to fix health care, performance transparency is the most important.  Only if we can see what has transpired – what processes have and have not been conducted, and what the outcomes have been – can we identify problems and opportunities and then begin to address them.

The New York Attorney General is right to be skeptical of the evaluative neutrality of UHC or, for that matter, any organization dedicated to profit rather than the public interest.

On the other hand, New York's AG's office should smell the coffee. To make health care and any other public function work, we need to publicly report performance information. Patients have a right to know how doctors compare within specialty and how hospitals compare within service.  They'll certainly want to go to the ones that have better track records, and the employers who pay for much of their care want to encourage them to learn which ones are best. 

The AG's office should also be skeptical of the doctors' motives.  Are the physicians against any public reporting of their performance, or just that done by for-profit entities like UHC?

To heal health care, we need transparency. But it should be provided by neutral organizations that don't have conflicts of interest, and handled to assure doctors and everyone else involved in health care that the reporting will be fair and without prejudice.

Health care is too important for patients and purchasers to not have objective information. Only if we get this accomplished properly can we say that we've taken the first steps to really fixing America's health care system.

Brian Klepper is a health care analyst based in Atlantic Beach, Florida. You can reach him at bklepper@gmail.com.