has released guidelines aimed at encouraging health insurers to standardize their physician profiling reports. These reports, which the plans send to physicians, are often used as the basis for pay-for-performance programs, tiered networks, and narrow networks, and they may also be used in public reporting of physician quality and cost indicators.
While the performance reports are mostly based on claims data, the AMA looks forward to the day when physician profiles will also include clinical data from electronic health records, said Steve Ellwing, director of physician practice advocacy for the AMA, in an interview with InformationWeek Healthcare.
The AMA also wants health plans to make the profiles available to physicians on web portals, rather than sending them long printouts. This would make it easier for physicians to peruse the data and to drill down to specific patient information, Ellwing said.
The overall purpose of the guidelines, he explained, is to get health plans to give physicians the data they need to improve the quality of care. "Some insurers will provide very minimal information--aggregate scores or whatever. Others will go down all the way to the individual patient level. If the insurers can give data at the patient level to physicians, the doctors can use that data to identify areas for practice improvement."
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The other requirement, Ellwing added, is that the information be easy to understand and use. Not only are many health plan reports complex and difficult to grasp, but each insurer reports the data differently.
Initially, the AMA proposed a standardized form that all insurers could use. But the plans rejected that concept, Ellwing recalled. "The message we got is, 'We've spent tens of millions of dollars developing our reporting format, so there's no way we're going to take a standardized form that you've developed.'"
The current guidelines for physician profiling reports were developed in conjunction with insurers, employers, consumer groups, and regulatory bodies, including the Centers for Medicare and Medicaid Services (CMS). In creating the guidelines, Ellwing noted, AMA tried to avoid calling for the plans to change any of their policies. However, the document does ask the insurers to let physicians report errors in reports, such as information on patients they've never seen, and to appeal quality or cost profiles that they believe misrepresent their performance.
So far, Ellwing said, two big national insurers--United and Cigna--have "signed on" to the guidelines. So have smaller plans such as Blue Cross Blue Shield of Tennessee, Intermountain, and Dakota Care. But many others have declined, in part because they feel the guidelines are too prescriptive.
Still, the AMA plans to continue discussions with the payers and hopes to convince more of them to go along. While Ellwing acknowledged that none are likely to follow the guidelines in toto, he said that they could use them to start moving toward standardized reporting that will be helpful to physicians. "The reason why insurers collect this data, analyze it, and put it in profiles is that they want physicians to do better. If they're really interested in improvement, they should want to provide this information in-depth enough and in a form that physicians can really use it. It's good for everyone."
While physician profiling has been around for decades, the AMA believes that its importance has grown in today's healthcare environment. "With the new payment methodologies that are coming, physicians who use their own data to improve their practice on quality and cost will be way ahead in the game," Ellwing stated.
It's not only large groups that can use this data to their advantage, he added. Even small physician practices can benefit if they understand how to use the data to improve their quality and efficiency.
The guideline document also makes clear that the AMA wants to influence how the health plans present the performance of individual physicians to consumers in web-based report cards. The AMA states, "Although consumer reporting is outside the scope of this document, the AMA recognizes that payers may provide physician performance data to their members and urges plans that provide these data to do so in a manner that facilitates consumer understanding of both the health plan information and the limitations of that data."
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