Laboratory News

Coming Soon: Rating Doctors Using National Guidelines

Ranking physicians by quality and outcomes is a trend that moved forward another step recently.  The first nationwide effort to improve and standardize doctor-rating programs is officially underway. With the growth in the number of pay-for-performance programs have come criticisms by doctors.  They object that too many sets of standards exist and the criteria used to determine provider rankings are not clear.  Thus, organizers of this new effort aim to create guidelines for health care provider rating systems that can be used by health care insurance companies to guide patients.

One goal of these national guidelines is that all measurement information will be publicly available.  Participating health insurance providers will also agree to have their rating system reviewed by an independent reviewer, a provision that appeals to those employers supporting pay-for-performance arrangements.  The proposed guidelines require an appeals system for doctors to challenge their ranking.  Health insurers must further agree to use both quality and cost to rate doctors, not just cost.

This effort to develop national guidelines is backed by a consortium of competing interests, including some of the largest U.S. health insurers, employers, patient groups, and physician organizations.  Participants include Aetna, UnitedHealthcare, Cigna, General Electric, General Motors, the AARP, and the AFL-CIO.  The effort is also supported by the American College of Surgeons (ACS) and the American College of Cardiology  (ACC).

All these parties agree that physician rating information helps contain healthcare costs and improve outcomes.  Health-care advocates say ratings systems are here to stay.  The question is now how to balance assessing quality and cost.  Existing rating systems developed by individual health insurance plans often do not give doctors or patients specific information on how or why doctors receive particular ratings.  Ratings are currently frequently based on utilization data and the cost of the tests and procedures that doctors provide to patients.

This effort will push insurers to use national standards-such as those endorsed by the nonprofit National Quality Forum  to ease the burden of patients and employers when they change insurers.  It will ensure that insurers are not simply using ratings to drive patients to the cheapest doctors.

These national guidelines are one more step toward total transparency of outcomes and the price of medical care to the public.  It is significant that both ACS and ACC support the effort-it suggests that the medical profession accepts the reality that physicians will be ranked, whether most physicians like this development or not.  Further, as guidelines are put in place that cover all physician specialties, including hospital-based physicians like pathologists, it may bring about the opportunity for pathologists and clinical laboratories to compete for business based on the quality of their clinical services, and not solely because of inclusion in managed care contracting networks.

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