Does your insurance company know who the good doctors/surgeons are?

Since affordable and more accessible health care is a critical national challenge, the use of rating systems will increase as one response to rising costs. Doctors receive notices from insurance companies about their ratings, although they do not fully understand how their tier was determined. When patients receive letters from insurers and see that their doctors are not in a top tier, their reactions may range from disappointment to confusion. This study is the first to analyze tiering system data as it applies in a specific setting.

"We examined data on 615 orthopaedic surgeons who had been accepted in one or more health plans in Massachusetts," explains one of the authors, orthopaedic surgeon Timothy Bhattacharyya, MD, Head, Clinical Investigative and Orthopaedic Surgery Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). "Tiering ranks physicians on the basis of cost efficiency and adherence to performance quality benchmarks. Thus, a higher physician rating could lead to lower co-pays and out-of-pocket costs for patients."

This study also reveals concerns that should be addressed:

• Study analysis showed that board certification, Medicaid acceptance, and practice in a suburban location were independent factors associated with a physician ranking in the top tier. However, more years in practice or fewer malpractice claims, important indicators of quality, did not influence or factor into tier rating. Dr. Bhattacharyya and his co-authors suggest that tiering data deserves more exploration and a clearer definition of quality.
• Insurance companies did not agree on physician inclusion in top tier. Since ratings are not consistent from one insurance company to another, a physician is often rated differently from one plan to another.
• Patients need more information about physician tiering. While health plans display a physician's tier in online and printed directories, explanation of stratification methodology and its relation to quality of care is limited. Currently, for example, there is no evidence to suggest that physicians ranked in a second tier provide lower quality care.

The authors note that their study has limitations. Data was examined for one specialty, orthopaedics, and in one state, and may not be applicable to other medical specialties or geographical areas. The lack of agreement between health plans may be the result of measuring different aspects of healthcare quality. A "gold-standard" consensus could serve as a benchmark and provide consistency across plans.

What should consumers do if they check a physician and discover that he/she is not in the top tier? Dr. Bhattacharyya explains that:

• Your physician's rating may change from one plan to another, so compare his/her rating with another plan.
• When checking on a physician, ask about board certification and experience in this medical area or procedure. Seek referrals from people you trust, such as your doctor or someone who has had the same procedure or condition.
• Information about methodology and its relationship to quality of care is limited. Because this issue can misrepresent doctors and confuse patients, we should seek a universal definition of quality.