Tuesday, July 1, 2014

qotd: UnitedHealth’s Premium Physician Designation Program is not about quality


UnitedHealth Premium® Designation Program

The UnitedHealth Premium® physician designation program uses
evidence-based, medical society, and national industry standards to
recognize physicians for providing quality and cost efficient care.

The following designation results are displayed publicly in
UnitedHealthcare's physician directories (e.g., myuhc.com
<http://myuhc.com>) to support informed decision-making by members when
making health care choices and by physicians when making referrals.

Designation information is as follows:

* Quality & Cost Efficiency
* Cost Efficiency & Not Enough Data to Assess Quality
* Quality & Not Enough Data to Assess Cost Efficiency
* Quality & Did Not Meet Cost Efficiency
* Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency
* Not Enough Data to Assess
* Not Evaluated
* Did Not Meet Quality & Cost Efficiency

Innovative Benefit Plan Designs

In addition, employers may offer health benefit programs (e.g., reduced
cost-sharing or tiered benefit programs) that provide benefit incentives
for members to use UnitedHealth Premium Tier 1 physicians.

Members in health plans that offer tiered benefits may pay lower co-pays
and co-insurance amounts for services provided by UnitedHealth Premium
Tier 1 physicians.

UnitedHealth Premium Tier 1 physicians have received one of the
following Premium designations:

* Quality & Cost Efficiency
* Cost Efficiency & Not Enough Data to Assess Quality



UnitedHealth Premium® Physician Designation Program
Summary Methodology

The UnitedHealth Premium physician designation program uses clinical
information from health care claims and other sources to assist
physicians in their continuous practice improvement and to help
consumers make more informed and personally appropriate choices for
their medical care.

Evaluation for quality compares a physician's observed practice to the
UnitedHealthcare national rate among other physicians who are
responsible for the same interventions. Cost efficiency is assessed by
comparing the case-mix adjusted cost of care attributed to the physician
to a benchmark and applying a statistical test to determine if the
difference is statistically significant.

Quality is the fundamental measurement, demonstrating our commitment to
evidence-based practice. The quality designation is separate from the
cost efficiency designation. Although the quality and cost efficiency
evaluations are performed separately, the results are used together to
determine the physician's designation.

Physicians who meet both the quality and cost efficiency designation
criteria will receive the quality and cost efficiency designation.
Physicians who meet the quality designation criteria will receive the
quality designation regardless of their cost efficiency evaluation.
Physicians who meet the cost efficiency designation criteria will
receive the cost efficiency designation if they do not have enough data
to assess quality.

Quality Assessment

A physician's quality individual outcome is determined by comparing the
number of times his/her patients received recommended care with a
benchmark number based on the UnitedHealthcare national rate of the same
recommended care for each quality measure.

Cost Efficiency Assessment

Episode cost measurement compares a physician's observed costs for
episodes of care to a peer group's costs for similar episodes of care,
with adjustments for the patient's severity of illness and the
physician's case mix.

For both episode cost and population cost measurement, the physician's
costs within each set are evaluated against their peer group's costs by
ordering the costs from lowest to highest cost. The costs are converted
into percentiles to allow comparison across different types of cases or

Physicians' costs must be statistically significantly lower than the
peer group's physicians at the 75th percentile performance for all
physicians (measured in the same specialty for the same types of
episodes in the same geographic area) in order to meet the episode cost
measurement criteria.

UnitedHealthcare informs members that designations are intended only as
a guide when choosing a physician and should not be the sole factor in
selecting a physician. As with all programs that evaluate performance
based on analysis of a sample, there is a risk of error.



Comment by Don McCanne

The perennial promise of private health insurers is that their insurance
products would bring us higher quality care at lower cost, even though
there is a paucity of evidence to support such claims. UnitedHealth now
claims to be serious about delivering on that promise with their new
Premium Physician Designation Program. They say that "quality is the
fundamental measurement." But let's sort through their program
description to see what the truth really is.

You can consult the websites at the links above for the detailed
descriptions of how determinations of quality and cost efficiency are
made. Although they state that quality is the fundamental measurement,
they combine that with cost efficiency measurements and then use this
information to classify each physician in one of the eight categories
listed above. There are really only two designations that physicians can
receive: quality and cost efficiency. If the physician receives either
one or both of these designations, then these honors are displayed
publicly in UnitedHealth's physician directories.

Those designations might be nice, but what the patient really wants to
know is if their physician is a Tier 1 physician. In plans that offer
tiered benefits - very commonplace today - plan beneficiaries pay lower
co-pays and co-insurance when they use Premium Tier 1 physicians. So
what determines whether on not a physician is in Tier 1?

Of the eight categories listed, only the first two will qualify the
physician as Tier 1. Either the physician must receive the designations
of "Quality & Cost Efficiency" or "Cost Efficiency & Not Enough Data to
Assess Quality." Although quality is the "fundamental measurement" and
is determined before cost efficiency, it is important to note that the
third category - "Quality & Not Enough Data to Assess Cost Efficiency" -
will not qualify a physician for Tier 1. The only way to become a Tier 1
physician is to be cost efficient; quality does not count.

It is also important to understand that even if all or almost all
physicians are actually cost efficient, they are compared to their
peers. "Physicians' costs must be statistically significantly lower than
the peer group's physicians at the 75th percentile performance for all
physicians." It is impossible, no matter how efficient they are, for all
physicians to gain Tier 1 status.

Further, the health care market in the United States is by far the most
expensive of all nations, not only because of our prices but also due to
our inefficiencies, especially our profound administrative waste.
Favoring prices at the lower end of a highly inflated health care market
falls far short of what we need to do to improve efficiency in our
health care purchasing.

Thus UnitedHealth, for Tier 1, is selecting the cheapest physicians in
an overpriced and inefficient market, irregardless of the quality of
their care. "Higher quality at lower cost" is a fraudulent marketing
slogan of the private insurance industry. We need to throw these con
artists out and replace them with our own efficient, quality-driven
single payer national health program. The sooner the better.

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