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

UnitedHealthcare

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

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b0465138a17210VgnVCM1000002f10b10a____

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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
patients.

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.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Unitedhealth%20Premium/UnitedHealth_Premium_Summary_Methodology_2013-2014.pdf

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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.

qotd: Supreme Court decision: Whose religious freedom?

SUPREME COURT OF THE UNITED STATES

June 30, 2014

Opinion of the Court

BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. v. HOBBY LOBBY
STORES, INC., ET AL.
and
CONESTOGA WOOD SPECIALTIES CORPORATION ET AL., PETITIONERS 13–356 v.
SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.

Justice Alito delivered the opinion of the Court.

We must decide in these cases whether the Religious Freedom Restoration
Act of 1993 (RFRA), 107 Stat. 1488, 42 U. S. C. §2000bb et seq., permits
the United States Department of Health and Human Services (HHS) to
demand that three closely held corporations provide health-insurance
coverage for methods of contraception that violate the sincerely held
religious beliefs of the companies' owners.

In holding that the HHS mandate is unlawful, we reject HHS's argument
that the owners of the companies forfeited all RFRA protection when they
decided to organize their businesses as corporations rather than sole
proprietorships or general partnerships. The plain terms of RFRA make it
perfectly clear that Congress did not discriminate in this way against
men and women who wish to run their businesses as for-profit
corporations in the manner required by their religious beliefs.

Since RFRA applies in these cases, we must decide whether the challenged
HHS regulations substantially burden the exercise of religion, and we
hold that they do.

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Ginsburg, J., dissenting

Importantly, the decisions whether to claim benefits under the plans are
made not by Hobby Lobby or Conestoga, but by the covered employees and
dependents, in consultation with their health care providers. Should an
employee of Hobby Lobby or Conestoga share the religious beliefs of the
Greens and Hahns, she is of course under no compulsion to use the
contraceptives in question. But "[n]o individual decision by an employee
and her physician — be it to use contraception, treat an infection, or
have a hip replaced — is in any meaningful sense [her employer's]
decision or action." Grote v. Sebelius, 708 F. 3d 850, 865 (CA7 2013)
(Rovner, J., dissenting). It is doubtful that Congress, when it
specified that burdens must be "substantia[l]," had in mind a linkage
thus interrupted by independent decisionmakers (the woman and her health
counselor) standing between the challenged government action and the
religious exercise claimed to be infringed. Any decision to use
contraceptives made by a woman covered under Hobby Lobby's or
Conestoga's plan will not be propelled by the Government, it will be the
woman's autonomous choice, informed by the physician she consults.

http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf

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Comment by Don McCanne

Allowing an employer to deny coverage of family planning services for
employees, strictly on the basis of the employer's own religion, is yet
one more flaw in our highly dysfunctional system of health care
financing - a system that is being perpetuated by the Affordable Care
Act. If we had a single payer national health program, the employer
would not be involved.

As Justice Ginsburg stated in her dissent, a woman's use of family
planning services should be "the woman's autonomous choice, informed by
the physician she consults." If religious beliefs enter into that
decision, it should be the religious beliefs of the individual and not
anyone else.

qotd: Problem with defaulting to automatic plan renewal in exchanges

Department of Health and Human Services
June 19, 2014
Proposed rule

This proposed rule would specify additional options for annual
eligibility redeterminations and renewal and re-enrollment notice
requirements for qualified health plans offered through the Exchange,
beginning with annual redeterminations for coverage for plan year 2015.

In paragraph (j)(1), we propose that if an enrollee remains eligible for
enrollment in a QHP through the Exchange upon annual redetermination,
and the product under which the QHP in which he or she was enrolled
remains available for renewal, consistent with 45 CFR §147.106, such
enrollee will have his or her enrollment in a QHP under the product
renewed unless he or she terminates coverage, including termination of
coverage in connection with voluntarily selecting a different QHP, in
accordance with §155.430. In this situation, we propose that the QHP in
which the enrollee will be renewed will be selected according to the
following order of priority: first, in the same plan as the enrollee's
current QHP, unless the current QHP is not available; second, if the
enrollee's current QHP is not available, the enrollee's coverage will be
renewed in a plan at the same metal level as the enrollee's current QHP;
third, if the enrollee's current QHP is not available and the enrollee's
product no longer includes a plan at the same metal level as the
enrollee's current QHP, the enrollee's coverage will be renewed in a
plan that is one metal level higher or lower than the enrollee's current
QHP; and fourth, if the enrollee's current QHP is not available and the
enrollee's product no longer includes a plan that is at the same metal
level as, or one metal level higher or lower than the enrollee's current
QHP, the enrollee's coverage will be renewed in any other plan offered
under the product in which the enrollee's current QHP is offered in
which the enrollee is eligible to enroll.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/508_CMS-9941-P-OFRv-6-26-14.pdf

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Avalere
June 26, 2014
Exchange Plan Renewals: Many Consumers Face Sizeable Premium Increases
in 2015 Unless They Switch Plans
By Elizabeth Carpenter

Under the Affordable Care Act, federal premium assistance is tied to the
second lowest cost silver plan ("benchmark plan") in a given region.
Subsidized exchange enrollees who select a more expensive plan must
pay the difference—dollar for dollar—between the benchmark plan premium
and their selection. In six of nine states analyzed by Avalere, the
2014 benchmark silver plan will lose benchmark status in 2015. Further,
in seven of the nine states, the lowest cost silver plan will also
change in 2015.

"Most enrollees in 2014 chose a plan based on the monthly premium.
However, the lowest cost plans in 2014 may no longer be low cost in
2015," said Elizabeth Carpenter, director at Avalere Health. "Before
consumers renew their 2014 plan, they should consider the tradeoff
between continuity of care and lower monthly premiums."

"Two-thirds of people enrolling in silver plans are choosing one of the
two lowest cost silver options," said Caroline Pearson, vice president
at Avalere. "The competitive landscape for plans is changing in 2015.
However, the premium subsidies are tied to the benchmark plan and a
percentage of income. Consumers have to pay the difference if they
enroll in a plan more expensive than the benchmark. Those receiving
federal premium subsidies may need to switch plans in 2015 to avoid
paying more than the limits established by the ACA, and the impact will
be more profound for lower-income consumers."

http://www.avalerehealth.net/expertise/managed-care/insights/exchange-plan-renewals-many-consumers-face-sizeable-premium-increases-in-20

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Comment by Don McCanne

Acknowledging the complexity of the administration of the exchanges
under the Affordable Care Act, HHS has decided to simplify the process
by making renewal of plan enrollment automatic unless the enrollee
decides on a different option. It is estimated that about 95 percent of
enrollees will qualify for automatic renewal, and undoubtedly many will
passively accept this hassle-free option. That may not be a wise choice.

The Avalere report indicates that the benchmark silver tier plan - the
plan with the second lowest premium in the silver tier - will change in
many of the exchanges since premium bids are changing for most plans.
Since the enrollee is responsible for the full balance of the premium
above the benchmark plan, net premiums for the enrollees could increase
significantly unless the person opted to change to next year's benchmark
plan or a plan close to it.

As Avalere director Elizabeth Carpenter states, "(consumers) should
consider the tradeoff between continuity of care and lower monthly
premiums." This means that those current enrollees who do not passively
accept higher premiums will be forced to choose between higher premiums
or a change in their narrow provider networks, the latter likely
resulting in disruption of continuity of care.

Further, according to the HHS rule, the individual could be transferred
to a different metal tier, thereby losing eligibility for the subsidies
for cost sharing, though that would likely occur only in exchanges that
have few choices.

Even something as simple as "automatic renewal" becomes complex when you
try to rely on market dynamics to satisfy private insurers. Imagine if
at renewal time you didn't have to make a decision on what premiums you
could afford, or on what provider networks you would choose when none of
them quite fit, or where you might fall based on subsidy eligibility
redetermination.

Imagine instead if the concept of renewal did not even exist - you were
simply automatically enrolled for life. We really do need to replace
this boondoggle with a single payer national health program - quality
health care for everyone at a price we can afford.