Opinion: Tiering up: Derms skeptical about national ranking standards

October 1, 2008

National standards for ranking physicians may be on the horizon, but many dermatologists doubt that they can be implemented fairly and accurately. Insurance companies have proposed ranking physicians in tiers that could be used to determine levels of reimbursement or the amount of co-pays for patients to see the physician of their choosing.

Key Points

National standards for ranking physicians may be on the horizon, but many dermatologists doubt that they can be implemented fairly and accurately.

Insurance companies have proposed ranking physicians in tiers that could be used to determine levels of reimbursement or the amount of co-pays for patients to see the physician of their choosing.

The American Medical Society, the American College of Surgeons and some of the largest health insurers in the country - such as Cigna, United Health Care and some labor unions, including the AFL-CIO - have signed on to develop national standards. The goal would be to assist insurance companies to direct patients to good care while trying to control healthcare costs.

Most doctors we spoke to are skeptical that third-party payers would be interested in anything more than containing costs, and they doubt whether meaningful ranking of physicians is even possible.

Obstacles

David A. Voron, M.D., in Arcadia, Calif., can understand the lure of the idea.

"On a theoretical level, it's conceivable physician rankings would have some limited appeal, but from a practical point of view, I don't think it is practical. It's fraught with execution obstacles.

"Developing criteria for evaluating physicians to get an accurate assessment of a physician would be difficult and so costly to implement, it wouldn't be cost-effective.

"In a way, it's a self-destroying concept, because the cost to find a truly cost-effective physician would be prohibitive, and the idea of measuring outcomes to determine quality of care, although possible, would be difficult in practice.

"Then, if you try to evaluate quality relative to cost, that's even more difficult," Dr. Voron says.

Dr. Voron, in practice 34 years and a clinical professor emeritus at Keck University of Southern California School of Medicine, gives an example of the illogicality of the idea.

"Clearly, the physician who provides no care at all, in the short term, obviously is the lowest-cost provider. So, although the idea sounds good, it's not viable, useful or logical," he says.

No easy answers

In Savannah, Ga., Adam S. Pritzker, M.D., says there is no easy answer to the difficult question, but he isn't convinced that quality would actually be a factor that concerns insurance companies.

"It's not clear what they want to base their rankings on, and it may not necessarily be that the doctor the insurance companies rank as the best, or who gives the best deal, is going to be the actual best physician - which is interesting.

"The idea of the medical associations helping to develop criteria is a throwback to the theory they came up with a few years ago for recertification -'If we do this ourselves, voluntarily, it won't be forced down our throats, and it will be more palatable.'

"But I don't think that necessarily follows. There's no easy or fair way to rank physicians, even if the doctors themselves help determine the criteria," Dr. Pritzker says.

Roadblocks

In some ways, Dennis C. Polley, M.D., in Wilson, N.C., wouldn't mind the rankings if he thought they could be done well. Unfortunately, he doesn't see that as a possibility, and he throws out a litany of roadblocks he thinks meaningful rankings would face.

"My initial reaction about this is as negative as trying to rank cardiac surgeons. Somebody who worked with Jarvik or DeBakey would obviously be getting the sickest patients, and they're going to be ranked on the same criteria as the community surgeon?

"My point is that I don't care who is going to rank me, as long as I know the parameters. But then, what parameters are used, and how are they weighted fairly?

"Is it going to be how many basal cells I treat? How many basal cells I treat successfully, that don't return in a year? How many I treat that don't get a scar? How will I be judged?

"When I start to break down the patient/ physician interaction into parameters, there are too many to figure. How many of my patients have mental illness? How many have an undiagnosed mental illness that interferes with them complying with my instructions on taking medication and doing follow-up?

"I had a patient recently who informed me she had 17 different personalities - the most recent of which was just released from prison after three years for taking three hostages with a shotgun at a Caterpillar factory. That patient took 1½ hours. What does that do to my patient wait time and efficiency rankings?

"Will there be a differentiation for patient populations? Obviously, we don't see the same ethnic mix in North Carolina that they do in Seattle. We don't have the same climatic and geographic factors.

"What about patients who come with a laundry list of ailments after not seeing a doctor for three years? That all takes time," Dr. Polley says.

After 28 years in practice, he says, "There's no possible way you can run a medical business, and run it economically, and see everybody in 16 to 20 minutes."

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