Thumbs down to report cards

Physician objections to performance ratings are nothing new, but two leading medical societies recently issued their strongest response to public reporting of physician performance to date. Government and private payers' planned use of aggregated claims data to issue report cards on individual physicians will mislead, and may even harm, patients, the AMA and the American Academy of Family Physicians say.

"We're committed to consumers being able to get more data and make more informed choices," internist Nancy H. Nielsen, president-elect of the AMA, told Medical Economics. "But we don't want to give them flawed data so they are making flawed choices." Under the current approach, she adds, "the possibilities for mistakes are legion."

The AAFP shares that view. "Attempting to draw conclusions about a physician's quality or experience based on a narrow and incomplete picture of services . . . is, at best, useless and, at worst, harmful to consumers," wrote then-president FP Rick D. Kellerman in an Oct. 15 letter to CMS. "Amassing and releasing to the public substantial amounts of raw claims data without measures of service quality, patient health status, and outcomes will not provide sufficient information upon which an informed choice can be based and can only lead to confusion on the part of the patient."

Testing the value of aggregated data

The medical societies' statements were prompted by two recent developments:

In September, CMS officially proposed a "master system of records," consisting of aggregated claims data, that would be used to report individual physician performance to Medicare beneficiaries. CMS' Better Quality Information (BQI) program is already testing this approach at six sites in Arizona, California, Indiana, Massachusetts, Minnesota, and Wisconsin.

A month later, the Quality Alliance Steering Committee, an organization with representatives from CMS, insurers, employers, consumers, and medical societies, announced a $16 million project along the same lines. The funds, which come from the Robert Wood Johnson Foundation, will be used to develop and test methods for measuring physician quality and cost by combining claims data from many payers. This addresses a key concern of critics of public report cards, who have argued that single-plan data can't possibly provide an accurate picture of doctors because of the small numbers of patients involved.

Later this year, the QASC program will start publishing data gathered by the entities involved in the Better Quality Information test. While the initial report cards will rate physician groups, "we'll explore whether the data can be effectively used" at the individual physician level, says internist Mark McClellan, the leader of the project and a former CMS administrator. But Susan Pisano, a spokeswoman for America's Health Insurance Plans (AHIP), fully expects it will be used to rank doctors. "The data will be aggregated in such a way that it provides a full picture of an individual physician's performance," she says. The intention is to "feed it back to local communities."

Combined data from most of a practice's third-party payers would certainly provide a much fuller picture of physician performance than data from particular plans would, Nielsen acknowledges. But she cautions that this information should be used only to provide actionable feedback to doctors so that they can improve the care of individual patients. Putting out report cards based on this data, she says, is "fraught with dangers, because I don't think you can do it accurately right now."