Pin the Tail on the Doctor

A dearth of information leaves health-care consumers in the dark.

Choosing a Physician

If information on hospital quality is hard to obtain, finding information on doctor quality is almost impossible. The numbers alone make it challenging, says Ted Nussbaum, director of health-care consulting with Watson Wyatt North America. “There are several hundred thousand physicians, versus a few thousand hospitals.”

A few tools are available. Aetna Inc. offers its members cost and quality information for physicians in about eight states, and price information alone for doctors in three additional states.

The measures assess doctors’ clinical performance and efficiency, says Robin Downey, head of product development at Aetna. Clinical performance is based on the number of patients suffering adverse effects from an in-patient treatment or readmitted to a hospital within 30 days of a treatment, among other factors. Efficiency is measured by tallying all services, such as lab work, X-rays, and physical therapy, performed during a particular episode of treatment, and comparing that with the treatment ordered by other doctors treating similar patients. While the doctor may not provide all these services, presumably he or she is directing them, Downey notes.

Here again, the measures aren’t immune to criticism. Many physician fee schedules provided by insurers overstate the amount doctors actually receive, according to the American Medical Association. “Physicians often receive less than the negotiated rate because of a health plan’s medical payment policy,” the AMA stated in a report from its interim meeting in November 2005. Most physicians receive 40 cents for every dollar of billed charges, says an AMA spokesperson. “It’s the dirty little secret: the charge for the procedure isn’t what the insurance company pays,” adds Jeffrey C. Bauer, a partner at Dearborn, Michigan-based ACS Healthcare Solutions.

Employer Options

Because transparency in health-care data is such a new concept, some employers are waiting before they move to a consumer-driven plan. That’s the case at United Parcel Service of America (UPS), says health and productivity manager Randall Price. “It’s not that we don’t believe they have a future. But we don’t have the data that’s central if people are to make the most effective health-care decisions.” Given that UPS employs around 427,700 people worldwide, both breadth and depth of data are key. For now, says Price, UPS plans to maintain its indemnity, PCP, and PPO-type plans.

Other employers are making the switch. Harrah’s Entertainment Inc. is tackling health care on several fronts. First, the company will operate in-house clinics covering about 70 percent of Harrah’s workforce, requiring just a $10 co-payment. The goal is to halt a trend seen over the past few years, in which some employees skimped on preventive care in order to avoid out-of-pocket costs, says Jeff Shovlin, vice president of benefits.

At the same time, the company will replace its traditional PPO medical-insurance plan with a consumer-directed plan using a health-reimbursement account. Enrolled employees will receive $500 ($1,000 for those with family coverage) as a credit to these accounts to pay for nonpreventive care. (Preventive care is covered.) Once the account is depleted, the employee must first pay a deductible, which can vary from $250 to $1,000 for an individual, and $750 to $1,500 for a family. After that, the company picks up the costs.


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