Truth in advertising?

Risk & Insurance, May, 2008 by Peter Rousmaniere

It's time for truth in advertising about how insurers recruit doctors into provider networks. Last October CIGNA, the health insurer, signed a settlement agreement with Andrew Cuomo, New York state's attorney general, about how CIGNA ranked doctors. Consumers Union and the American Medical Association were co-signatories to the settlement.

It appears that CIGNA was telling its subscribers that it was concerned about quality of care when in fact it was really trying to nail down the lowest-price providers ... saying one thing, doing another. Settlements had at the time not been reached with other targeted insurers--Aetna, United Healthcare, and Blue Cross.

If settlement terms are applied to the workers' compensation community, preferred provider organizations and their customers such as workers' comp insurers could be forced to either stop saying that they are evaluating quality of medical care or begin actually do to it.

Our PPOs and insurers have been given the freedom to say they are recruiting doctors on the basis of quality, when in reality they are predominately or entirely focused on extracting fee discounts.

One of the leading workers' comp PPOs in the country says on its Web site that it offers "superior penetration, high quality and proven savings" to insurers. When I see "high quality" sandwiched between penetration and savings claims, I wonder if it is substantive or paper-thin.

CIGNA can no longer "confuse or deceive consumers in violation of consumer protection laws," according to a press release by the attorney general.

Cuomo expects insurers to use physician performance measures endorsed by the National Quality Forum or "other entities whose work in the area of physician quality performance is generally accepted in the healthcare industry." Insurers will have to disclose how they go about rating doctors. CIGNA is required to engage an independent party to audit its evaluation methods.

Judith Kunisch, an expert with decades of experience in health insurance management thinks that the CIGNA settlement is one of the best things that has happened in health insurance in years and awaits its application in workers' comp. She says that "with the continuing development of robust, statistically significant data-driven tools in the health insurance industry, it is inexcusable for this not to happen."

To Kunisch, the New York state agreements create a basis for a "Good Housekeeping seal of approval" for doctor evaluation.

Employers have led the drive to evaluate quality of medical care and identify top providers using the data analysis tools. Today there is a loose network of nonprofit, employer-sponsored evaluation programs, such as Bridges to Excellence and the Leapfrog Group. Bridges identifies physicians who provide high levels of back care using sixteen evidence-based care criteria. I looked at the criteria and they can fit well into workers' comp.

Evaluating physician performance in workers' comp is complicated because one has to take disability experience into account. But many of the clinical measures can be easily borrowed from the group health side, along with healthcare analysts to build and apply the databases.

Two nonprofit workers' comp organizations are teeing up to perform assessments of individual doctors. They are the Workers' Comp Research Institute and the California Workers Compensation Institute.

I hope we don't have to wait for an activist attorney general to bring truth in advertising to workers' comp.

PETER ROUSMANIERE is a Vermont-based columnist for Risk & Insurance [R]. He can be reached at riskletters@lrp.com.