Transparency in physician profiling

Tuesday, May 01, 2012 01:16 PM
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Susan Liptak, Director of Marketing and Health Care Policy Communications

A 2010 Washington Post investigative report about the nation’s security system unearthed a surprising and alternative geography of the United States. The report spotlighted top-secret areas on maps that were previously hidden from public view. Needless to say, the government wasn’t thrilled to have the lid lifted on classified information. Let’s hope they weren’t surprised.

One group that wasn’t surprised was middle and high school students, who responded with a collective eye roll, because they already discovered the maps on websites titled “Blurred-out stuff you’re not supposed to see on Google maps.”

The days of business, government, school districts or physician practices operating in relative secrecy are over. The credit goes to the digital age, which arrived with camera phone in hand, amped up on Wi-Fi, Facebook and 24-hour Google.

Information hungry
The Internet has created a transparency that’s impossible to escape. Physicians are now finding themselves publicly rated and ranked on the Web – not only by patients, but also by public and private payers. Health care in America is moving toward an information-hungry, market-driven model. Survival in this environment requires new systems of care that include performance measurement and feedback, transparency and public accountability, and rewards for quality outcomes.

It’s important to remember that for transparency to work in health care, it must be reciprocal. According to CMS President Brent Keeler, MD, all stakeholders, from payers to physicians to patients, must share information openly and honestly. “Ideally, this means patients should not rate or rank a doctor anonymously. Payers must be purposeful in presenting their rating methodologies in a way that can be understood and verified by all,” he says. “And physicians, understanding that it’s in the best interest of patients, should welcome public scrutiny and allow their record to speak for itself.”

Payment reform building blocks
Trying to understand physician profiling is much like a dog chasing a car and wondering what to do with it when he catches it. What is clear is that these programs must be reckoned with because they’re not going away. To help physicians make sense of physician profiling and designation programs, Colorado Medical Society (CMS) consolidated, sorted, analyzed and translated 956 performance measures used in 14 different programs by Aetna, Anthem, Cigna, United HealthCare and Medicare. CMS then created a toolkit with instructions, tips and resources to help physicians like you begin to use these programs to your advantage to strengthen your practice’s viability and to improve your care. If understanding physician profiling programs is like the dog chasing the car, then payer performance measures are the white elephants sitting in the corner of the room. Many physicians, convinced that the measures and methodologies are flawed and the reports are inaccurate, simply choose to ignore the reports. Others are unsure how to proceed so they choose to wait things out. Aurora emergency room physician Jennifer Wiler, MD, understands physicians’ concerns and frustrations, but says, “Even if the claims data is inaccurate, there is still value in the information, which physicians can put to good use. You may not recognize it now but these same measures are likely going to define how you are going to be paid in the future.”

Transparency and accountability programs are part and parcel of new payment systems. Whether it’s pay-for-performance, bundled payments or shared savings, all of the evolving alternatives to the fee-for-service framework require tracking and evaluation systems in order to demonstrate better value for the scarce health care dollar. So in effect, time spent working on transparency and profiling programs, no matter how flawed they may currently be, is an investment in not only better care delivery but also the future of your practice.

Importantly, developing and refining the performance measures to reflect the latest evidence and best practice has and must continue to be a hallmark of the profession and its commitment to quality innovation.

What you can do now
Dig into the data. Read the reports when they arrive and look for inconsistencies. Compare your records against the plan’s data. “It is important that physicians carve out time to examine their report and address any data that is incorrect or misleading,” said Dr. Keeler. To file an appeal, visit for instructions.

Measure. Once practices know how they are being evaluated, they can monitor themselves using the same parameters. According to Wiler, even if you are satisfied with your rating, it’s important to know how payers are evaluating you. And if you’re not satisfied, don’t be a victim; be proactive.

Educate patients and train staff. Share profiling results with staff and assign a project manager to create and oversee a practice-wide improvement plan around the measures. Make sure the entire team understands the ratings, knows what each person’s role is in your improvement plan strategy and can explain to the patient what, for example, one star or no stars next to your name means.

EHR. Electronic health records are critical to measuring and tracking performance. These clinical data surpass the effectiveness of claims data. Make the investment now, or at least start researching products. Check out Colorado Regional Health Information Organization’s (CORHIO) list of approved EHR vendors at Get the help you need to achieve meaningful use by using the CMS/CORHIO Path to Meaningful Use Web portal at The AMA has a wealth of resources at If you or your staff need training on a new EHR program, make it a priority to get up to speed.

Start small and use available resources. Colorado Medical Society has identified
38 performance measures that physicians should consider adopting to help make sense of their profiles and performance improvement strategies.

We analyzed 956 performance measures from six of the major commercial and public payers. From there, we looked for measures that were included in at least four programs and created the following set of crosscutting measures:

  • Chronic condition monitoring for ailments such as diabetes, coronary artery disease and low back pain
  • Prevention and screening including age-appropriate screening and prenatal care
  • Patient safety and experience for issues such as medication monitoring and falls
  • Resource use measures including readmissions, complications and re-do procedures

By focusing on these measures first, physicians can leverage their efforts across four different programs at once, which may help incentivize the work.

Doctors unite. Begin working and collaborating with other providers and specialists in your community to help focus on core measures and drive unified system improvement activities.

Know that you are not alone. Colorado Medical Society has worked tirelessly on this issue. We helped to pass the nation’s first legislation for health plan physician profiling that set standards for transparency, fairness and accountability. We’ve been advocating on your behalf with payers and making sure physician concerns are addressed. We’ve created education programs and other tools and resources to help you along the way.

The need for change in health care is striking – but attainable. For questions, contact me at or (720) 858-6305.


Posted in: Colorado Medicine | Practice Evolution | Transparency


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