Editorial: Demoted!


The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these performance measures to rank doctors: the higher the tier, the lower the copay for patients.

Not too long ago, I crowed about being Tier 1. They say pride goes before a fall. Sometimes it goes before the spring.

An insurer who rated me Tier 1 for 2010 sent this year’s ratings. Tier 2. Demoted.

The shame!

But then I saw hope – I could appeal! I e-mailed a request for the data on which my designation was based. Promptly it came: a spreadsheet with 49 columns, plus A through Z, plus AA ... you get the picture. Reading down, there were 4,253 rows listing patients’ financial and demographic details. Across were headings like, "ACT_WT_PAID_TOT_AMT," explained elsewhere as, "Weighted actual payments for this ETG at peer rates."

By Dr. Alan Rockoff

Scanning screens of unfamiliar acronyms and tiny numbers (the spreadsheet was far too unwieldy to print out), I prepared my appeal. It had three main points:

– Only 47% of the patients showed names and dates of birth; the demographics for the rest were blank, making it impossible to check the data’s relevance and accuracy.

– Some categories made little or no sense. For instance, one ETG (see below) on which I had supposedly done well relative to peers was, "Malignant neoplasm of the skin, major, w/o surgery." What could major skin cancer without surgery possibly mean? An ETG on which I had done poorly was, "Malignant neoplasms of the skin, major, with surgery" – but 1,655 patients were classed as "Neoplasm of." Were these benign Neoplasms of? Malignant Neoplasms of? Major? Minor? W/ surgery? W/o? Who could know?

– One named patient I recognized was listed under the ETG "Infection." Line K, "weighted, actual payments," for this patient were $1,850.04 for 2009 (the "midpoint year.") I had seen this patient three times for oral herpes simplex in 2009, twice in 2008 for seborrhea, and not at all in 2010. I’d ordered no tests, made no referrals. Had the insurer truly paid $1,800 for five office visits? If only.

With impressive efficiency, the insurer responded to my appeal within 4 hours:

Appeal denied. Your tier level will remain: Tier 2. No change in tier.

Explanations followed. Here are two of them:

"We have forwarded data which is not labeled because it is for patients from other plans. He would have to obtain the data from those plans to fill in the table." (Dismissing me in the third person was a nice touch.)

"The ETG’s group claims into categories and are not specific submitted diagnoses."

Perhaps the acronym, "ETG" is unfamiliar. You may know one of its other meanings: Emerging Technologies Group, Enhanced Target Generator, Evangelische Täufergemeinde. Here, however, it signifies "Episode Treatment Groups," undefined on the insurer’s spreadsheet but discoverable via Internet search as follows:

By combining related services into clinically homogenous units that describe complete episodes of care, ETGs may be utilized to provide the basis of valid comparisons. ETGs create episodes by collecting all inpatient, outpatient, and ancillary services into mutually exclusive and exhaustive categories.

Got that? In that case, can you tell me why another identified patient had solar keratoses, squamous cell carcinoma, and a cold sore – and an ETG classification of "Infection?" How clinically homogeneous, exclusive, and exhaustive is that? Or you can help me understand how a woman with herpes simplex incurred charges of $1,850 for five office visits. And when you’re done, you can explain what "Malignant neoplasm of the skin, major, w/o surgery" means. Although I asked that question directly, the insurer felt no obligation to tell me.

Challenging my appeal’s denial, I shot back an e-mail, which was of course ignored. Protocol had been followed. The case was closed. The medical director had spoken. I don’t know the man, but he must be a fan of Franz Kafka: indict the prisoner, order him to fill in his own charge sheet, but don’t tell him how. ("He would have to obtain the data [how?] from those plans [which plans?] to fill in the table." [It’s his table?])

Welcome to the future, dear colleagues. Our professional efforts will be increasingly judged from the inside of large black boxes, from the bowels of which statistical oracles will utter complex formulas they probably grasp as well as too-big-to-fail investment bankers understood derivatives trading.

The emperor, I submit, is wearing very little. No reason you should take my word for it, though. I’m only Tier 2.


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