PHYSICIAN QUALITY: Newsday Urges Consumer Caution
Managed care organizations in New York regularly fail to tell patients when network physicians are disciplined by the state -- an oversight that raises questions about insurers' commitment to high-quality patient care, argues Newsday in the first of a four-part series running this week. In a 10-month investigation of state MCOs, the paper found 132 physicians included in provider networks who had been punished by state authorities since 1990, including ten who "couldn't possibly see patients legally" because their licenses had been revoked. Of that 132, 86 physicians were punished for patient mistreatment and 13 for sexual misconduct. The paper's Sunday issue contends that such numbers are evidence that health plans are not fulfilling their "most basic promise to consumers," a viewpoint echoed by some industry analysts. Notes Geraldine Dallek, director of Georgetown's Institute for Health Care Research and Policy: "To the extent that a managed care company contracts with physicians with a serious history of wrongdoing, they are not fulfilling their promise to ensure that enrollees get a high quality of care. I, as a consumer, would be very wary."
In defense, insurers say that state-disciplined physicians "account for only a small fraction of their networks" and contend that, in the interest of fairness to providers, they rely on independent panels to do a separate review of incidents in order to determine whether the physician poses a risk. Dr. William Osheroff, medical director of Empire Blue Cross and Blue Shield, adds that patients, not insurers, are responsible for checking into a physician's disciplinary record. Finally, insurers admit that poor record-keeping may play a role, as physicians removed from the network may continue to appear on lists marketed to consumers (Maier, 11/14).
Medicare Under the Microscope
In Monday's issue, Newsday points a finger at the Medicare program, noting that "Medicare has yet to develop a system that can eliminate doctors for bad quality in the same way" it has cracked down on physicians for financial wrongdoing. The paper's investigation found that over the last decade, Medicare paid more than $81 million for care involving disciplined New York physicians. Though Medicare officials have said they hope that Medicare MCOs will provide an extra layer of quality control, Newsday argues its study raises questions about whether insurers will be any more effective at this task than the government has been (Maier, 11/15).
'The Board Game'
Tuesday's installment of the Newsday series attempts to unmask health plans' claim that board certification is a mark of physician quality. Oxford Health Plans' Chief Medical Officer Dr. Alan Muney said, "The public perception is that board certification is the be-all and end-all -- and it really isn't. It shouldn't be viewed exclusively as an important issue." "Privately," the article notes, managed care officials concede that "board certification really doesn't distinguish one doctor from another and is no guarantee of quality care." Newsday performed a computer-assisted analysis that found 71% of managed care doctors disciplined in the last decade by the state were board certified. The rate is "comparable to all practicing physicians" in New York, leading to the conclusion that the designation "really says little about a doctor's relative skills." For most physicians, board certification in a specialty follows medical school and residency, and "can involve two or more years of training and a battery of written, oral or clinical exams." The article also notes that the term "board eligible" is widely considered "meaningless" by "medical experts," and that the American Board of Medical Specialties says the term is so vague that it has "lost its usefulness." It says that physicians may continue to use the term board eligible "year after year while making no perceptible progress toward certification," and recommends that the term "be disavowed." In the meantime, many plans continue to cite board certification to boast physician quality in their patient literature. Oxford, New York's largest HMO, proclaims, "Perhaps the highest credential a physician can receive is board certification," and boasts that the plan actively recruits qualified doctors. Finally, the state health department tells consumers, "While no guarantee of excellence, board certification is one way the average consumer can be certain of a physician's training" (Maier, 11/16).
Part four of the series today discusses medical experts' growing concern over the safety of ambulatory surgery. Some contend that its growing popularity places patients at great risk due to shortfalls in safety regulations. One medical professor said outpatient clinics have "little oversight, little regulation and little accountability for patient safety." A New York State Senate investigation committee report out in February showed that 65% of all elective surgeries in the state have shifted from hospitals to outpatient surgery centers, with 15% taking place in doctors' offices. Officials say the "economics of managed care" is driving the phenomena, primarily due to dramatically lower costs in outpatient overheads. In their defense, insurers say they only list state-licensed ambulatory surgery centers in their catalogs, stressing that these clinics are periodically investigated by state regulators. Some managed care companies, such as Aetna U.S. Healthcare, establish their own independent panels to review surgery centers and require facilities to have emergency equipment on hand to prevent "unplanned admissions" at hospital emergency rooms. They further contend "cost-saving considerations play little or no role in encouraging" outpatient surgery, adding that patients have "embraced" ambulatory surgery because they are "eager to return home after surgery." Insurers believe hospitals are critical because they fear losing more patients to outside facilities (Maier, Newsday, 11/17).