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Do Insurance Companies Know Who the Good Doctors and Surgeons Are

  • Published: 2010-09-15 (Revised/Updated 2010-10-27) : Author: American Academy of Orthopaedic Surgeons
  • Synopsis: Several health plans have introduced physician rating systems to offer consumers more information when choosing their doctors.

Main Document

Does your insurance company know who the good doctors/surgeons are- New study finds that physician ratings do not help consumer decision-making.

Several health plans have introduced physician rating systems to offer consumers more information when choosing their doctors. However, a recent study presented in the September issue of the Journal of Bone and Joint Surgery (JBJS) reveals that physician-tiering guidelines and results are not consistent across insurance companies, do not fully define quality; and could confuse consumers.

Since affordable and more accessible health care is a critical national challenge, the use of rating systems will increase as one response to rising costs. Doctors receive notices from insurance companies about their ratings, although they do not fully understand how their tier was determined. When patients receive letters from insurers and see that their doctors are not in a top tier, their reactions may range from disappointment to confusion. This study is the first to analyze tiering system data as it applies in a specific setting.

"We examined data on 615 orthopaedic surgeons who had been accepted in one or more health plans in Massachusetts," explains one of the authors, orthopaedic surgeon Timothy Bhattacharyya, MD, Head, Clinical Investigative and Orthopaedic Surgery Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). "Tiering ranks physicians on the basis of cost efficiency and adherence to performance quality benchmarks. Thus, a higher physician rating could lead to lower co-pays and out-of-pocket costs for patients."

This study also reveals concerns that should be addressed:

The authors note that their study has limitations. Data was examined for one specialty, orthopaedics, and in one state, and may not be applicable to other medical specialties or geographical areas. The lack of agreement between health plans may be the result of measuring different aspects of healthcare quality. A "gold-standard" consensus could serve as a benchmark and provide consistency across plans.

What should consumers do if they check a physician and discover that he/she is not in the top tier? Dr. Bhattacharyya explains that:

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