I Am Tier 1

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these measures to rank doctors: the higher the tier, the lower the copay for patients. Earlier this year I got my report card.

I am Tier 1. Hear me roar.

Flushed with pride, I wrote the commission and insurers:

Dear Sirs:

Thank you for sending me my tier information. While I appreciate your endorsement and confidence, I hope you can help me understand your evaluation more fully so I can become an even better and more efficient doctor.

▸ Under Quality Measures, you reported that I had three "Opportunities in Your Practice" to avoid inappropriate use of Lotrisone (betamethasone and clotrimazole), and that I overcame temptation in each. I never use this combination steroid-antifungal preparation, however, choosing instead either a steroid or antifungal cream alone. Every scaly rash is an opportunity for using Lotrisone, and I treat hundreds of scaly rashes every year, yet you identify only three such opportunities. How did you choose them?

▸ Under Efficiency Performance, your first category is "viral skin infection." This could include warts, herpes simplex, herpes zoster, molluscum contagiosum, and viral exanthems. Warts take several visits; mollusca, one or two; herpes simplex, zoster, and exanthems, usually one. Is lumping all these into one category and giving a "cost per episode" a useful way to measure and guide clinical practice?

▸ You reported I had one case of "environmental trauma" with an episode cost of $2,335.47 (compared with a peer cost of $395.28). Could you please tell me what this refers to? A bolt of lightning? A falling tree? A really big spider?

▸ You refer to a category, "fungal skin infection without surg." Is there a fungal skin infection with surg? In the meantime, you reported for this nonsurgical category my surgical costs were $42.

▸ Under "All ETG's," you show a cost of $82 for "inpatient ancillary," but I haven't hospitalized a patient in almost 30 years.

▸ Category 4 within Efficiency Performance is "inflammation of the noncranial nerves, except carpal tunnel, w/o surgery." You reported I had one episode, with a cost of $2,155.64. Since I am not a neurologist, I'm not sure what this refers to. I could not have charged $2,155.64 for herpes zoster, since I never see shingles patients more than once or twice (and always w/o surgery.)

▸ Category 5 is "other minor orthopedic disorder." I am not an orthopedist.

In 4 months, I've received no answer. The man in charge of the state insurance commission hasn't answered either—I wrote him twice—even though he's my patient. Because our medical society is suing the state for using flawed data, perhaps his nonresponse is on advice of counsel.

It is, of course, easier to mock efforts to solve difficulties than to fix them, and the problems our health care system faces are severe. Fixing these problems, although essential, will be hard and costly. I can't help being skeptical, though, when I read that better outcomes data and performance measures can be counted on to improve care and save money. Will patients really choose doctors with higher rankings and lower copays? Do we really know how to figure out which neurosurgeon or dermatologist is superior?

It's hard for me to be confident that better measurement is the answer, when the model in my neighborhood has reportedly sanctioned doctors for giving care to patients they never saw. The quality measurement I know about takes sensible criteria (nonuse of Lotrisone) and applies them in incomprehensible ways; deals in unintelligible and self-contradictory categories (fungal infection w/o surgery, but with surgical fees); lumps the incommensurate; cannot figure out how to categorize data in a way that makes sure a dermatologist is not an orthopedist; and is administered by remote bureaucracies that respond, if at all, only to lawsuits.

This, of course, is just the worm's eye view of one doctor. May I remind you, however, that I am Tier 1.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these measures to rank doctors: the higher the tier, the lower the copay for patients. Earlier this year I got my report card.

I am Tier 1. Hear me roar.

Flushed with pride, I wrote the commission and insurers:

Dear Sirs:

Thank you for sending me my tier information. While I appreciate your endorsement and confidence, I hope you can help me understand your evaluation more fully so I can become an even better and more efficient doctor.

▸ Under Quality Measures, you reported that I had three "Opportunities in Your Practice" to avoid inappropriate use of Lotrisone (betamethasone and clotrimazole), and that I overcame temptation in each. I never use this combination steroid-antifungal preparation, however, choosing instead either a steroid or antifungal cream alone. Every scaly rash is an opportunity for using Lotrisone, and I treat hundreds of scaly rashes every year, yet you identify only three such opportunities. How did you choose them?

▸ Under Efficiency Performance, your first category is "viral skin infection." This could include warts, herpes simplex, herpes zoster, molluscum contagiosum, and viral exanthems. Warts take several visits; mollusca, one or two; herpes simplex, zoster, and exanthems, usually one. Is lumping all these into one category and giving a "cost per episode" a useful way to measure and guide clinical practice?

▸ You reported I had one case of "environmental trauma" with an episode cost of $2,335.47 (compared with a peer cost of $395.28). Could you please tell me what this refers to? A bolt of lightning? A falling tree? A really big spider?

▸ You refer to a category, "fungal skin infection without surg." Is there a fungal skin infection with surg? In the meantime, you reported for this nonsurgical category my surgical costs were $42.

▸ Under "All ETG's," you show a cost of $82 for "inpatient ancillary," but I haven't hospitalized a patient in almost 30 years.

▸ Category 4 within Efficiency Performance is "inflammation of the noncranial nerves, except carpal tunnel, w/o surgery." You reported I had one episode, with a cost of $2,155.64. Since I am not a neurologist, I'm not sure what this refers to. I could not have charged $2,155.64 for herpes zoster, since I never see shingles patients more than once or twice (and always w/o surgery.)

▸ Category 5 is "other minor orthopedic disorder." I am not an orthopedist.

In 4 months, I've received no answer. The man in charge of the state insurance commission hasn't answered either—I wrote him twice—even though he's my patient. Because our medical society is suing the state for using flawed data, perhaps his nonresponse is on advice of counsel.

It is, of course, easier to mock efforts to solve difficulties than to fix them, and the problems our health care system faces are severe. Fixing these problems, although essential, will be hard and costly. I can't help being skeptical, though, when I read that better outcomes data and performance measures can be counted on to improve care and save money. Will patients really choose doctors with higher rankings and lower copays? Do we really know how to figure out which neurosurgeon or dermatologist is superior?

It's hard for me to be confident that better measurement is the answer, when the model in my neighborhood has reportedly sanctioned doctors for giving care to patients they never saw. The quality measurement I know about takes sensible criteria (nonuse of Lotrisone) and applies them in incomprehensible ways; deals in unintelligible and self-contradictory categories (fungal infection w/o surgery, but with surgical fees); lumps the incommensurate; cannot figure out how to categorize data in a way that makes sure a dermatologist is not an orthopedist; and is administered by remote bureaucracies that respond, if at all, only to lawsuits.

This, of course, is just the worm's eye view of one doctor. May I remind you, however, that I am Tier 1.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these measures to rank doctors: the higher the tier, the lower the copay for patients. Earlier this year I got my report card.

I am Tier 1. Hear me roar.

Flushed with pride, I wrote the commission and insurers:

Dear Sirs:

Thank you for sending me my tier information. While I appreciate your endorsement and confidence, I hope you can help me understand your evaluation more fully so I can become an even better and more efficient doctor.

▸ Under Quality Measures, you reported that I had three "Opportunities in Your Practice" to avoid inappropriate use of Lotrisone (betamethasone and clotrimazole), and that I overcame temptation in each. I never use this combination steroid-antifungal preparation, however, choosing instead either a steroid or antifungal cream alone. Every scaly rash is an opportunity for using Lotrisone, and I treat hundreds of scaly rashes every year, yet you identify only three such opportunities. How did you choose them?

▸ Under Efficiency Performance, your first category is "viral skin infection." This could include warts, herpes simplex, herpes zoster, molluscum contagiosum, and viral exanthems. Warts take several visits; mollusca, one or two; herpes simplex, zoster, and exanthems, usually one. Is lumping all these into one category and giving a "cost per episode" a useful way to measure and guide clinical practice?

▸ You reported I had one case of "environmental trauma" with an episode cost of $2,335.47 (compared with a peer cost of $395.28). Could you please tell me what this refers to? A bolt of lightning? A falling tree? A really big spider?

▸ You refer to a category, "fungal skin infection without surg." Is there a fungal skin infection with surg? In the meantime, you reported for this nonsurgical category my surgical costs were $42.

▸ Under "All ETG's," you show a cost of $82 for "inpatient ancillary," but I haven't hospitalized a patient in almost 30 years.

▸ Category 4 within Efficiency Performance is "inflammation of the noncranial nerves, except carpal tunnel, w/o surgery." You reported I had one episode, with a cost of $2,155.64. Since I am not a neurologist, I'm not sure what this refers to. I could not have charged $2,155.64 for herpes zoster, since I never see shingles patients more than once or twice (and always w/o surgery.)

▸ Category 5 is "other minor orthopedic disorder." I am not an orthopedist.

In 4 months, I've received no answer. The man in charge of the state insurance commission hasn't answered either—I wrote him twice—even though he's my patient. Because our medical society is suing the state for using flawed data, perhaps his nonresponse is on advice of counsel.

It is, of course, easier to mock efforts to solve difficulties than to fix them, and the problems our health care system faces are severe. Fixing these problems, although essential, will be hard and costly. I can't help being skeptical, though, when I read that better outcomes data and performance measures can be counted on to improve care and save money. Will patients really choose doctors with higher rankings and lower copays? Do we really know how to figure out which neurosurgeon or dermatologist is superior?

It's hard for me to be confident that better measurement is the answer, when the model in my neighborhood has reportedly sanctioned doctors for giving care to patients they never saw. The quality measurement I know about takes sensible criteria (nonuse of Lotrisone) and applies them in incomprehensible ways; deals in unintelligible and self-contradictory categories (fungal infection w/o surgery, but with surgical fees); lumps the incommensurate; cannot figure out how to categorize data in a way that makes sure a dermatologist is not an orthopedist; and is administered by remote bureaucracies that respond, if at all, only to lawsuits.

This, of course, is just the worm's eye view of one doctor. May I remind you, however, that I am Tier 1.