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Physicians Should Be Able To Review Performance Ratings Before Release

Adopted Policy Will Help Consumers Make Informed Decisions, Physicians Will Be Able to Assess and Improve Performances

April 20, 2007

SAN DIEGO, April 20, 2007 – A policy paper and principles assuring that physicians are given the opportunity to comment on performance ratings that they believe are inaccurate were adopted this week by the American College of Physicians (ACP) at its annual meeting. The principles, part of the paper Developing a Fair Process Through Which Physicians Participating in Performance Measurement Programs Can Request a Reconsideration of Their Ratings, also address performance ratings that do not take into account the characteristics of the practice or patient population being treated prior to the release of ratings to the public.

ACP is host to 6,000 physicians for Internal Medicine 2007 from April 19-21 at the San Diego Convention Center.

Accurate reports of physician performance will allow physicians to effectively assess and improve their performance, and enable consumers and purchasers to make informed decisions concerning treatments, coverage and the quality of care. The principles, ACP says, should be considered in tandem with other organizational principles on developing measures; sharing, aggregating, and reporting data; and the ethics of physician performance measurement.

ACP has stated in previous position papers that programs measuring physician performance should operate in a fair, objective and scientifically sound manner. Performance data should be used for public reporting or to determine physician payment only after data are fully adjusted for case-mix composition, including age, severity of illness, co-morbidities, and other features of a physician’s practice and patient population that may influence the results.

“A fair and accurate reconsideration process is yet another way to minimize unintended consequences that may compromise the care of the patient,” said ACP President Lynne M. Kirk, MD, FACP. “These principles reflect the importance of balancing stakeholders’ urgent need for useful information with the need for due diligence to ensure that the information provided is valid, reliable, and useful.”

Voluntary payer utilization of the general guidelines are designed to ensure a fair and accurate process through which physicians participating in a performance measurement program can request a reconsideration of performance ratings prior to public release.

The 11 principles included in the paper are listed below.

The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 120,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection and treatment of illness in adults.

1. Prior to public release of performance ratings to the public or use of ratings to determine payment, physicians should be given the opportunity to review the ratings for accuracy, and at the physician’s request, initiate reconsideration of their individual ratings. The payer should employ all possible means to ensure that no adverse determination regarding physician performance be made without prior review by the rated physician, and, when requested by the physician, ratings should be reconsidered by an appropriate and objective group of reviewers.

2. At the time of enrollment in a performance measurement program, and when ratings are first distributed for internal review, payers should provide physicians with a clear explanation of all program facets, including: the clinical guidelines and evidence that is graded upon which measures are based; the analytical methods used to aggregate, rate, and report data; the physician’s right to an objective, timely, and expeditious reconsideration and appeals process; and a clear description of the reconsideration and appeals process, including the grounds for challenging ratings.

3. Payers should have a well-defined and distinct mechanism for responding to physician inquiries and requests for reconsideration. Practical time frames must be established to ensure timely resolution of the contested matters and to minimize the delay of public reporting.

4. In submitting a request for reconsideration, physicians should be given an opportunity to clearly identify the grounds for challenging the ratings. Physicians should be able to challenge the accuracy and fairness of the application of performance measures. Ratings may be challenged on a variety of factors, including: the validity, reliability, appropriateness, and applicability of the measure and its evidence base; the appropriateness of the statistical methods used to aggregate the data, including the size of the sample; the effectiveness of statistical adjustments (or lack of) used to account for confounding factors, including care attributable to the individual physician, case-mix composition, co-morbidities, severity of illness, and patient non-adherence; the suitability of the measure implementation process; and the accuracy of the reporting format.

5. Submitting a request for reconsideration should not create an undue administrative burden on physicians to the extent that it discourages physicians from challenging ratings. Similarly, user fees and penalties should not be imposed on physicians who challenge performance rating decisions.

6. Fairness must be integral to methods used by payers to evaluate requests for reconsideration. Decisions about the appropriateness of ratings should be thorough and responsive to the concerns of the physician. In responding to physicians with the results of a reconsideration appeal, payers should state their findings and the clinical basis for their findings as clearly as possible.

7. The payer should establish unambiguous parameters to determine when a dispute cannot be resolved through an internal review process, and instead warrants consideration by an independent, external review or appeals board. These parameters should be set high enough to minimize the delay of public reporting and to preserve the goals of transparency.

8. If the physician still contests a rating after all mechanisms for reconsideration have been exhausted, the physician should be permitted to include comments adjacent to the disputed rating in the public report.

9. Payers should provide a central source for collecting, monitoring, and analyzing all inquiries and requests for reconsideration in order to enhance accountability, ensure that concerns are adequately addressed, and improve processes through the identification of recurrent issues and concerns.

10. If the physician successfully challenges an erroneous rating, he/she should receive full payment from the third party payer. Any “withholds” that may have occurred from physician reimbursement during the period of appeal should be paid within sixty days to the physician along with interest based on the medical Consumer Price Index.

11. Recognizing the importance of educating physicians about the potential difficulty and associated expenses of a performance measurement auditing process, the College will educate its membership about the appeals process and encourage its membership to use it judiciously to avoid frivolous appeals. ACP is willing to engage in a multi-stakeholder process to promote an appeals process that is fair and reasonable for both physicians and health care payers.

Contact:
David Kinsman, (202) 261-4554, dkinsman@acponline.org
Jacquelyn Blaser, (202) 261-4572, jblaser@acponline.org

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