What to Do If an Insurer Profiles You as a High Utilizer

Laird Harrison


May 26, 2015

In This Article

Higher Copays and Deductibles for Patients

Patients using other health plans may be forced to pay higher copays and deductibles for seeing ophthalmologists whose costs are higher than their peers for a given diagnosis, says Dr Rich, the AAO's president-elect.

He has no objection to the idea of analyzing cost and quality data to compare physicians. In fact, the AAO was one of the first specialty organizations to standardize benchmarks that can be used to evaluate the quality of care, he says. Ophthalmologists can already use the academy's Intelligent Research in Sight (IRIS) Registry to compare their performance with that of colleagues with similar practices.

Accurate measures of cost-effectiveness can help individual ophthalmologists control their costs, he says. "There are people who do too many tests," he says. "They're going to get caught up in this web. I don't have a problem with that."

He does have a problem with data that don't capture the reality of the physicians' practices. Simplistic measures of cost punish subspecialists in particular, whose costs are higher because their patients have more complex conditions requiring more treatment. "They lump bad apples doing too many tests and good docs doing the right thing into the same basket and whack them," says Dr Rich.

That happened to three pediatric ophthalmology subspecialists at Northern Virginia Ophthalmology in Falls Church, Virginia, where Dr Rich is the senior partner, he says. Cataract surgery in a baby is much more expensive than in an adult because it must be done in a hospital with specialized anesthesia. An insurer threw all three physicians out of a plan, claiming that their cataract costs were too high.

Such designations can disrupt the continuity of care, says Reed Tinsley, a practice management consultant in Houston, Texas. "People want choice. And people don't want to change their current doctor."

A family of four may have annual deductibles over $10,000, Dr Rich says, making it difficult to afford extensive eye care. "If you create barriers to those in greatest need, they won't go to the doctor."

Andrew Iwach, MD, executive director of the Glaucoma Center of San Francisco, California, recently experienced physician profiling from the patient's perspective when his personal health plan was eliminated. In searching for new coverage, Dr Iwach discovered that many of the local Blue Cross preferred provider organization (PPO) networks were being discontinued, were closed to new patients, or were only available with higher premiums. Newer networks with lower premiums had much smaller panels of physicians.

Then he experienced profiling from the physician's perspective when his office received a letter similar to the one received by the Wheaton Eye Clinic from UnitedHealthcare, with the designation "not enough data to assess quality and did not meet cost efficiency." "They had no comment on quality, but obviously the cost is the most important factor," he said at a recent ophthalmologist gathering.

The complexity of the new plans is providing plenty of work for people like David Dopp, administrator of the Wheaton Eye Clinic. Not only do the same insurers offer multiple types of plans, but some employers contract separately with a pharmacy benefit management company, which might create its own tiers for drugs. Often, patients and providers don't know whether a drug is covered until the patient attempts to fill a prescription. Ophthalmologists may then have to revise the patient's treatment plan.

"One of the challenges we all have as providers is that nothing, absolutely nothing, is communicated prior to the patient visit," Dopp says.


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