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

Laird Harrison


May 26, 2015

In This Article

Physician Profiling: A Growing Trend

The need to defend your cost of care is only going to become greater, says Dr Rich. The Affordable Care Act has encouraged physician profiling by creating platinum, gold, silver, bronze, and catastrophic plans, he says. Most people choose the silver and bronze plans for their lower premiums, but end up with much higher copayments and deductibles, he says.

The trend is also likely to continue because payers see economic profiling of physicians as a successful experiment overall. "If you're a business, you're going to want to save money on your costs, so you're going to want your employees to have skin in the game when they decide to do a test or something," says Dr Rich. "The aggressive tiering of physicians and increased deductibles and copays are the reasons for the lowering of healthcare inflation since 2005."

Although physician profiling isn't likely to go away, it may become more sophisticated, says Dr Rich. Under a congressional mandate to develop its own episode grouper software, CMS is working to create algorithms that accurately link quality and cost data, he says. "They are struggling to do it right."

The agency has a long way to go, in his opinion. "The risk-adjustment factors they use have nothing to do with ophthalmology," says Dr Rich. "For example, they don't look at rates of diabetic retinopathy among Hispanic persons."

He hopes that registries like IRIS will fill some of the gap by taking advantage of electronic health records to track patients for a longer period, adjusting for the stage of the disease, and capturing more of the cost data. "This is where the hope is to effectively and fairly capture research use and cost," he says.

IRIS is off to a good start. Launched in April 2014, it is on track to exceed its goal of enrolling 2200 ophthalmologists and 18 million patients by 2017. By February of this year, it had already enrolled 5800 ophthalmologists and 6.6 million patients. "You can really get an idea of the impact you're having on the course of disease with those kinds of numbers," says Dr Rich."

But, he says, payers may need a lot of nudging to use the data already available, let alone the granular information IRIS could provide.

"They could differentiate between specialists and subspecialists," he says. "That recommendation has been made to Medicare and private insurance, but it's not in the best interest of their clients. Until there is a public outcry from patient advocacy groups, and we have documentation of more people losing eyesight faster—and until there's pushback from employees—I don't think they'll change."


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