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Aetna, CIGNA, Empire BlueCross Establish Standards With New York State AG

Aetna, CIGNA and Empire BlueCross have reached an agreement with the New York State Attorney General on standards for physician-rating programs.

As health insurers deliver more online self-help tools to meet consumer demand for information to support consumer-directed healthcare decisions, a need is emerging for industry standards to ensure the transparency and accuracy of the data contained within those tools. In what could be a major breakthrough to that end, three major health insurers -- Aetna, CIGNA and Empire BlueCross BlueShield -- recently agreed with the New York State Attorney General on guidelines for physician-ranking systems.

Many healthcare industry groups, such as the American Medical Association (Chicago), welcomed the news. The AMA had expressed concerns that, if left unchecked, carriers' doctor-ranking programs could unfairly or inaccurately evaluate physician performance by, for example, focusing too much on economic factors.

"A lack of proper oversight has allowed health insurers ... to unfairly evaluate ... physicians," AMA President-elect Nancy H. Nielsen said in a statement. "Physician evaluations can be skewed through the use of economic criteria, insufficient sampling of patients, questionable quality measures and poor adjustments for risk."

Under the recently adopted guidelines, the insurers will identify the degree to which their rating systems are based on cost, use established national standards to rate clinical quality and ensure more accurate comparisons through valid sampling and risk adjustment techniques. "With regard to information that's made available to members, any health plan should be clear about how they developed the information and what it is appropriate to be used for," says Mark Wagar, president and CEO of New York-based Empire BlueCross BlueShield, a subsidiary of Indianapolis-based WellPoint ($54 billion in total assets).

Wagar adds that a large and growing segment of Empire's (almost $8 billion in 2006 premium) group customers are requesting more access to data for their employees (or union members). "Ultimately, any major insurance provider is going to need to have this kind of information available to their members and providers," he relates. "Consumers are anxious for this information. They're going to use what they find useful and ignore what they don't."

Under their agreements, Aetna (Hartford; more than $1.7 billion in 2006 net income) and CIGNA (Philadelphia; $16.5 billion in 2006 revenue) will tweak their current doctor-evaluation tools to meet New York State Attorney General Andrew Cuomo's guidelines. Empire BCBS still is developing its doctor-rating tool, BluePrecision, according to Wagar, but will incorporate the guidelines when it is launched later in 2008.

"The first time we do it, [BluePrecision] will be based on these principles," Wagar says. "It'll be very clear to anybody who looks at the information where it comes from, what it's based on and what standards were used."

Start of a National Standard?

Nationwide doctor-rating system standards could change as a result of the recent New York State agreements, Wagar suggests, noting that major health insurance carriers view the New York Attorney General's guidelines as a good foundation on which to build doctor-rating systems. Aetna, for example, already has decided to apply the principles of the agreement nationally, according to the company.

"When you have Empire, the largest carrier in New York, and WellPoint, the largest carrier in the country, stepping up, ... and you have other major carriers doing the same thing, it's sort of 'game over' at that point," Wagar says. "This is going to become the standard."

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