Patients, physicians lose in health care tiering system

ATLANTA — Private insurance companies are tiering physicians based on efficiency measurements, putting up financial barriers to the best care for patients, a surgeon said here.

William I. Rich III

"The goal with these ... products was to create a network of providers who were cost conscious and provided good care. The reality is we have a network of those providers who don't provide comprehensive care and won't, don't or can't take care of the sickest patients," William I. Rich III, MD, said during Retina Subspecialty Day preceding the American Academy of Ophthalmology meeting.

Dr. Rich explained that these companies are using software to measure physician efficiency, which often comes down to the ratio of actual resource use to the expected resource use.

"Medicare has totally abandoned this now because they don't think this software is valid, but the commercial players ... could not wait to get into the fray, so you're already being measured now by the use of this software," he said. "This is a tremendous disadvantage to those of you in academic medical centers or to all of you in this room who are retinal subspecialists."

Subspecialists care for much sicker patients, making their resource use much higher than that of a general ophthalmologist and increasing the amount patients will have to pay for treatment.

"Patients are the big losers," Dr. Rich said. "Basically, we're creating financial barriers to care, and it is a big surprise to patients when they really do get sick."

He recommended reviewing commercial contracts, requesting copies of the company's profile and looking at the profiling methodology.

"You can immediately stop and ask for an appeal," he said.