BILL ANALYSIS
AB 2533
Page 1
ASSEMBLY THIRD READING
AB 2533 (Fuentes)
As Introduced February 19, 2010
Majority vote
HEALTH 19-0 APPROPRIATIONS 17-0
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|Ayes:|Monning, Fletcher, |Ayes:|Fuentes, Conway, Ammiano, |
| |Ammiano, Carter, Conway, | |Bradford, Charles |
| |Bradford, De Leon, | |Calderon, Coto, Davis, |
| |Emmerson, Eng, Gaines, | |Nava, Hall, Harkey, |
| |Hayashi, Hernandez, | |Miller, Nielsen, Norby, |
| |Jones, Bonnie Lowenthal, | |Skinner, Solorio, |
| |Nava, V. Manuel Perez, | |Torlakson, Torrico |
| |Salas, Smyth, Audra | | |
| |Strickland | | |
| | | | |
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SUMMARY : Revises current law that requires health care service
plans and health insurers (collectively carriers) to submit a
description of their policies and procedures related to
"economic profiling" as defined, to the Department of Managed
Health Care and the California Department of Insurance
respectively, to include policies and procedures on "quality
rating." Specifically, this bill :
1)Requires, on or after July 1, 2011, and in addition to current
reporting requirements related to economic profiling policies
and procedures, carriers to submit a description of their
policies and procedures related to "quality rating" to state
regulators.
2)Defines "quality rating" as any efforts by a carrier or by an
entity contracted by a carrier to develop, evaluate, rate, or
designate individual or group performance of physicians based
on quality measurements and claims data.
3)Revises current law to require the filing to also describe how
the policies and procedures are used in network modification
and patient screening. Requires the filing to indicate how
the economic profiling or quality rating system being used by
the carrier takes into consideration risk adjustments that
reflect the accuracy and reliability of data and patient
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compliance with a recommended procedure.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, minor and absorbable workload to state regulators to
continue oversight of health plan and health insurer reporting.
COMMENTS : According to the author, many insurers are attempting
to rate physicians based on quality or costs measures without
the consent of physicians. For example, the California
Physician Performance Initiative (CPPI) is a physician rating
project based on national quality measures. The author writes
that CPPI has mainly focused on measuring primary care
physicians and internists, but it continues to expand to other
specialties, such as cardiologists, endocrinologists,
pulmonologists, gastroenterologists, and rheumatologists. The
author states that quality or physician rating programs, such as
the CPPI, are fraught with multiple problems, including
incompleteness of claims data, statistical validity of patient
sample size, and the likelihood of misleading patients due to
inaccurate information.
According to a March 2010 New England Journal of Medicine
article regarding physician cost profiling, health care
purchasers are experimenting with a variety of ways to control
costs; several of which involve physicians, since they often
write the orders that drive spending. Towards that end, health
plans have limited the number of physicians who receive
in-network contracts, offering patients differential copayments
to encourage them to visit "high-performance physicians" (i.e.,
those providing higher-quality, lower-cost services), paying
bonuses to physicians whose patterns of resource use are lower
than average, and publicly reporting the relative costs of
physicians' services.
Researchers from RAND, the University of Pittsburgh School of
Medicine, and the University of Southern Maine, Portland
examined claims data from four health plans in Massachusetts to
analyze programs offering incentives to choose physicians
classified as offering "lower-cost care." The stated intent was
to evaluate the reliability of current methods of physician cost
profiling. The researchers found that overall, the majority of
physicians did not have cost profiles that met common thresholds
of reliability. For example, 43% of all physicians sampled
(across specialties) were misclassified as lower cost, which
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suggested to the researchers that there are serious threats to
health plans' abilities to achieve cost-control objectives and
to patient expectations of receiving lower-cost care when they
change physicians for that purpose. The researchers concluded
that "Current methods for profiling physicians with respect to
costs of services may produce misleading results."
In 2007, the New York State Attorney General commenced an
industry-wide investigation into insurers' "doctor-ranking"
programs. As a result, settlement agreements were reached with
several health insurance companies, and out of those agreements
the Patient Charter for Physician Performance Measurement,
Reporting and Tiering Programs (Patient Charter) was created.
The Patient Charter, which is endorsed by the AARP, the National
Partnership for Women & Families, the AFL-CIO, the Leapfrog
Group, Pacific Business Group on Health, the National Business
Coalition, and several physician groups (including the American
Medical Association) creates a national set of principles to
guide measuring and reporting to consumers about doctors'
performance. As of March 10, 2010, six plans had committed to
fulfilling the Patient Charter: Aetna, Blue Cross Blue Shield
of Tennessee, Blue Shield of California, Cigna,
UnitedHealthcare, and Wellpoint.
According to the CPPI Web site, the initiative began in 2006 to
measure and report the quality of patient care that is provided
by individual physicians in California. The project is
administered by the California Cooperative Health Care Reporting
Initiative, a group that collaborates on quality issues, and
whose members include employer, consumer, health plan, and
physician groups. Start-up funding for CPPI was provided by the
federal Centers for Medicare and Medicaid Services, the
California HealthCare Foundation (CHCF), the Pacific Business
Group on Health, and the pharmaceutical company Merck.
According to CHCF, this multi-stakeholder initiative is
investigating how California physicians stack up against
benchmarks and whether care provided to Medicare beneficiaries
varies against other payers.
CPPI assessed physician performance using clinical quality
measures that are evidence-based and endorsed by national
standard-setting bodies (the National Quality Forum and the
American Medical Association's Physician Consortium on
Performance Improvement). According to CPPI, the measures for
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2008 and 2009 were related to preventive care and chronic
condition management. For 2008 data, individual reports were
sent to over 13,000 physicians for their review and correction
over an eight-week period. Based on that review by physicians,
a number of errors in the data were identified. Results were
not released publicly, and a November 2008 briefing on CPPI by
one of the partners noted that data improvements were needed in
the project moving forward.
The California Medical Association (CMA), the sponsor of this
bill, writes that many insurers and plans, and other third party
entities, are conducting physician quality ratings without the
knowledge or consent of physicians. CMA states that given that
there are many concerns about the accuracy of the claims data
used by insurers, and the irreparable harm such ratings may
bring to a physician's personal and professional reputation or
how patients could be mislead by the information, it believes
that health plans, insurers, or any third party contracted to
conduct a quality rating program should be required to simply
disclose a description of the policies and procedures related to
the rating.
The California Chiropractic Association (CCA) supports the
concept of this bill, but seeks an amendment to make the bill
apply to all health care providers, not just physicians. CCA
writes that the term "physician" generally means a physician as
defined by the Medical Practice Act excludes other types of
health care providers, many of whom are concerned by the use of
quality ratings by insurers.
Analysis Prepared by : Melanie Moreno / HEALTH / (916)
319-2097
FN: 0004029