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Physicians' Ratings of Health Plans

Physicians' Ratings of Health Plans To the Editor.—The central premise of the article by Dr Borowsky and colleagues1 —that physicians have a unique and valuable window into the quality of health plan performance—is compelling. Although the physician viewpoint has all but been forgotten in public debate over plan performance measurement, the authors have made a valuable initial empirical attempt to correct this omission. For example, it is important to recognize that physicians were highly critical of mental health care in all 3 evaluated plans and that this presents an immediate opportunity for improvement. However, the authors overreach their data when applying these measures to assign report card rankings to these plans. First, uncontrolled differences in plan type bias the results. The authors compared a staff model health maintenance organization (HMO) (plan 2) with 2 network model plans gatekeeper (plans 1 and 3, of which plan 3 had a primary care physician format). Previous work has traced differences in patient satisfaction between plans to plan type.2,3 These health plans may genuinely differ on the indicators used in this study, but this distinction could not be adequately controlled (statistically or otherwise) given the study design. The most likely explanation for the more positive perception of physicians in plan 2 toward managed care practices—a possibility raised but not investigated by the authors—is that physicians who choose to work in this setting have greater understanding of, and a more positive view toward, the same managed care practices than their colleagues in the 2 network model plans. A more credible comparison would have pitted each of these plans with similar types of plans or asked physicians who work with all 3 plans to compare them against each other. Second, the rate of attrition was problematic. Of the target plan 3 sample, 45% were lost either to initial difficulty in locating the physicians or because respondents asserted that they rated another plan because they did not know enough about plan 3. The attrition rate for plan 3 was large and was much greater than the rate for the other 2 samples, and undercut any claim that the final plan 3 sample was representative of the corresponding physician population. An unacknowledged urban-rural bias also confounds the comparison because plan 3 includes comparatively more rural physicians. These flaws render any conclusion about the relative performance of these 3 plans premature. Pioneering work often falls prey to this kind of overreach, but, as a result, it would be erroneous to link the reported differences in physician perceptions to actual differences in practices that promote or hinder the provision of high-quality care to patients. There is much to learn from physicians' perceptions of health plans, but only when the static introduced by preexisting attitudes can be sorted out successfully. Furthermore, to assert that the ability of physician satisfaction measures "to distinguish between plans stands in contrast to some surveys of consumer satisfaction that find small, if any, differences between plans" is unfounded. This study with its shortcomings is hardly sufficient to compare physician-supplied and patient/member-supplied data in differentiating plans. References 1. Borowsky SJDavis MKGoertz CLurie N Are all health plans created equal? the physician's view. JAMA. 1997;278917- 921Google ScholarCrossref 2. Allen Jr HMDarling HMcNeill DBastien F The employee health care value survey: round one. Health Aff (Millwood). 1994;13 (4) 25- 41Google ScholarCrossref 3. Allen Jr HMRogers WH The consumer health plan value survey: round two. Health Aff (Millwood). 1997;16 (4) 156- 166Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Physicians' Ratings of Health Plans

JAMA , Volume 279 (3) – Jan 21, 1998

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Publisher
American Medical Association
Copyright
Copyright © 1998 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.279.3.193
Publisher site
See Article on Publisher Site

Abstract

To the Editor.—The central premise of the article by Dr Borowsky and colleagues1 —that physicians have a unique and valuable window into the quality of health plan performance—is compelling. Although the physician viewpoint has all but been forgotten in public debate over plan performance measurement, the authors have made a valuable initial empirical attempt to correct this omission. For example, it is important to recognize that physicians were highly critical of mental health care in all 3 evaluated plans and that this presents an immediate opportunity for improvement. However, the authors overreach their data when applying these measures to assign report card rankings to these plans. First, uncontrolled differences in plan type bias the results. The authors compared a staff model health maintenance organization (HMO) (plan 2) with 2 network model plans gatekeeper (plans 1 and 3, of which plan 3 had a primary care physician format). Previous work has traced differences in patient satisfaction between plans to plan type.2,3 These health plans may genuinely differ on the indicators used in this study, but this distinction could not be adequately controlled (statistically or otherwise) given the study design. The most likely explanation for the more positive perception of physicians in plan 2 toward managed care practices—a possibility raised but not investigated by the authors—is that physicians who choose to work in this setting have greater understanding of, and a more positive view toward, the same managed care practices than their colleagues in the 2 network model plans. A more credible comparison would have pitted each of these plans with similar types of plans or asked physicians who work with all 3 plans to compare them against each other. Second, the rate of attrition was problematic. Of the target plan 3 sample, 45% were lost either to initial difficulty in locating the physicians or because respondents asserted that they rated another plan because they did not know enough about plan 3. The attrition rate for plan 3 was large and was much greater than the rate for the other 2 samples, and undercut any claim that the final plan 3 sample was representative of the corresponding physician population. An unacknowledged urban-rural bias also confounds the comparison because plan 3 includes comparatively more rural physicians. These flaws render any conclusion about the relative performance of these 3 plans premature. Pioneering work often falls prey to this kind of overreach, but, as a result, it would be erroneous to link the reported differences in physician perceptions to actual differences in practices that promote or hinder the provision of high-quality care to patients. There is much to learn from physicians' perceptions of health plans, but only when the static introduced by preexisting attitudes can be sorted out successfully. Furthermore, to assert that the ability of physician satisfaction measures "to distinguish between plans stands in contrast to some surveys of consumer satisfaction that find small, if any, differences between plans" is unfounded. This study with its shortcomings is hardly sufficient to compare physician-supplied and patient/member-supplied data in differentiating plans. References 1. Borowsky SJDavis MKGoertz CLurie N Are all health plans created equal? the physician's view. JAMA. 1997;278917- 921Google ScholarCrossref 2. Allen Jr HMDarling HMcNeill DBastien F The employee health care value survey: round one. Health Aff (Millwood). 1994;13 (4) 25- 41Google ScholarCrossref 3. Allen Jr HMRogers WH The consumer health plan value survey: round two. Health Aff (Millwood). 1997;16 (4) 156- 166Google ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Jan 21, 1998

References