Economic profiling can have effects on ophthalmic practice


Insurers are funneling patients to providers based on cost and quality data that may not always be accurate, said Ruth D. Williams, MD.

San Francisco-Insurers are funneling patients to providers based on cost and quality data that may not always be accurate, said Ruth D. Williams, MD.

Dr. Williams, president of the Wheaton Eye Clinic, Wheaton, IL, described this problem in economic profiling at the Glaucoma 360 CME Symposium.

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Insurers are trying to use statistical methods to shift patients to lower-cost, higher-quality providers, she said.

The insurers use grouper software, cost data, and patient satisfaction data to rank providers in tiers, but rarely more sophisticated measures of quality, she added.

Watch as Ruth Williams, MD, provides details behind economic profiling and its effects on the ophthalmic practice.

“The methodology is opaque,” she said. “When there is not sufficient quality data available, they use cost data.”

The insurers charge higher co-payments for providers in lower tiers. In general, existing patients do not change providers because of these rankings, Dr. Williams said.

“However, if it’s a new patient, and they’re trying to figure out who to go see, they’re going to pick the patient who has the lowest co-pay,” she said.

Next: Tiering system explained


She used the example of UnitedHealthcare because its website makes a lot of information available on the practice. However, the Wheaton Eye Clinic had similar experiences with other insurers.

The company sorts physicians into tiers depending on the quality of care they provide and the cost of that care.

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The Wheaton Eye Clinic physicians recently learned they were not in UnitedHealthcare’s top tier.

“We each got a letter, and if you read the letter it said we did not meet ‘cost and quality designation,’” Dr. Williams said. “We pushed back.”

The clinic filed an appeal using the process outlined in the letter, and the insurer changed the status of all but three physicians to “not enough data to assess.” As a result, UnitedHealthcare now only charges a co-payment differential for only these three physicians.

All three physicians whose statuses weren’t changed were comprehensive ophthalmologists doing glaucoma.

“You can get tiered more extensively if you are taking care of patients who have glaucoma, or macular degeneration, or things that require more resources than a comprehensive exam,” she said.

Next: Six lessons you need to know


Dr. Williams listed six lessons:

  • Open your mail. Sometimes notifications from insurers look like junk mail, and are easy to overlook.

  • Appeal. The Wheaton Eye Clinic found the appeal process worthwhile, not only for UnitedHealthcare but for other insurers.

  • Request transparency about methodology.

  • Get to know a person on the payer side.

  • Develop your own quality data. Having your own data strengthens your argument about how you should be classified.

  • Use the American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS). This eye disease clinical registry can help provide evidence of your quality of care.

Economic profiling is a discouraging development, but ophthalmologists are adaptable and can learn to cope with it, Dr. Williams said.

“We have to figure out how to do this and I’m positive we can,” she said.


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