When your doctor is examining your sore shoulder, who is looking over his shoulder?
In theory, in this age of "managed care," your insurance company should be. It has the smarts and the access to reams of pertinent data that it could use to take the measure of various doctors, clinics and hospitals, even providing customers with ratings and other data they could use to become more intelligent consumers of health care services.
After all, as stand-up philosopher George Carlin has observed, "Somewhere out there is the world's worst doctor. And someone has an appointment to see him tomorrow."
But who oversees the overseers? Who is it who might take care that, in assigning ratings to doctors, even placing some underachievers on a naughty list that would discourage you from visiting them, the insurance company is looking out for your best interests -- and not just its own?
Fortunately, and with astonishing speed, that job has been filled by New York Attorney General Andrew M. Cuomo. After the new AG broke from the gate with his efforts to clean up the unseemly back-scratching in the college loan game, this news offers still more reassurance that at least one elected official seems downright obsessed with helping real people navigate complicated and expensive territory.
Correctly worried that insurance companies could well be tempted to use the wrong criteria for picking the best doctors, Cuomo recently stepped into the matter by putting some of the state's -- and the nation's -- larger health insurance firms on notice that he was watching them.
It didn't take long before Cigna HealthCare, followed by Aetna, United Healthcare and GHI/HIP, agreed to use Cuomo's model health care ranking system to rank doctors and other health care providers, not just in New York but nationally. Empire Blue Cross Blue Shield, which hadn't even rolled out its ranking system, has agreed to follow Cuomo's guidelines when it does. The Health Insurance Plan of Greater New York, as well as MVP Health Care of Schenectady and its Rochester affiliate, Preferred Care, also have signed on.
The most important part of the new rules, as is often the case with health care, is transparency. Insurance companies have to document what criteria they are using to sort the doctors from top to bottom, and at least some of it must be the kinds of things that deal with the quality of care, as established by existing national standards.
This will go a long way to ensure that the insurers don't reserve their highest rankings for the doctors who send the lowest bills, those who don't order the tests that should be ordered, who don't refer to specialists when special care is proper, who prescribe the generic medication in those cases where the name brand would clearly be better. It moves toward giving the best rankings to the doctors who give the best care.
Cuomo's mantra goes beyond even that, though. His proclaimed formula is one of targeting problems that affect real people in real time, acting to correct them -- and providing real solutions, backed if need be by legislation. To that end, it was good to see State Legislature leaders Monday pledging to pass a law based on Cuomo's model code, which also has been supported by doctor and consumer groups.
It would be wonderful indeed if the oversight of health care by health insurers actually ensured a higher quality of care, not just a lower cost. It could happen. But, unless there is the kind of diagnosis that Cuomo is demanding, it will be a lot less likely.