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Health Care Reform:

Health Insurance & Affordable Care Act

HMOs Not Reporting on Questionable Doctors.


The first is that the economic demands of the health marketplace have led HMOs to "devote little attention to clinical oversight," focusing on keeping prices down rather than devoting resources to costly monitoring systems. Health plans may also believe that kicking out doctors can hurt them competitively, because it would cut down on the choice they can offer their enrollees.

The second reason, the report says, is that HMOs rely on quality monitoring from other entities -- hospitals, physician practice groups, and state licensure boards.

A spokesperson for the National Committee for Quality Assurance, a national group that accredits HMOs based on their performance on various clinical quality measures, said that its executives were traveling and could not comment on the OIG report.

Susan Pisano, spokeswoman for the American Association of Health Plans, tells WebMD that plans are not reporting because they thought they were only supposed to make their reports to state medical boards. "Health plans take their reporting obligations very seriously," she says. "They have understood that their responsibility is to report to states. The original regulations relating to the data bank tell plans to report to the state licensing boards, and that the boards will in turn report to the practitioner data bank."

Others buy more into the economic argument. Jeff Stoddard, MD, a physician researcher with the Center for Studying Health System Change, tells WebMD: "Managed care organizations have neither the resources nor the motivation to really identify or take action against practitioners who are performing poorly. The state medical boards have a hard enough time doing it."

Stoddard also says that plans would pay a "political" cost with their doctors, if they aggressively monitored competence and reported disciplinary actions. "You've already seen relations reach all-time lows in the last few years," he says. "I can't think of many ways in which a managed care organization could jeopardize itself more with its providers than to get heavy-handed in this kind of realm."

Pisano tells WebMD that health plans do prefer a lighter touch with their doctors. She says, "Plans aim to do, when they need to, a short-term intervention that solves a small problem, rather than letting a small problem escalate to a big problem."

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