CMA is urging United Healthcare to delay implementation of its "Premium Designation" program in California for a minimum of six months to allow time for the insurer to address some serious deficiencies with the program. United plans to implement the program in California this June based on a historical review of claims data from 2011 and 2012.  Physicians in 26 different specialties will receive their initial Premium Designation reports in June 2014, and their designation will be marketed immediately thereafter to employer groups and health plan members.

The program, which has already been rolled out in 41 states, uses clinical information from health care claims to evaluate physicians against various quality and cost-efficiency benchmarks. The evaluation for quality will compare a physician’s observed practice to the United Healthcare national rate among other physicians of the same specialty who are responsible for the same type of services. Evaluation for cost efficiency will compare a physician’s costs to the risk-adjusted costs of his/her peers in the same specialty and market. The combined results will determine a physician’s designation result.

Physicians achieving United’s criteria for quality and cost thresholds will receive a "Premium Designation" on their physician profile, marketed to United enrollees through resources on the United online physician directory. In addition, employers may choose to offer health benefit programs (e.g., reduced cost-sharing or tiered benefit programs) that provide benefit incentives for enrollees to use only designated UnitedHealth Premium physicians.

CMA recently sent a letter to United expressing concerns with the program and urging the health plan to delay implementation, raising the following issues:

·         CMA believes that the program as currently planned will only lead to confusion among patients and physicians, and fails to achieve the central goal of improving quality and cost-effectiveness.

·         CMA is concerned that the designation is based on data that is more than a year old, and that physicians will not have the ability to alter their designation until 2015.

·         CMA is urging United to utilize the initial report as an educational tool to inform physicians of their historical practice patterns and as a basis for evaluating improvements in quality and cost prospectively.  

·         CMA is urging United to provide an effective appeal mechanism for physicians who identify errors in the data, have been grouped incorrectly by specialty, or who have a high rate of patient non-compliance. CMA is requesting that the appeals process afford physicians the ability to discuss their concerns with a medical director of the same or similar specialty and that physicians have a minimum of 60 days to appeal rather than the 30 days proposed by United.

Click here for CMA’s article that includes a list of impacted specialties, and links to the United's webpage and FAQ article on this program.