The Hindu Business Line : Rating doctors: A win-win for patients, insurance cos

Rating doctors is a sensitive issue. But in the long run it will benefit patients by helping them choose the doctor, treatment method and hospital. It will also enable hospitals and insurance companies offer customised solutions.

Vikram Venkateswaran

Imagine a scenario in which you could choose a doctor of your choice based on his track record, not purely on the basis of reference from your family and friends but from well documented past history of the surgeries performed by the doctor, the outcomes and the prognosis of the patients.

Just think how it would change the way we made our decisions with regards to hospitals. These are the not scenes from some Robin Cook fiction but the new offerings from health insurance companies in the US. Physician or doctor ratings are the next paradigm shift in healthcare and this would enable these insurance companies to provide customised health plans for individuals.

There is a move in the entire healthcare industry to move from plan-centric offerings to member-centric offerings. A member-centric offering allows individuals to choose a physician they want to consult and the care-provider (hospital) they want to visit, based on the severity of their ailments, and the track record of the hospital and physician in dealing with such ailments. A health insurance plan can be chosen accordingly.

Advantage Health Insurance Plans

The US healthcare payers’ market (comprising insurance companies, managed care organisations, self-insured employers, health plans and health maintenance organisations) has undergone consolidation in the last 10 years. From 31 players in 1993 now there are only nine indicating a high degree of mergers and acquisitions in this space.

Traditionally payers have looked at memberships as a benchmark rather than the premium per member. But that is all changing now. Payers would benchmark their growth as the number of new members that have subscribed to their plan rather than the revenue the plan is generating per member. Often in the hurry to add new members certain critical aspects regarding the patient’s health are overlooked, which later affect the profitability of the plan. This also leads to cases of fraud.

In order for the plan to generate profits the average revenue per member is going to be the new benchmark. Plans are increasingly focusing on premium per member rather than the total members.

In such a scenario the plans have to be more customised and offer value-adds such as giving the member the convenience of choosing the hospital and the physician he/she wants.

Physician ratings would go a long way in helping members and insurance companies to come up with such offerings.

Physician Ratings

References are the only way physicians are rated these days. References are provided by our families and friends based on their experience with that hospital/physician. These are time-tested yet highly unscientific methods, as there is no way of knowing if two similar cases being treated by the same physician would end up with similar results. Though the results cannot be determined the probability of getting a favourable result can be ascertained with the help of data analytics.

Physician ratings would require the past data of the physician or surgeon to be entered into a repository.

Once the data has been archived, business intelligence tools can be used to generate patterns and analysis of these patterns would give us results, not only for the physicians but also for the hospital where the surgery was conducted.

This could evolve into the first scientific referral system in India, where physicians could be rated based on such criteria as:

(i) Time taken for the patient to resume a normal functional life for his age;

(ii) The extent to which normal functionality has been restored;

(iii) The time before the patient has to go in for further surgery or any other major treatment.

Resistance

Historically healthcare remains a final frontier whether it is adoption of new processes or new technology. The reasons for that have been two-fold — one, this is a heavily regulated industry with legal implications at every step, and two, because neither doctors nor healthcare administrators have been enthusiastic in incorporating changes due to the sheer complexity of diagnosis. They have also been risk-averse.

Any decision to rate physicians and doctors would be unwelcome from the medical fraternity as this would involve trying to document the process of diagnosis and prognosis, which according to doctors would be unfair because the variables for treatment and recovery differ from case to case.

For instance, the outcome of the treatment would depend on factors such as:

(i) Skill of the physician;

(ii) Overall general health of the patient;

(iii) Patient’s response to the treatment, depending on his genetic make-up;

(iv) Prognosis would depend on the post-operative care by the provider and mostly the individual himself.

Though physicians may not respond favourably to ratings, hospitals may actually benefit from them.

The providers, just like any other business, would like to utilise their resources effectively, not only to sustain themselves but also to ensure that the patients get the best care possible. Hospitals can use ratings to ascertain in which therapeutic areas they can best utilise their resources and they can focus on these.

They could also recruit the best doctors in those areas and also decide if the physicians already working for the hospital actually deserve their high billing, and vice-versa.

Similarly, doctors can decide if the surgeries they performed at a particular hospital have had better prognosis than the ones they performed elsewhere and, hence, schedule more surgeries at that hospital.

Customer is King

The biggest beneficiary of physician ratings would undoubtedly be the customer (patient). Instead of being fixed to a hospital, he can choose a plan that provides access to the best hospital for a particular ailment he is predisposed to.

Such a decision can be made based on his general health check-up before he signs up for a plan, family history and habits. For instance, if an individual is more predisposed to cardiac problems, he may choose hospitals such as the Manipal Hospital for Cardiac Diseases.

Implications for India

India has remained relatively unaffected by the health insurance market, but not any more. More and more plans are making inroads into the Indian health insurance space. Given this scenario, adopting physician ratings would greatly benefit individuals signing up for insurance plans.

(The author, who was a practising dentist for seven years, is Senior Business Consultant, Healthcare Payer Business Development, Covansys, a CSC Group company.)

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