The Inevitable Law Suit
While the Massachusetts Medical Society MMS) accepts both the principles of quality assurance and cost control, they argue that Clinical Performance Improvement (CPI), the GIC’s system for evaluating doctors is so bad that it defrauds doctors by giving them lower ratings than they deserve. How does that happen? The MMS alleges that the GIC tier system has rated doctors on medical procedures they have never done. More egregiously, some doctors were rated on patients they have never seen. One ophthalmologist, for example, was surprised to find he had treated a patient for epilepsy. The same doctor may also be ranked differently by different health plans bringing into question the validity of the ratings.
The law suit cites several instances of the GIC’s faulty rating system:
Dr. Joseph Adolph, of Marlborough, one of the plaintiffs, learned that a single high-cost radiotherapy session for a prostate cancer patient impacted his score because of faulty computer logic
Dr. Linda Buchwald, chief of neurology at Mount Auburn Hospital in Cambridge, treats multiple sclerosis patients. Her ranking did not take into account that many such patients have advanced conditions, whose are is often expensive.
Another physician went to the extraordinary time and trouble to get all his data from each plan and match it to all of his patient records. He found that 68 percent of the patients attributed to him were not his.
The court dismissed some claims against the GIC and its health insurers. It also allowed some claims to stand; these include defamation, interference with advantageous relations, breach of contract, and M.G.L. c93a. The MMS applauded the court’s decision.
I don’t know that the Massachusetts Medical Society’s lawsuit has any bearing on increasing the number of people entering the GIC’s programs. If, as the MMS alleges, the GIC’s rating system is indeed unjust, more patients will face higher copayments based on the faulty data of a faulty system. If the GIC and its insurers are held responsible for damages, it also may cost the state some money.
