MMS Applauds Court Decision on Tiering Program

WALTHAM — The Mass. Medical Society is applauding the decision of the Suffolk Superior Court in legal action filed by the MMS and five physicians against the Mass. Group Insurance Commission (GIC) and two health plans, allowing a lawsuit to proceed on two issues of physician defamation and consumer protection.

The case centers on the GIC’s Clinical Performance Improvement (CPI) initiative, a physician-ranking program implemented by the GIC in 2006 that places individual physicians in one of three tiers using various cost and quality measures. Patients are charged higher co-payment fees to be treated by physicians assigned to the lower tiers, or must try to change physicians to avoid higher co-payments.

The society has said that the program lacks a valid and accurate methodology to properly evaluate physicians and therefore harms physicians and misleads patients. The court’s decision responded to requests by the GIC and the health plans named in the suit to dismiss the lawsuit filed by the MMS and five physicians last year.

Noting that the medical society has legal standing to sue on behalf of its members, the court, while dismissing several counts in the complaint as a matter of law, allowed the two most important claims of defamation and consumer protection, which means the lawsuit can move ahead.

“This is a huge step forward for physicians and patients,” said Dr. Bruce Auerbach, MMS president. “Physicians have been unfairly evaluated, and patients have been misled by a seriously flawed system designed simply to control costs. The tiering program forces patients to pay more for their care and damages the physician-patient relationship and the hard-earned reputations of physicians. We are thrilled that the court has allowed the case to move ahead.”

Last May, the MMS and five physicians sued the GIC and Tufts Health Plans and Unicare, alleging that patients have been defrauded and harmed and physicians have been defamed by the GIC’s initiative. The filing asked the court to either stop the tiering program, or to require that the CPI adhere to specific standards, including transparency, fair notice, formal feedback, and correction processes; show meaningful physician involvement in the development of the CPI; demonstrate the program’s accuracy, validity, and reliability; and submit their programs to an independent oversight authority.

Dr. Auerbach said the MMS took legal action as a last resort after trying to work with the GIC for four years to fix alleged flaws in the system. He said the GIC refused to correct the CPI’s most glaring problem, which is its ranking of individual physicians using inaccurate, unreliable, and invalid tools and data.

“Even today,” said Auerbach, “with the program entering its fourth year, we are hearing complaints from physicians.”