The agreement, which was revealed last week, came three months after Cuomo launched an investigation into health insurers' doctor ranking programs, concerned that the programs might steer members to physicians based on price rather than quality.

Under the agreement, Bloomfield, Connecticut-based Cigna will ensure that its rankings include established national standards to measure quality in addition to cost, and to disclose to consumers and physicians how the rankings are determined, breaking them down by cost, quality and when a combined score is given, what proportion is based on cost vs. quality. The insurer also agreed to submit to outside oversight (see terms of the agreement below).

Although a deadline for publishing the new doctor rankings was not set, Cigna officials said they expect to have something available by early 2009. In the meantime, current rankings, which Cigna asserts "always included both quality and cost" factors, will continue to be made available to plan members until the new rankings become available, a spokeswoman says.

The new ranking system will apply to the 12,247 New York doctors in Cigna Care Network, a so-called high-performance network that is also available in 27 other states.

Although Cigna officials did not say whether the new ranking system would be applied in those other states, Dr. Jeffrey Kang, senior VP and chief medical officer for Cigna Healthcare, says the insurer is continuing to work with the attorney general's office to establish "a national model for the entire health insurance industry."

The agreement was reached with input from the Medical Society of the State of New York; the American Medical Assn.; and the Consumer-Purchaser Disclosure Project, a group of consumer, labor and employer organizations, including the National Business Group on Health.

The ranking programs investigated by Cuomo's office over the past several months, in some cases, lower or waive co-payments and/or deductibles for plan members who use the providers they have identified as being more cost-effective or higher quality.

"Our members believe that quality trumps cost and that good quality is more cost-effective," says Susan Pisano, vice president of strategic communications at America's Health Insurance Plans, a Washington-based insurance industry trade organization, of which Cigna is a member.

Employers also have been supportive of the high-performance networks because lower premiums are generally charged for plan members who use them.

In addition to Cigna, as part of the investigation, Cuomo's office sent letters to Aetna Inc., UnitedHealth Group Inc., Empire Blue Cross Blue Shield and several other insurers that use physician ranking.

The letter to UnitedHealth prompted the Minnetonka, Minn.-based insurer to hold off implementation of its UnitedHealth Premium Designation in New York until the fourth quarter of 2007. The program is available in 94 other markets across the country.

Although the agreement reached with Cigna does not apply to any of the other insurers being investigated, the attorney general's office is continuing to negotiate with them with the intention of using the agreement as a template,  Cuomo said when he announced the agreement last week.

"This rating system could serve as a model for the nation—and for other companies," he says.

Also during the October 29 announcement, Charles Bell, program director for Consumers Union based in Yonkers, New York, says that the agreement "brings the process for evaluating doctors squarely into the sunlight."

And Dr. Nancy Nielsen, president-elect of the Chicago-based American Medical Assn., says the agreement was "a balanced approach that acknowledges physician ratings have a risk of error and should not be the sole basis for selecting a physician."

She adds that "the AMA expects this agreement will influence other states to implement careful and independent oversight and evaluation of physician performance measurement projects to assess their integrity and fairness."

"If the goal is really to improve the care and help patients make informed choices, then we're all for it. If it's done in a fair, accurate and transparent way," Nielsen says.

The other insurers under investigation also commented positively on Cigna's agreement and said it was consistent with their physician ranking programs.

"The principles of our Premium Designation program are also at the core of this agreement," says a spokesman from UnitedHealth.

"The outline of the New York attorney general's agreement with Cigna appears consistent with the general principles of Empire's transparency efforts," says a spokeswoman for Empire Blue Cross Blue Shield.

"We welcome working with the New York Attorney General on a similar agreement and to sharing details of our program with a nationally recognized external entity to help make these physician ranking programs the best they can be for consumers," a spokeswoman for Aetna says.

"The guidelines aren't far from what many of the plans were already doing," says Laurel Pickering, executive director of the New York Business Coalition on Health. However, she acknowledges that "the process may not have been transparent, which is definitely what we need."

She also says that the coalition's employer members are relieved that an agreement was reached.

"We were concerned that these programs might be in jeopardy," she says. "We're guessing that others are going to follow suit. So it's good all around."

"It's new and I think that there are going to be bumps," said Susan Pisano of America's Health Insurance Plans. "The business community and consumer community have been advocating for there to be information for consumers, and my sense is that they have wanted to make sure we are moving ahead in this area, but we can't wait for the perfect system. Don't let the perfect be the enemy of the good."

Terms of the Agreement (click to return to the top of the story)

Under an agreement with the New York attorney general's office, Cigna Healthcare will:

● Ensure that doctor rankings are not based solely on cost and clearly identify the degree to which any ranking is based on cost.

● Use generally accepted national standards to measure quality, including measures endorsed by the National Quality Forum.

● Employ several measures to foster more accurate physician comparisons, including risk adjustment and valid sampling.

● Disclose to consumers how the program is designed and how doctors are ranked, and provide a process to register complaints about the system.

● Disclose to physicians how rankings are designed and provide a process to appeal incorrect ratings.

● Nominate and pay for a ratings examiner—subject to the approval of the attorney general—to oversee compliance with all aspects of the new ranking model and report to the attorney general's office every six months. The ratings examiner must be an independent "national standard-setting organization" and a 501(c)(3) nonprofit organization.

Filed by Joanne Wojcik of Business Insurance, a sister publication of Workforce Management. To comment, e-mail editors@workforce.com.