The AMA has developed various resources and tools to aid physicians and their practice staff in developing strategies for influencing payers to make policies fair and clinically appropriate.
Find tools and resources on:
Physician Profiling
Bridges to Excellence
Prometheus payment methodology
Tiered and Narrow Networks
Efficency measurements
Patient Registries
Pay for Performance
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CME Video for Physicians: "Understanding Episodes of Care"
Visit the North Carolina Medical Society Web site to view the above video produced by the Physicians Advocacy Institute, Inc. that could earn you CME credit.
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AMA analyses of health insurers' physician profiling programs
The AMA has recently studied CIGNA's "CIGNA Care Network" program and the Centers for Medicare & Medicaid Services "Physician Quality Reporting Initiative" in great detail and had discussions with physicians practicing in these programs. From these discussions, as well as from extensive research of public information, the AMA has constructed charts that analyze how components of the below five programs compare with the five AMA Principles for Pay for Performance Programs. Each of the four charts of programs in the private sector has been reviewed by the respective insurer.
The charts are presented so that physicians can effectively analyze and identify problems and positive practices for each program. It is anticipated that this type of comparison can be used by individual physicians and physician practices in their managed care contracting activities and by AMA and the Federation to influence change in the design of programs utilizing physician profiling. It is anticipated that additional analyses/reports of other major physician profiling programs will be prepared in the future.
CIGNA Care Designation program (CCD) (PDF, 165KB)
CMS Physician Quality Reporting program (PQRI) (PDF, 82KB)
UnitedHealthcare's "Premium Designation" program (PDF, 103KB)
Wellmark's "Incent and Reward Best Practices" program (PDF, 101KB)
Aetna’s “Aexcel” program (PDF, 113KB)
Physician Profiling: How to prepare your practice (PDF, 72KB)
This flyer created by Physician Practice Advocacy, is the companion to the first physician profiling flyer, How to Challenge Your 'Profile' or Placement in a Tiered or Narrow Network, and offers five steps for physician practices to follow to prepare for insurers' profiling programs. These steps encompass the basic elements of the physician profiling process, i.e., contract language, program metrics, data, coding, and patient education.
Had It with Unfair/Inaccurate Physician Profiling and Ratings?
Pay for Performance (PFP) and other programs using physician profiling can be a plus when they promote effective, safe healthcare and adhere to the AMA’s Principles and Guidelines for PFP. Unfortunately, many programs are poorly constructed and often focus primarily on finding ways to save money – not to improve care. The AMA, in conjunction with the Kentucky Medical Association and several other medical societies, created cobranded posters pointing out the truth about many of these poorly constructed programs. The AMA now has a version of this poster that is available free to all AMA members for patient display and education.
See a copy of the poster 
(PDF, 119KB).
Order your free poster now.
Bridges to Excellence Overview
(PDF, 38KB) Four years ago, large employers and others launched the Bridges to Excellence (BTE) effort to incentivize physicians to adopt better care processes to improve the health outcomes for chronically ill patients and decrease health care costs. Now, a growing number of health insurers are licensed to offer the BTE programs in their markets. This report provides AMA members with information on the components of BTE, offers some participating physician observations and summarizes a cost analysis of their diabetes program. Please relay questions or comments to Steve Ellwing at 312-464-4367 or steve.ellwing@ama-assn.org.
A Snapshot of the PROMETHEUS Health Care Payment System
(PDF, 17KB) There is a growing school of thought among many health care experts that our current payment system is in need of a complete makeover. Many of these prominent leaders from governmental agencies, health plans, health systems, large employer groups and coalitions, health care consulting groups, and physician organizations have collectively designed a new proposed healthcare payment model dubbed PROMETHEUS. Although exceedingly complex in design, this model bears watching due to the stature and expertise of its designers. this one page document provides a basic description of PROMETHEUS, plus a link to the actual 60 page proposal.
Tiered and narrow physician networks
(PDF, 206KB) Are you concerned that your patients will no longer have access to your care because health plans have placed you in their high-cost tiers? Learn how health plans and other payers are profiling you by applying analytical software programs to their claim data. This booklet explains the episode grouper process that insurers use to profile physicians for network replacement and provides a sampling of some tiered and narrow networks that are currently in operation.
How to Challenge Your 'Profile' or Placement in a Tiered or Narrow Network (PDF, 115KB), created by Physician Practice Advocacy, offers physicians seven steps to follow when challenging their network placement with insurers. These steps mirror the problems physicians have identified with these types of programs, i.e., the use of claims data, inadequate risk adjustment, lack of an appeal mechanism and invalid ratings.
Economic Profiling of Physicians: What is it? How is it Done? What are the issues?
(PDF, 118KB) Economic Profiling of Physicians: What is it?
(PDF, 21KB)An increasing number of health plans use cost-of-care data from claim databases to profile physicians for network selection. Report cards, containing these profile results, are posted on health plan Web sites in an effort to incentivize patients to seek care from the lowest-cost physicians. As an expert consultant to the AMA, J. William Thomas, PhD, has written a ten-page paper explaining in detail the process health plans use to profile physicians on cost. For those who prefer brevity, and abbreviated version is also available.
Patient registries: Optimizing outcomes and pay for performance: Can patient registries help?
(PDF, 42KB) Patient registries assist physicians in identifying and managing the health of their patients with chronic diseases. They are also increasingly being used by practices to facilitate and improve their quality of care and as a means to participate in and/or check on the validity of their results for pay for performance programs. This resource discusses the pros and cons of implementing these registry systems.
Pay for performance: A Physician's Guide to Evaluating Incentive Plans
(PDF, 42KB) contains a series of questions and observations that can be useful in looking at common properties of pay for performance and other physician incentive programs. Physicians are encouraged to use this information to evaluate such programs for their potential to improve health care quality and ability to operate in an ethical and fair manner. AMA Principles and Guidelines for PFP
At its June 2005 Annual Meeting, The AMA House of Delegates amended and approved the AMA Principles (PDF, 48KB) and Guidelines (PDF, 65KB) for the formation and implementation of pay-for-performance programs.
As the pay-for-performance concept becomes more commonplace, the physician community will work to ensure pay-for-performance programs are positively structured and appropriately applied. The AMA believes pay-for-performance programs must be aligned with the following five principles:
• Ensure quality of care
• Foster the relationship between patient and physician
• Offer voluntary physician participation
• Use accurate data and fair reporting
• Provide fair and equitable program incentives
Physician Pay For Performance Initiatives
(PDF, 610KB), developed by AMA staff, takes a dispassionate but critical look at these programs and asks a series of questions about the potential impact that program components can have on patients and physicians. This piece is intended to be informational and does not reflect the official position of the AMA in regards to PFP.Physician profiling poster #NC424607 order form
Disease management
The AMA has recently updated its DM educational documents to help physicians understand the evolving disease management industry.Content provided by: Private Sector Advocacy