<img height="1" width="1" style="display:none;" alt="" src="https://dc.ads.linkedin.com/collect/?pid=118459&amp;fmt=gif">
Show all

How Physician Quality Data Impacts Your Health Plan Costs

how physician quality data impacts your health plan costs

Rebecca was a married mother of two who enjoyed bike riding, boating, and spending time with family. Over the course of a few months, she began having migraine headaches and extreme fatigue. Her ability to function each day became difficult, forcing her to take a leave of absence from work. She was seeing several specialists but was frustrated that she wasn’t getting a proper diagnosis or appropriate treatment options. Despite taking several prescribed medications, Rebecca’s headaches and fatigue were getting worse, not better.

When employees lack the tools and transparency to find doctors best suited for their health condition, they may go from doctor to doctor seeking answers. They may choose doctors who, while highly skilled in one area, may not be well-suited for their particular condition. Or worse, employees may unknowingly choose physicians who have been sanctioned or have a history of poor outcomes. When this happens, claims increase, and so does your renewal.

Employees who connect with the highest quality physicians receive measurably better outcomes at lower costs compared to their lower quality peers. Here are some examples:


Colon Cancer Screenings

Colon cancer is the second deadliest form of cancer.1 Yet 28% of people have never received a screening.2 Patients who see top-rated primary care physicians are almost 15% more likely to receive a screening than those whose doctor is rated in the bottom half.3 Early detection of colon cancer can drastically alter the patient’s prognosis: five year survival rates are 9x higher if the cancer is detected early before it spreads to other organs.4



Opioids and barbiturates are commonly prescribed medications that offer short-term relief. However, they can actually lead to increased headache severity and frequency. This is called “medication-overuse” headache. 

The National Headache Foundation survey found that only 54% of primary care doctors were aware that barbiturates cause medication-overuse headaches.5 Further data shows that the bottom ranked (10%) doctors are prescribing these medications more frequently than their higher quality counterparts, who are more aware of the risks.6


Benzodiazepines (BZDs)

BZDs (Xanax & Valium) are prescribed to treat anxiety, sleep disorders, and mood-related disorders. Although they offer rapid symptomatic relief, they don’t reduce anxiety permanently and carry a substantial risk of addiction, falls and fractures, and motor vehicle accidents.7 Physicians whose quality rates are in the bottom 10% are prescribing BZDs to anxiety patients 3x more often than the top 10%.7

Inappropriate BZD use can also have a substantial impact on employees’ health insurance utilization. A recent study of primary care patients found that patients who received BZDs had 25% more primary care visits, 41% more specialist visits, 62% more emergency room visits, and 73% more hospitalizations.8


Genomic Testing

When faced with a breast cancer diagnosis, the patient’s selection of an oncologist can have a dramatic impact on the care they receive.9 One recent study found that only 27% of eligible breast cancer patients received genomic testing9 (which can identify which patients can safely forgo chemotherapy). Research suggests that genomic testing could help up to 40,000 American women with early-stage breast cancer avoid unnecessary chemotherapy.10


How can you connect employees to higher quality care?

Grand Rounds is an example of a new service that employers can offer alongside their health plan. These services provide employees with quality information, ratings, tools, and remote second opinions to help them choose the right physicians, so they can get the right treatment, at the right cost. Some may offer a return on investment (ROI) guarantee, so employers feel confident that their investment pays off when utilizing their services.

By leveraging clinical insights gleaned from billions of data points, Grand Rounds predicts which physicians are most likely to deliver appropriate care and best possible outcomes. To measure provider quality, they use both practice data (e.g. outcomes, process measures, procedural volumes, etc.) and biographical information (e.g. hospital affiliations, medical training, certification, etc.)

After months of seeing physicians who were unable to provide a clear diagnosis and treatment plan, Rebecca reached out to Grand Rounds. Contacting this service transformed her case and course of treatment. The Grand Rounds Care Team collected her medical records and their Staff Clinician reviewed her case to understand her symptoms as a whole. With the guidance of the physician-led care team and the proprietary algorithm, Grand Rounds was able to identify a high-quality specialist appropriate for her clinical situation for an expert opinion. She was able to use the service’s tools to communicate and share information with her doctors and family members.

Once Rebecca received a diagnosis of a hyperparathyroidism, Grand Rounds found a high-quality doctor in her area who could operate and treat her condition, who is both local and in-network. The care team made it easy for Rebecca, scheduled her appointments with the appropriate specialists and checked in with her on a regular basis. Now Rebecca is back to her active lifestyle of bike riding and enjoying time with her family.

Employers are turning to these types of health plan add-ons for a variety of reasons: to help optimize their existing carrier network for quality, to help employees find high-quality providers, to avoid unnecessary procedures and pharmaceutical spend from their employees, to mitigate high-cost claimants, and to provide peace-of-mind to employees and loved ones that they are getting the best care possible.

  • Read more about how physician scores drive down health insurance costs.
  • Learn more about realize a return on investment by addressing high-cost medical conditions with your employees.

For more information, contact your Employee Benefits Consultant.


1Common Cancer Types,” National Cancer Institute, https://www.cancer.gov/types/common-cancers

2Vital Signs: Colorectal Cancer Screening Test Use – United States, 2012,” Centers for Disease Control and Prevention, https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a4.htm

3The Importance of Colorectal Cancer Screening,” David E. Beck, MD, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307509/

4Freese, Nate. “Patients Seeing High-Quality PCPs Are More Likely to Receive Colon Cancer Screening” Web blog post. Grand Rounds, 17 October 2017. Web. 23 June 2018.

5NHF Survey – Migraine-Specific Medications vs. Nonspecific Medications for Acute Treatment,” HealthCentral, http://www.healthcentral.com/migraine/medications-39685-5_3.html, May 2007

6Freese, Name. “Low-Quality Doctors Prescribe Significantly More Addictive Medications for Headaches.” Web blog post. Grand Rounds, 3 October 2017. Web. 24 April 2018.

7Freese, Nate. “It Isn’t Just Opioids: Low-Quality Doctors Prescribe Far More Benzodiazepines, Too.” Web blog post. Grand Rounds, 14 November 2017. Web. 20 March 2018.

8 “Benzodiazepines are Prescribed More Frequently to Patients Already at Risk for Benzodiazepine-Related Adverse Events in Primary Care,” Journal of General Internal Medicine, https://link.springer.com/article/10.1007/s11606-016-3740-0, May 2016

9“Gene Tests Identify Breast Cancer Patients Who Can Skip Chemotherapy, Study Says,” New York Times, https://www.nytimes.com/2016/08/25/science/gene-tests-identify-breast-cancer-patients-who-can-skip-chemotherapy-study-says.html?_r=0, August 2016

10“Under-Utilization of Gene Expression Profiling for Early Stage Breast Cancer in California,” National Center for Biotechnology Information, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4871729/, April 2016

Webinar: Reducing Healthcare Costs Using the Power of Physician Quality Assessment Data

National Insurance Services is not a law firm and no opinion, suggestion, or recommendation of the firm or its employees shall constitute legal advice. Readers are advised to consult with their own attorney for a determination of their legal rights, responsibilities and liabilities, including the interpretation of any statute or regulation, or its application to the readers’ business activities.

5 Things to Review Before Changing Life or Disability Insurance Carriers
July 16, 2018
Hope for Wisconsin Cities Struggling with Unfunded Retiree Health Care Liabilities
July 16, 2018
Ken Zastrow

Ken Zastrow

Ken Zastrow enjoys establishing a strong rapport with his clients. He believes that education is key in helping them understand their benefit plans. Ken has a strong background in underwriting and post-employment benefits. As Employee Benefits Consultant at National Insurance Services, Ken is responsible for the overall assessment and management of all an employer’s benefit plans including claim reconciliation, policy changes, renewals, and medical and dental analytics. He is also well versed in compliance, benefit integration, and early retiree benefits. Ken is a licensed insurance agent (Health, Life, Series 6 and Series 63) as well as a registered financial representative with GWN Securities. He works with schools, cities, and counties in Wisconsin.