BCBST Rolls Out Quality and Cost Transparency Initiative

SHARON H. FITZGERALD

BCBST Rolls Out Quality and Cost Transparency Initiative

Yarnell Beatty, TMA general counsel

BlueCross BlueShield of Tennessee is set to make available this month to its commercial members quality and cost information on nearly 4,000 Tennessee physicians. The giant insurer originally planned to unveil the transparency initiative on April 1, but outcries from physicians and advocacy groups such as the Tennessee Medical Association and the Tennessee Medical Group Management Association prompted BlueCross to make some changes before the program was finalized.

"We are doing this to meet consumer and employer demand, but we hope that at the end of the day this program will lead to new conversations between patient and doctor as well as BlueCross and the provider community," said Scott Neal Wilson, BlueCross public affairs manager. "Anyone who is paying attention to the healthcare landscape can see that quality and cost transparency programs are where the industry is moving." Wilson said BlueCross' large group employers in particular were demanding access for their employees to physician data "and we had to respond."
Available online to BlueCross' commercially insured members, the data is based on eight HEDIS (Healthcare Effectiveness Data and Information Set) quality indicators and whether basic screening tests were administered by doctors. The eight measures are:

Chlamydia screening for women,

colorectal cancer screening,

mammography screening,

cervical cancer screening,

glycosylated hemoglobin (HBAIC) test for diabetes,

LDL monitoring for diabetes,

monitoring for diabetic nephropathy and

diabetic retinal exam.

Because these tests wouldn't be administered by all physicians, only about 4,000 of the 13,000 physicians in the BlueCross network are affected. Those physicians had 45 days, from July 15 to Aug. 29, to review the information about them before it was finalized. Physicians were invited to log on to a secure section of the BlueCross Web site to compare the insurer's information, based on claims data, with each patient's medical record. They then had the option to update the data.

Yarnell Beatty, TMA general counsel, noted that this responsibility for physicians to check the data's accuracy "is extremely time-consuming, and I think it's important to remember that BlueCross is not the only health plan that is doing ranking and tiering schemes." Thus, physicians may be called on to verify medical information on a variety of patients for several insurers. "One of our macro issues with the whole deal of ranking and tiering schemes is that the benefit goes to the health plan, but the onus of the work is on the physician to make sure that the data is correct," he said.

TMGMA President Steve Dickens echoed Beatty's concern, saying that physician verification of the data is "a pretty laborious process … that puts the onus on the physicians to say that what BlueCross has done is correct. Somehow that doesn't seem quite right."

Wilson acknowledged that checking the information will take time, yet he noted that it's only a once-a-year commitment. He added, "It isn't as though the entire panoply of possible diagnoses are what we're talking about. There are only eight. … We acknowledge that for quality to happen, it's going to take effort. I wish there was another way, but until there is, this is what we've come up with because we can't do nothing."

When physicians and advocacy groups earlier in the year pushed for a delay of the transparency program, they complained about "errors" in the data. Wilson said he believes the word "discrepancies" better characterizes the problem – discrepancies between the claims data and the medical record. "That's why we have the ability for them (physicians) to self-report," he said. "The self-report is the tool for them to make, as much as possible, our records and their records mesh so that these quality ratings are accurate."

After BlueCross delayed the rollout of the transparency initiative until this month, the insurer set up a Physician Advisory Panel to recommend doctor-friendly changes to the program and its processes. "Their input was very valuable," Wilson said. One of the panel's recommendations that BlueCross embraced was reporting costs by episodes rather than procedure costs. "The physicians felt very strongly that a much more useful and better picture would be to show the whole episode of care. That's a change that absolutely made sense and we're happy to make," he said.

Other changes included: removing all members for whom BlueCross is a secondary payer, requiring at least 30 patient records in order to report a measure, excluding hospitalists, emergency room physicians, radiologists, pathologists and anesthesiologists and adopting language for the consumer site that acknowledges limitations with the claims data and encourages interaction with physicians.

In addition, BlueCross has endorsed the Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs. The Patient Charter is national set of standards introduced earlier this year by the Consumer-Purchaser Disclosure Project, funded by the Robert Wood Johnson Foundation to improve healthcare and aid consumer choice. Wilson said BlueCross also plans to seek certification from the National Committee for Quality Assurance, a nonprofit organization that accredits and certifies a variety of healthcare organizations and providers.

What BlueCross' 1.9 million commercial members will see on the insurer's Web site this month is just the beginning of transparency efforts. "I want to stress that this program is a first step. This is by no means the perfect program, and we already are thinking about phase two," Wilson said. He speculated that including government members might be a next step.

Dickens had another idea. "I appreciate BlueCross' stance, and I do think that they have moved forward from where they were a year ago and from this spring. What I would really like to see them do is to put resources toward some sort of uniform method of gathering the clinical information, and we're happy to work with them," he said. He suggested that "true data collection" might mean BlueCross representatives in physician offices to gather the data or introduction of "some sort of data repository where clinical information is gathered as opposed to claims information."
Beatty was succinct when asked what the next step should be. "Phase two for all health plans should be making this process easier for physicians," he said.