Locking Horns

SHARON H. FITZGERALD

Locking Horns

BlueCross Launches Transparency Ratings Amid Provider Concerns

As BlueCross BlueShield of Tennessee's quality and cost information on physicians was revealed online last month, the giant insurer and many doctors and administrators in its network remained locked in a philosophical struggle over the transparency initiative's purpose and accuracy.

"BlueCross BlueShield is the 800-pound gorilla, and they basically can do what they want to," said Vernon Carrigan, MD, an internist and medical director of Premier Medical Group in Clarksville. "Our practice has thousands of patients. We don't have the manpower or the inclination to go in and make all those corrections, so we're not going to do it. Basically, I think the whole thing is worthless, and most of the other physicians in the state do, too."

On the flip side, Scott Neal Wilson, BCBST public affairs manager, said the insurer is striving to meet transparency demands that are, in particular, coming from its large group employers, and that the ratings unveiled Sept. 15 are only "a first step. … We're already working on Phase 2. That I can say definitively."

Taking a broader view, Wilson said, "I don't know why it's taken this long for cost and quality measures to be out there. It's kind of ludicrous when you think about it. … Whatever has gotten us to this place — and, let's face it, it's healthcare costs — it's still good that people know these things. All this is, is another tool."

Using Claims Data


Physicians and administrators interviewed expressed the most concern over the quality information now posted on the BCBST Web site and available to its commercial members. Based on claims data, the information is purported to gauge physician compliance with eight "quality indicators." Those indicators are screening tests certain patients should receive and are included in the National Committee for Quality Assurance's list of HEDIS (Healthcare Effectiveness Data and Information Set) measures. The measures BlueCross uses 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.

Detractors of BlueCross' strategy say using only claims data to determine compliance is flawed and presents an incomplete picture of a physician's care and of the relationship the doctor has with the patient. Scott Whitby, MD, of East Wood Clinic in Paris gave this example: A woman passing through Paris on a weekend had recently undergone cosmetic surgery, and her stitches were bothering her. A physician at East Wood Clinic took a look and removed a stitch. Then she went on her way. "We got dinged on her because she hadn't had her pap smear. That is an actual case. I've got the chart," Whitby said.

On July 25, Whitby sent a certified letter to Mark Austin, BCBST senior vice president of network management, citing an 83.7 percent error rate in the information he and clinic staff had reviewed up to that point. "Investigating this data required five hours of physician time and four hours of staff time obtaining charts. This sample represents only 5.5 percent of the data concerning East Wood Clinic physicians on your Web site," the letter said. In an interview, Whitby added, "The burden on the primary-care network of doctors is enormous, and we can't defend ourselves on this." He called the process "a quagmire." Adding to the pressures are similar initiatives by CIGNA and United Healthcare, he notes, although these plans insure much smaller patient numbers.

BlueCross received Whitby's letter during the 45-day window that physicians were given to review the information that would be posted about them and submit changes based on medical-chart data. On Aug. 27, five BCBST executives, including Austin, visited East Wood Clinic to hear concerns and to gather suggestions which may be incorporated into the program in the future, Wilson said. In particular, Wilson said that BlueCross took to heart Whitby's concerns regarding urgent-care patients and will work to address that issue. "It sounds like to me there are some kinds of coding issues that will have to take place, and that's doable," he speculated.

Patient Compliance and Outcomes


Joey Peay, CEO of Murfreesboro Medical Clinic, said he sees "no reason" to spend time countering the BCBST data using the insurer's online feedback mechanism. "We're going to publish our own quality data to refute the data of BlueCross and any other payers that choose to do this. We're the ones that have the accurate data with the medical records," he said.

Peay believes a flaw with the BCBST strategy is that it fails to measure the care patients receive. "If the patients aren't controlling their diabetes, then where's the quality?" he asked. He and Whitby both expressed concerns, as well, that patient noncompliance will negatively impact physician scores, contending that it's not the physician's fault if a patient chooses not to have a test the physician orders.

Whitby predicted the result could be physicians who eventually sever ties with patients who don't follow the doctor's orders. That would especially be true, he said, if the quality measures are eventually tied to reimbursement. "I think when it comes to the bottom line, doctors will have to make difficult decisions on whether or not to continue seeing patients who really need them because it's going to hurt their quality scores and then, in turn, affect their income. I think that a realistic concern," he said.

What's an Insurer to Do?


Several people interviewed pointed to HealthSpring, a Nashville-based Medicare Advantage plan, as having a system better designed to determine physician quality. HealthSpring physically audits practices' charts.

While Peay acknowledged that a 100 percent audit of medical charts by BCBST probably isn't feasible, he said, "As a CPA and a former auditor, I also know that there are ways to structure a sample size to draw statistical conclusions as opposed to using bad data to begin with to publish something that the public may not understand."

Peay, Whitby and Carrigan all questioned whether the BCBST transparency initiative made available to nearly 2 million Tennesseans last month really answers the demand made by the large employer groups. Peay said he has actually talked about this subject with Nissan North America executives, whose business certainly doesn't resemble healthcare. "They have their expected error rates, their tolerances, and they can measure those types of things down to the nth degree and be able to judge their quality. It's much more difficult to apply that same type of measurement to health," he said. Those auto executives were "kind of amazed that we don't have in the health realm those types of measurements," he said. "Is that a failing in our industry? Possibly."

Yarnell Beatty, general counsel for the Tennessee Medical Association, said BCBST is "putting the cart before the horse. I don't think you can capture all the necessary data with respect to procedures, with respect to outcomes, with respect to true costs until everyone is speaking the same language … and that is electronic health records that are portable, and every health plan has the ability to read those." That won't happen until EMR systems are affordable for practices, he noted, adding, "The plans should be more concerned about assisting in the implementation of electronic health records, and then going to a system of rating and tiering as opposed to doing it now, and they may or may not have accurate information out there."

Meanwhile, Christopher Garrett, communications director for the state Division of Commerce and Insurance, said, "The state is monitoring the matter very closely. And, by 'the matter,' I mean transparency programs as a whole."