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Dr. David Maroney, BCBST

BlueCross BlueShield of Tennessee (BCBST) is giving its network physicians additional months to review information that the health plan intends to post on its Web site regarding doctors’ quality and prices. The decision is the result of backlash from physicians and advocacy organizations such as the Tennessee Medical Association, all concerned that the data might not adequately represent performance.

The Blue Cross tightrope walk is one being played out nationwide by third-party payers as employers and individuals demand more transparency. Recognizing that healthcare quality is variable and that inefficiency plagues the system, patients need reliable methods to choose their healthcare providers, consumer organizations contend.

Thus, Blue Cross, the state’s largest health insurer, decided last year to answer calls from its members for quality, performance and cost transparency, according to Dr. David Moroney, BCBST chief medical officer. On Jan. 30, the company notified its physicians by letter that cost and clinical quality information was online for their review and comment by March 3 before the information was made available to member employers and patients on April 1. What followed was a substantial hue and cry and a decision by BCBST to give doctors “a good deal of time. We’re not talking in terms of several weeks, but possibly in terms of several months,” Moroney said, for physicians to have input on the data gathered.

“BlueCross recognizes the concerns of physicians very well,” he said. “We understand how sensitive this issue is, and we have heard very clearly from medical groups in response to the information we shared with them in January. They’re concerned about the reputations of their individual physicians, they’re concerned about the patient-physician trust and that they maintain that trust. What they have said to us is that they understand why we’re doing this. They support efforts to recognize and reward better quality and better cost. What they want to ensure is that the comparative information that we put out is as accurate as it can be.”

Dr. F. Michael Minch, chairman of the TMA Board of Trustees, agrees. “A lot of people feel that physicians don’t want to have themselves measured, but that’s not really the case. It seems very reasonable to me and to most physicians. We get judged all the time. We had to go through all sorts of testing in order to get to be physicians. We’re not afraid of that. At every level, you had to prove yourself. But it’s important, to promote good medical practice, that the information that’s being given to the public is good information and really represents what the public needs to know.”

Moroney said BlueCross has originally focused on “well-established measures that most physicians are familiar with.” Thus, the company chose to compare eight HEDIS (Healthcare Effectiveness Data and Information Set) quality indicators associated with adult primary care: four tests related to diabetes including retinal examination, cervical cancer screening, Chlamydia screening for women, colorectal cancer screening and breast cancer mammography. In addition, board certification and maintenance of certification would be posted for all physicians. “What we want to do over time is to use both claims data and information like board certification and combine that with medical records information and other types of information provided by the physician practices,” Moroney said. “We very much see the need to work with physicians as partners in this effort.”

When it comes to cost information, BCBST initially proposed to present costs based on payments by procedural code. Moroney said currently the insurer is considering a more sophisticated method of presenting cost “by episode of care,” such as services provided by multiple providers during an asthma episode or acute myocardial infarction. He called this method “a better approach. We know from our experience that there’s a great deal of variability in cost consciousness among physicians.”

Blue Cross isn’t the only insurer that’s tackling the issue of transparency. In fact, UnitedHealthcare rolled out its Premium Designation Program for physicians in 20 pilot markets, including Nashville, in October 2005. By the end of 2006, all physicians in the network had received a ranking of 0, 1 or 2. Later this year, the plan will begin a pay-for-performance strategy. “So those physicians who achieve the highest ranking of two stars will be bonused by virtue of being moved to a fee schedule that is higher than the one they have today,” explained Larry Nall, UnitedHealthcare vice president of network management for Tennessee and Arkansas.

Dr. Richard Lachiver, the plan’s medical director for the two states, added that physician feedback has been “fairly positive. Physicians generally are not overwhelmed by being evaluated, but the way the program is structured, it tends to be as good as you’re probably going to get out there.” He said physicians in 21 specialties are evaluated using evidence-based standards and a physician peer-review panel meets weekly.

“You have to walk before you can run,” Nall added. “We’ve really spent the last two years firming up the designation, making sure all the physicians understood the rankings.” He said UnitedHealthcare has seen “a continual increase” in the number of physicians earning the two-star distinction, “causing better care and better outcomes and better quality.”

Minch said UnitedHealthcare’s approach has been “a little more collaborative. … “They really have moved towards the idea of evidence-based medicine. Evidence-based medicine is where we’re all going.”

Nonetheless, Minch added, “You’ve got to watch the motives. I guess that’s our whole message here — let’s figure out the best way to practice medicine, but let’s not make it about how you get it cheaper and how to maximize profits. … When the people who are publishing the data have a motive to save money, it’s kind of like the fox guarding the hen house.”



April 2008

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