Medical Economcis Feature - November 2009
Tex Med . 2009;105(11);41-44.
By Ken Ortolon
Nacogdoches obstetrician-gynecologist Charles A. Thompson, MD, was stunned in August when Blue Cross and Blue Shield of Texas (BCBSTX) terminated him from its physician network.
The termination was based on Dr. Thompson's failure to respond to two letters informing him that he ranked poorly compared with his peers in the network on evidence-based measures (EBMs) used to rate physicians as part of BCBSTX's BlueCompare program.
But Dr. Thompson says he never received the two letters from BCBSTX, and even the termination letter was sent to the wrong address. On top of that, when Dr. Thompson reviewed the patient charts upon which his poor rating was based, he found that he had been penalized because of faulty data.
"I got dinged for not doing Pap smears on women who had a hysterectomy, who had their cervix removed," Dr. Thompson said. "You can't develop cervical cancer if you don't have a cervix. You don't need a cervical Pap smear."
Dr. Thompson is among several physicians who recently complained to the Texas Medical Association about the accuracy of data BCBSTX uses in the EBMs evaluations. Those complaints, coupled with complaints from physicians deselected from the BCBSTX network as part of a separate recredentialing process, prompted TMA to invite officials from Blue Cross to discuss the issues with members of its Patient-Physician Advocacy Committee in September.
Following that meeting, however, committee members say it is clear that the claims data BCBSTX uses to evaluate physicians in its network are inadequate to produce true quality rankings. They also say that it is clear BCBSTX still ranks physicians based on cost.
"It seems they selectively remove the doctors who are costing them too much money," said J. Patrick Walker, MD, chair of the Patient-Physician Advocacy Committee.
But TMA officials say a new state law the association helped pass earlier this year may solve some of these issues. It requires all health plans that do quality rankings on physicians in their networks to give the physicians greater due process in appealing their rankings and more transparency in the measures and methodologies used to produce those rankings.
In 2009, BCBSTX ranked physicians in its network on 16 EBMs.
Allan J. Chernov, MD, BCBSTX medical director for health care quality and policy, says the measures are "heavily weighted" toward primary care.
In his presentation to the Patient-Physician Advocacy Committee, Dr. Chernov said BCBSTX sent letters to 218 physicians in the Blue Cross PPO and HMO networks earlier this year informing them their performance on the EBMs was "significantly below that of your specialty peers."
The letters asked the physicians to submit a written response including supporting patient documentation and/or an updated performance improvement plan. The letters also warned that failure to respond could lead to termination from the network.
Of the 218 physicians who received the letters, 24 did not respond and were terminated. Of those, 22 doctors subsequently did respond and their terminations were rescinded, including Dr. Thompson's, says Dr. Chernov.
He also says there seems to be some misunderstanding among physicians that BCBSTX is using the EBMs evaluations to deselect physicians from its network. That is not the case, says Dr. Chernov.
Instead, the termination letters are simply a means to get the attention of those physicians who fail to respond to the letters regarding their poor quality rankings.
"Our purpose was to engage in a dialogue and to work with physicians whose results would suggest there may be improvements in their practice around the particular service or care that was related to the measure," he said. "The expectation was that the physicians respond and either provide additional information or tell us what changes they are going to make in their practice to improve those results. As happens, certain practices don't respond for different reasons. A staff person may not have taken the letter seriously and may have thrown it away and not given it to the physician. Or it got put at the bottom of the pile because it was a low priority."
Dr. Chernov says physicians in the BCBSTX network are contractually obligated to cooperate with peer review activities.
While Dr. Chernov says the EBM evaluations are not meant to be punitive, Dr. Thompson is angry that his practice was jeopardized because of flawed data.
"This is a serious problem because Blue Cross is somewhere between 60 percent and 80 percent of my business," he said. "Nineteen of the top 20 employers in Nacogdoches County have Blue Cross. I'd have to close my doors if I'm terminated from Blue Cross. If I took a 60-percent or 70-percent pay cut, I couldn't survive. I don't think many people could."
And TMA officials say they still have serious concerns about the fact that the BCBSTX evaluations - and those of other health plans -continue to rely solely on claims data.
Dr. Walker served on a BCBSTX-TMA advisory committee that vetted the measures used under the BlueCompare program. While the measures may be valid, Dr. Walker says members of the advisory committee were uncomfortable with the use of claims data in the program.
"There was no question that all of the physicians on the committee felt it was very difficult to measure quality with billing data. As a matter of fact, it is probably impossible," he said.
Erin Gregorcyk, reimbursement specialist in TMA's Payment Advocacy Department, says TMA officials planned to meet with BCBSTX officials again in late October to dig deeper into problems with the health plan's claims data.
"We want to know why they keep using this claims data information when they hear over and over again that it's flawed," Ms. Gregorcyk said. "And it's an administrative burden on the physician's part to have to go through all their medical records to prove that."
Dr. Thompson says he had to review records of between 200 and 300 patients to show that his ranking was flawed.
But Dr. Chernov defends the use of claims data, saying a "confounder" such as how many women who have had hysterectomies might be in a physician's practice cuts across all practices in which physicians do pelvic examinations and Pap smears.
"Obviously it's not going to be exactly the same in every practice, but every physician faces that confounder," he said. "We are always looking for ways that we can account for that, but the available information is basically in the claims system. It would be incredibly costly for everyone to be doing this entirely by chart review."
Meanwhile, TMA officials hope the new law will force BCBSTX and other health plans to do a better job with the quality rankings. House Bill 1888 requires health plans beginning on Jan. 1, 2010, to provide physicians with the measures used in quality rankings before the evaluation period begins. It also requires the plans to provide a due process mechanism where physicians can discuss their rankings with health plan officials through either a teleconference or face-to-face meeting.
The law also requires that the measures and methodologies used be transparent and valid.
"What's happening right now is you've got circumstances where the methods being used on some of the physician rankings aren't valid because [they're] using bad data," said Lee Spangler, JD, TMA vice president of medical economics. "This new law places a duty on them to have good data for the rankings."
Dr. Chernov says BCBSTX has evaluated how its program stacks up against the new requirements. "We'll make any changes that are necessary," he said, "but we think for the most part, what we're doing is in compliance with the requirements of the law."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
TMA Efforts to Improve Rating Tool Pay Off
While the Texas Medical Association continues to have concerns about the evidence-based measures used by Blue Cross and Blue Shield of Texas (BCBSTX) to rank physician performance, the association has succeeded in getting the health plan to make a number of improvements in the program.
In 2008, BCBSTX announced that it would stop using the controversial Risk-Adjusted Cost Index (RACI) tool to rate physicians' performance in the BlueChoice Solutions program after a TMA ad hoc committee examined the system and found that it did not use an accurate and independently validated method to determine a physician's risk-adjusted cost.
The committee concluded that and other problems with RACI rendered it deceptive and invalid for credentialing and related performance assessment purposes for both individuals and groups.
BCBSTX later entered into an Assurance of Voluntary Compliance with Texas Attorney General Greg Abbott, agreeing to stop using RACI scores to rate doctors' affordability or as an eligibility criterion to remove physicians from or add physicians to its networks.
TMA physicians also served on a BCBSTX Advisory Committee on Measures of Clinical Performance that vetted the evidence-based measures used in the rating programs. The work of that committee resulted in a reduction in the number of evidence-based measures used in the program from roughly 50 to 16.
Blue Cross officials did not respond to Texas Medicine 's request for a comment.
Blue Cross's Evidence-Based Measures
Blue Cross and Blue Shield of Texas (BCBSTX) rates physicians in various specialties based on 16 evidence-based measures. The measures include:
- Mammography screening;
- Cervical cancer screening;
- Colorectal cancer screening;
- Annual diabetic retinal examinations;
- Annual glycosylated hemoglobin (HbA1c) tests for diabetics;
- Annual LDL monitoring for diabetics;
- Annual monitoring of lipid levels for patients with cardiovascular conditions;
- Annual visual field test for patients with primary open-angle glaucoma;
- Appropriate treatment for children with upper respiratory infections;
- Use of long-term control drugs for persistent asthma;
- Measurement of risk-adjusted complication likelihood for appendectomy or cholecystectomy surgeries;
- Appropriate use of imaging in low back pain assessment;
- X-ray before MRI/CT scan in the evaluation of lower back pain;
- Radiation therapy following breast-conserving surgery;
- Follow-up after initial diagnosis and treatment of colorectal cancer with a carcinoembryonic antigen test every six months; and
- Follow-up after initial diagnosis and treatment of colorectal cancer with a colonoscopy within 15 months after resection.
Additionally, BCBSTX collects data on three measures for information only, including:
- Chlamydia screening for women;
- Monitoring for diabetic nephropathy; and
- Hearing tests for children aged between 2 and 12 years before tympanostomy tube insertion for otitis media with effusion.
A complete list of the measures and specialties they apply to is on the BCBSTX Web site .
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