Cover Story - September 2008
Tex Med . 2008;104(9):18-25.
By Crystal Conde
Donald Young, MD, was shocked to learn he could be faulted for failing to provide screenings to a patient who died in early 2006. But that's exactly what happened to the Houston family physician.
After allocating many hours of staff time to scour patients' medical records, Dr. Young discovered that Blue Cross and Blue Shield of Texas (BCBSTX) used inaccurate information to rate his quality of care in the BlueCompare program.
In March, Dr. Young's office received a letter indicating he had been awarded a light-blue ribbon in the program, which uses claims data to rate physicians' quality of care. The ribbon designates that Dr. Young meets expected performance indicators compared with other physicians. BCBSTX awards dark-blue ribbons to physicians who exceed expected performance indicators compared with other physicians.
Upon examining charts for the patients listed as not receiving certain evidence-based treatment, Elaine Roch Young, Dr. Young's office manager and wife, came to the upsetting realization that one diabetic patient listed as not having received a colorectal cancer screening, a low-density lipoprotein test, a hemoglobin test, and other screenings had died in February 2006.
BCBSTX indicated its rating of Dr. Young for that particular patient applied to claims data from 2006. Ms. Young says that because the patient died in the hospital two months into the year, Dr. Young didn't have an opportunity to provide the preventive measures by which BCBSTX evaluated him. Those inaccuracies in BCBSTX's review of evidence-based measures for that one patient resulted in an erroneous lowering of Dr. Young's score.
On top of that, Ms. Young found inaccurate information for another patient regarding a mammogram. Dr. Young wasn't the woman's primary care physician under the HMO Blue plan any longer and couldn't have ordered the screening. Nevertheless, Ms. Young says, the inaccurate information unfairly counted against Dr. Young's BlueCompare rating.
"I understand we all want to have quality medical care," Ms. Young said. "The patient is the highest priority. But to determine quality blindly from claims data isn't very helpful."
Dr. Young says the inaccuracies discovered in his ratings are disconcerting.
"It's very bothersome because it's very inaccurate. We looked up several charts, and the more we looked, the more inaccuracies we found," he said. "It's absurd, especially if BCBSTX is going to advertise this, and especially since we pride ourselves on giving the best care to patients."
In addition, BCBSTX informed Dr. Young that it deemed him ineligible to participate in the BlueChoice Solutions alternative professional provider network because he's considered less affordable than his peers.
Ms. Young contacted BCBSTX to discuss Dr. Young's rejection from BlueChoice Solutions. Blue Cross e-mailed her an Internet link to download the data used to make its decision on Dr. Young. She describes the information she accessed as difficult to understand.
In search of additional help, Ms. Young contacted the Harris County Medical Society, which referred her to the Texas Medical Association for more information on requesting a review of Dr. Young's BlueCompare rating and risk-adjusted cost index (RACI) determination.
TMA encouraged her to submit a written request for a review to BCBSTX. She sent the request, along with a report of the inaccuracies she'd found, to BCBSTX on March 25.
BCBSTX responded to Dr. Young on April 28 and notified him that, after review, it had changed his BlueCompare rating to a dark-blue ribbon and restored his eligibility in the BlueChoice Solutions network.
BCBSTX has set up online resources where physicians can learn more about the review process , request reviews of their BlueChoice Solutions determinations, and ask questions about their review requests or any aspects of BlueCompare.
Ms. Young also filled out TMA's online feedback form to document the inaccuracies she'd discovered.
Physicians who have encountered problems with their BlueCompare and BlueChoice Solutions information can submit feedback by visiting the TMA Web site .
TMA urges physicians who find errors in their ratings to request a review with BCBSTX. In addition, TMA has quickly responded to physicians' complaints about BCBSTX's use of claims data to rate physician performance in BlueCompare and its use of the RACI to determine the affordability of doctors' care in its BlueChoice Solutions network.
A "Hilarious Situation"
Keith Bourgeois, MD, chair of TMA's Council on Socioeconomics, can attest to the problems with RACI. A Houston ophthalmologist, Dr. Bourgeois practices in a main office where he performs more complex testing and treatment on patients and in satellite offices where he sees patients but doesn't have the proper equipment to undertake procedures that are more complex.
BCBSTX deems Dr. Bourgeois ineligible to participate in BlueChoice Solutions for services at his main Houston office because, he says, he's considered too expensive. He is, however, part of the BlueChoice Solutions network at his satellite offices.
"It's a hilarious situation," he said. "If this has anything to do with quality, I'm a different quality in my main office but have good quality miles away."
As TMA gathers information on the inaccuracies in BCBSTX's ratings programs, the insurer has, in turn, shown willingness and commitment to work with physicians. And, BCBSTX, which has the largest network in the state with more than 36,000 physicians and 400 hospitals, is changing how it measures Texas physicians' performance and costs.
Most notably, BCBSTX President and Chief Executive Officer Darren Rodgers says the insurer has stopped using the RACI for reporting on physician performance.
"At this time, we have no plans to use the RACI in any other way," he said.
RACI reflected differences in the attributed costs of physician and professional practitioner episodes of care. The index relied on claims data to make cost and affordability determinations.
In a May 22 letter to TMA, Mr. Rodgers wrote:
- No further physicians will be removed from the BlueChoice Solutions network based on the RACI;
- BCBSTX will remove the depiction of the affordability scale from its online Provider Finder and all information regarding affordability measures from its BlueCompare program materials; and
- BCBSTX will focus its efforts on communicating more specific treatment cost information to consumers, rather than a general measure of physician affordability.
TMA leaders acknowledge the progress BCBSTX has made and applaud the plan's dedication to work with physicians.
However, TMA President Josie Williams, MD, says physicians want to see continued advancements and improvements in BCBSTX's physician-rating programs.
"I haven't seen any retreat from any insurance company on this order. It's not just BCBSTX; they're all doing it," she said. "Until they can get data from physician records, insurance companies will continue to use claims data. Claims data don't measure quality, and as long as they're using claims data, it's economic credentialing."
Working Toward Change
Indeed, many health care payment plans, including UnitedHealthcare, CIGNA, and Aetna, have a mechanism to evaluate physician performance. They contend the ratings programs are a response to employers' demands to judge physicians' affordability and quality of care as a way to control health care costs.
Many physicians assert, however, that insurance companies often use flawed data and unclear methodologies to assess a physician's quality of care, with the ultimate goal of saving money.
BCBSTX has been the most engaged insurer. It has talked to TMA about its measurement of physician performance and has responded to the association's feedback by taking steps to remedy some concerns. In addition, UnitedHealthcare discussed its ratings program with TMA.
BCBSTX's decision to eliminate the RACI follows a report by the TMA Ad Hoc Committee on BlueChoice Solutions/RACI to the TMA Board of Trustees and Council on Socioeconomics during TexMed 2008. Created after physicians complained to TMA about the BCBSTX ratings, the ad hoc committee evaluated the RACI and examined problems with clinical attribution, accurate comparisons to peers, and attributed expense associated with inpatient facilities.
The report details significant problems the committee uncovered with BCBSTX's episode-of-care construction and attribution, claims coding and processing, lack of transparency and due process, and the validity of risk-adjusted cost-scoring methods. (See " TMA Recommendations to BCBSTX .")
Overall, the committee concluded that the method used to determine risk-adjusted costs in the BlueChoice Solutions plan is "inaccurate, deceptive, and invalid for credentialing and related performance assessment purposes at the individual and group physician levels." TMA sent a letter outlining the committee's recommendations, findings, and conclusions to Mr. Rodgers and BCBSTX Medical Director of Network Analytics William Taylor, MD, in May.
Mr. Rodgers says BCBSTX quit using the RACI due to new developments in physician reporting.
He says part of the reason relates to recommendations in the Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs, released by the Consumer-Purchaser Disclosure Project in April. The project consists of employer, consumer, and labor organizations collaborating to ensure all Americans have access to publicly reported health care performance information.
The Patient Charter calls on health plans to "retain, at their own expense, the services of a nationally recognized, independent health care quality standard-setting organization to review the plans' programs for consumers that measure, report, and tier physicians based on their performance." The charter also requires health plans to adopt the Criteria for Physician Performance Measurement, Reporting and Tiering Programs.
Additionally, BCBSTX has reviewed the National Quality Forum's proposed measurement framework for evaluating efficiency across episodes of care, as well as patient use of BlueCompare and the results of focus group discussions with patients about the information they want and find useful.
Paul B. Handel, MD, senior vice president and chief medical officer of Health Care Service Corp. (HCSC) in Chicago, says TMA's feedback helped BCBSTX take the appropriate steps to improve its programs. HCSC operates the Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma, and Texas.
"At the time we developed the RACI, we thought it was good. As we gathered information, we had a sense it was a systemic problem and that it was less accurate. The RACI has gone away," said Dr. Handel, who also is a member of the TMA Board of Trustees.
RACI isn't the only concern the ad hoc committee addressed. Among the findings is physicians' continuing frustration over the lack of access to an easy-to-use process for requesting a review of their ratings. (See " Making Sense of the System .")
Because of the ad hoc committee's recommendations, Dr. Williams hopes BCBSTX will:
- Look closely at the findings and continue to work with TMA to correct inequities;
- Complete an independent audit of the measures used to rate physicians for quality and affordability;
- Clean up the database and ensure it is accurate; and
- Be honest in advertising both programs to patients.
Dr. Handel estimates the company deselected about 3,600 physicians from the BlueChoice Solutions network. In a May 30 letter to BCBSTX, Dr. Williams recommends it reinstate those physicians removed from BlueChoice Solutions because of their RACI scores.
Dr. Handel says BCBSTX is continuing to process requests for review from those physicians deselected from BlueChoice Solutions as of September 2007. Upon review, some physicians may be reinstated, he says.
In a June 4 letter to TMA, Mr. Rodgers says BCBSTX has not chosen a means to convey more specific treatment cost information to consumers. He says, however, the company is reviewing ways to provide estimates of the costs for medical procedures and bundles of services.
Improving communication with physicians and enhancing the programs used to rate physician performance are priorities for BCBSTX, according to Dr. Handel. He says the company is examining new technologies to capture hospital, pharmacy, and laboratory data. That way, he says, physicians could be notified when patients have received tests, medications, or immunizations outside the medical home.
At TMA's request, BCBSTX formed the Blue Cross and Blue Shield of Texas Advisory Committee on Measures of Clinical Performance (ACMP). TMA has been working with the committee, funded by the insurance company, to focus on improving BCBSTX communication with TMA members about their BlueCompare ratings and to identify strategies to improve clinical performance. The ACMP has been successful in getting the company to reduce the number of evidence-based measures it uses to rate physicians from 50 to 18.
Of continuing concern, however, is BCBSTX's use of claims data to determine quality of care.
The ACMP has shared physician feedback with BCBSTX on the ratings programs. TMA members complain of inaccurate data; incorrect attribution of care; inability to collect accurate immunization data; and inability to capture noncompliance, patient choice, and refusal.
Isabel Hoverman, MD, MACP, vice chair of the ACMP, says organized medicine must continue to urge BCBSTX to clean up the data it uses to rate physicians.
"Blue Cross has been responsive to a lot of the discussions and suggestions that we've [ACMP] had, but we still don't have a good way to measure practice accurately," she said. "They have some real problems in the accuracy of the data that they're collecting. For example, they're not capturing mammograms, and I have no idea why."
To ensure accurate data and a fair method of rating physicians, TMA asked BCBSTX to undergo an independent audit of the scientific measures and practice strategies used to rate physicians on affordability and quality. BCBSTX agreed but has not yet done so.
Mr. Rodgers says BCBSTX is reviewing recently published national standards regarding rating physicians.
"Assuming we select a standard that requires an audit, we'll pursue that, but we are always cautious about incurring the expense of third-party audits, which divert our financial resources from other areas that physicians and members may find more valuable," he said.
Until the data are correct and physicians reinstated in BlueChoice Solutions, Dr. Williams says BCBSTX is inadvertently punishing a large number of physicians who should be in the network. She urges the insurer to verify the data to assure physicians that BCBSTX is measuring them fairly and accurately.
Physicians should look at their data to see if they're accurate and make any necessary changes in their practices to ensure they're meeting evidence-based standards of quality care, Dr. Hoverman says.
Dr. Handel says taking responsibility for errors in claims data is a two-way street. Not only should BCBSTX make sure it is capturing evidence-based measures accurately to determine physicians' compliance, but physicians also should make every effort to code claims correctly and completely.
TMA can help physicians and office staff members deal with claims-payment problems. Physicians can get answers to questions about correct coding and other insurance matters by contacting the Payment Advocacy Department at (800) 880-1300, ext. 1414, or (512) 370-1414 to learn about services available to TMA members.
Drs. Williams and Hoverman say BCBSTX needs to develop educational tools to help physicians improve their performance. Dr. Williams encourages the company to move everyone's bar upward, rather than deselecting those who don't make the grade.
"Give them an opportunity to understand what they need to do to meet their criteria, and give them a chance to get there. The criteria need to be upfront and transparent," she said. "People need to know what it is they've done differently than anyone else after their data have been validated."
Dr. Handel says insurance carriers can make a difference by identifying those physicians who aren't meeting the evidence-based measures and directing them to the appropriate resources for improvement.
In letters to physicians who didn't meet the threshold for recognition in BlueCompare, the health care payment plan included information on the evidence-based measures and the underlying guidelines used to rate physicians, as well as links to resources, according to Mr. Rodgers. The information also is on the BCBSTX Web site .
Mr. Rodgers suggests physicians visit the Web sites of the American Medical Association and the Agency for Healthcare Research and Quality for additional guidance. (For more performance improvement tools, see MedBytes in the June 2008 issue of Texas Medicine .)
TMA' Web site features a Performance Improvement Resource Center, with information on improving quality of care and patient safety, as well as tools to assist physicians in reaching their performance improvement goals.
Dr. Hoverman says the three-page letter BCBSTX currently sends to low-performing physicians is too cumbersome and wordy to get their attention and get the message across. The ACMP encourages BCBSTX to simplify and clarify its communications with physicians.
BCBSTX does have patient education elements. For example, Dr. Hoverman praises its disease management programs in which patients with chronic diseases and other health problems can access a nurse to discuss diet, exercise, smoking cessation, and other behavior modifications.
Drs. Hoverman and Handel agree that physicians' awareness of the evidence-based measures and meeting quality standards set by specialty societies must be emphasized.
Dr. Handel says physicians can improve their quality of care by focusing on five preventive services that "every physician ought to be doing … over and over again, almost to every patient." The Partnership for Prevention's report Priorities for America's Health: Capitalizing on Life-Saving, Cost-Effective Preventive Services outlines the following five services with the highest preventive value but lowest utilization in the medical practice:
- Physicians discussing daily aspirin use with male patients older than 40, female patients older than 50, and others at increased risk for heart disease;
- Screening patients to determine whether they smoke or use other tobacco products, providing brief smoking cessation counseling and offering therapies and referrals to help them quit;
- Recommending the pneumococcal immunization for patients 65 and older and those with chronic diseases;
- Screening adults older than 50 regularly for colorectal cancer; and
- Screening sexually active women for chlamydia at the time of their Pap smears.
BCBSTX is exploring ways it can expand benefits coverage for smoking cessation counseling and other preventive measures that lead to primary lifestyle changes and overall improved health among the patient population, Dr. Handel says.
At press time, TMA was discussing steps BCBSTX can take to move toward long-term progress and positive outcomes in the BlueCompare and BlueChoice Solutions programs. TMA will work with BCBSTX to modify the BlueCompare program's rating system with new evidence-based measure results and symbols.
Dr. Williams says she hopes BCBSTX will continue to work with TMA through its various committees to resolve physicians' concerns.
"We'd like to see them pay attention and do the independent study like we asked them to around their measures," she said.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
TMA Recommendations to BCBSTX
The report of TMA's Ad Hoc Committee on BlueChoice Solutions/RACI examines problems with how affordability is determined for physician participation in the network. Committee Chair Robert William Kottman, MD, says the group unearthed tremendous inaccuracies in the use of claims data in determining overall cost.
"The only way you can really develop an accurate assessment of a physician's quality of care and cost is by looking at medical records. Claims give you one glimpse but no insight into quality of care," he said.
The committee's report to the TMA Board of Trustees and Council on Socioeconomics includes four observations and recommendations:
- The current method for "actual cost" assignment that BlueChoice Solutions uses to determine a physician's risk adjusted cost index (RACI) is seriously flawed and is not scientifically validated, and Blue Cross should not use it as a relative measure of "affordability." Costs are inaccurately and/or unfairly attributed to physicians caring for BlueChoice Solutions patients. "Examples would be imaging and/or lab tests ordered by other physicians, or a patient's decision to pursue an emergency department visit in lieu of scheduling a physician office/medical home visit. When more than one physician is involved in treating a complicated patient with multiple co-morbidities, it often becomes virtually impossible to assign the costs of care to a single physician appropriately. The BlueChoice Solutions RACI, however, does exactly that."
- BCBSTX should immediately resolve claims coding and processing system problems. There is a serious question about BCBSTX's capacity to receive electronic or paper submissions with all of the coding information necessary to process BlueChoice Solutions claims fairly and completely. The issue deserves Blue Cross's prompt attention since an important root cause of the problems with the BlueChoice Solutions claims database is inaccurate and/or incomplete data generated from the BCBSTX claims coding and processing systems. These capacity concerns threaten the integrity of transactions in the network and the viability of the network itself.
- Important information related to covered benefits and related patient service costs outside physician offices is generally not available nor disclosed to participating and/or billing physicians. All relevant cost-of-service attribution and covered-benefit information affecting BlueChoice Solutions network physicians' service and referral decisions for patients/enrollees should be fully transparent, available, and disclosed to physicians and patients in all applicable, covered settings of care.
- Clear and unambiguous information that describes the process for appealing their rankings is not easily available to physicians, their offices, and patients. In addition, the company's local provider service representatives sometimes give BlueChoice Solutions physicians or their staff conflicting, incomplete, or inaccurate information about how to appeal, and the distinctions between requesting disputed data on RACI scores and filing a formal appeal. BCBSTX should substantially improve and make transparent all due process options under the Health Care Quality Improvement Act.
The full report [ PDF ] is available on the TMA Web site.
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Making Sense of the System
Robert William Kottman, MD, chair of the Ad Hoc Committee on BlueChoice Solutions/RACI, says physicians often are unsure how to request a review of their ratings or deselections from the BlueChoice Solutions network.
G. Edward Clark, MD, a pediatrician practicing in Paris, turned to TMA when he was unable to locate the appropriate person at BCBSTX to answer questions regarding his ratings.
"When I read this and found errors, I wanted to speak to someone about it. I called multiple 800 numbers, and I was unable to find a human being to talk to. I wrote a letter but wasn't sure where to send it. In the end, the TMA set up the Web site, and that's where I decided to vent," he said.
According to BCBSTX Medical Director of Network Analytics William Taylor, MD, physicians who have questions regarding their review requests or any aspects of BlueCompare should contact their local Professional Provider Network office listed on the BCBSTX provider portal .
Dr. Clark filled out the TMA online feedback form to document BCBSTX's inability to collect immunization data accurately for 23 of his patients. The inaccuracy caused him to receive a light-blue ribbon in the BlueCompare program.
Eric Salzman, MD, a pediatrician in Dr. Clark's group, Primary Care Associates of Paris, wrote BCBSTX in April and outlined the inaccuracies five physicians in the practice group found in their BlueCompare ratings. BCBSTX notified the physicians in May that it changed their ratings to a dark-blue ribbon.
Before his rating had been changed, Dr. Clark consulted the files of the patients listed and accessed the ImmTrac database to find that all patients but two had received immunizations at the appropriate ages.
"We did miss the first MMR on a set of twins," he said. "I appreciate them [BCBSTX] picking that up for me. I don't mind them reviewing and making sure we're giving appropriate care, but it needs to be accurate."
ImmTrac is a free, confidential registry managed by the Texas Department of State Health Services (DSHS) that stores children's immunization information electronically.
House Bill 1921, passed in 2005, requires an insurance company, an HMO, or another organization that pays a health care professional to provide health care benefits to report to DSHS data it receives from a physician who administers immunizations to children younger than 18 years within 30 days of receipt of the information from a physician.
HB 1921 also authorizes insurance companies to have access to registry data. DSHS receives electronic immunization history requests from physician offices and health care payment plans.
Adriana Rhames, ImmTrac program specialist for DSHS, says BCBSTX has never requested an immunization history for any of its covered members from ImmTrac, while many of the other 38 health plans reporting to the registry have.
Ms. Rhames says members of DSHS's Health Plan Payer Working Group have indicated the data in the immunization history requests enable them to have complete information for Healthcare Effectiveness Data and Information Set (HEDIS) reporting. The data also give health care payment plans a way of tracking which children have received vaccinations.
Additional information about ImmTrac and health plan participation is available by calling (800) 348-9158 or by e-mailing firstname.lastname@example.org .
The Advisory Committee on Measures of Clinical Performance planned to discuss how BCBSTX can access and incorporate ImmTrac data in its review of physicians at its August meeting.
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