Blue Cross to Can Ratings Scheme

Blue Cross and Blue Shield of Texas (BCBS) told Attorney General Greg Abbott earlier this month it will stop using the controversial Risk Adjusted Cost Index (RACI) tool to rate physicians' performance in its BlueChoice Solutions program. The company also pledged not to punish physicians for referring patients for medically necessary care outside its network.

Blue Cross signed an Assurance of Voluntary Compliance [ PDF ] saying it will no longer use RACI scores " to rate doctors' affordability or as an eligibility criterion to remove doctors from or add doctors to BCBS networks."

The Blue Cross agreement ends an attorney general's Consumer Protection Division investigation that began in 2008 and is the latest development in the ongoing saga of physician ratings. TMA, responding to numerous physician complaints about the RACI tool, previously convinced Blue Cross officials to eliminate it and worked with Blue Cross officials to make ratings more fair to doctors. A TMA ad hoc committee of physician experts examined the system in 2007 and concluded it "does not use an accurate or independently validated method to determine a physician's risk-adjusted cost" and that, combined with other problems with the program, "renders the method deceptive and invalid for credentialing and related performance assessment purposes at both individual and group physician performance levels as well."

The attorney general announced on April 9 that Blue Cross had promised to stop using the RACI "to rate doctors as more or less affordable in providing quality medical treatments and achieving a desired health outcome for patients." He agreed with the TMA ad hoc physician committee that the Blue Cross rating tool had serious problems. A news release from his office said state investigators found that the ratings "were based on inaccurate information and flawed methodology. As a result, these ratings misled patients about their doctors and unfairly penalized physicians whose patients suffered from costly medical conditions."

Under Texas law, he said, "insurance providers cannot interfere with patients' right to receive medical advice from their doctors. That legally protected advice includes treatment options, health care-related recommendations and physician referrals. Doctors have a right - and a duty - to inform patients about treatment options without interference from health insurance providers. The law ensures that Texas patients have a legal right to their physicians' best treatment advice."

The agreement says Blue Cross denied it had ever threatened to remove a physician from its network solely because he or she discussed treatment options with a patient. The news release added that Blue Cross cooperated with the state authorities and did not acknowledge any wrongdoing, the attorney general's news release said.

Texas Medical Association President Josie R. Williams, MD, applauded the attorney general for his efforts. 

"TMA has asked state lawmakers for the past two legislative sessions to stop health plans from ranking physicians based on inaccurate and flawed claims data, and solely on cost. These ranking systems only serve to mislead employers and patients," she said.

Dr. Williams said the association is "thrilled that General Abbott took steps to protect the physician's ability to make sound health care decisions based on what the patient needs - instead of what saves the health insurer money. Blue Cross was threatening to terminate physicians solely for referring their patients for medically needed treatments to qualified specialists that were outside the Blue Cross provider network.

"As stated by General Abbott, 'It is not appropriate to interfere with the protected doctor-patient relationship by terminating a doctor solely for making good-faith out-of-network referrals for necessary care.' We agree completely and encourage all health insurance companies operating in Texas to adopt this same pro-patient approach," said Dr. Williams.


Action , April 15, 2009