Blues plans are creating a giant claims database

For years insurers have been creating databases to warehouse the details of claims data. Insurers have also used the same claims data to assess quality and efficiency designations, a practice many physicians say is notoriously unreliable.

With Blue Health Intelligence, a HIPAA-compliant claims database with information from 20 Blues plans, Blue Cross Blue Shield Assn. is joining the list of insurers using claims data to track medical trends. The database compiles treatment details, minus the patient's name, of 79 million people nationwide.

Blues officials say the data are expected to provide a peek into how people use the health care system, part of an ongoing industry trend to provide more transparency. But physicians say insurers, including the Blues plans, are using claims data to cut costs. They also say insurers have often used claims data to unfairly guide patients to physicians identified as the cheapest.

"Claims data are for doctors to get paid," said Larry Fields, MD, president of the American Academy of Family Physicians. "It's not for insurance companies to try to direct patients to low-cost facilities or physicians. It certainly has nothing to do with quality, and insurance companies should not try to disguise their use [of claims data] as quality measurers."

Dr. Fields said insurers have relied on claims data because they already have this information at their fingertips. He said insurers haven't been as ready to use evidence-based quality guidelines because physicians would have to be paid to report that kind of information.

"If you're going to try to measure quality, you have to pay for the measurement," Dr. Fields said. "You have to use evidence-based data that are gathered in a scientific way."

Blue Intelligence is being tested and is expected to debut in 2007. Initially, local Blues plans will provide the information to employers. The local plans also will share the information with physicians and hospitals in reports on their own quality of care, such as tracking a heart patient's use of beta-blockers or tracking a diabetic patient's recommended blood tests.

Following review of the data by medical professionals, the insurer will give summary reports to consumers. Prescription drug companies and medical device makers have also expressed interest in the information.

"BHI will provide consumers with the information they need to make informed health care decisions and will heighten collaboration with providers as they deliver high-quality, evidence-based care to their patients," said Blues Assn. president and CEO Scott P. Serota.

But medical societies across the country have received complaints from physicians, many of whom report that they have been unfairly penalized based on an insurance company's use of claims data to reach certain conclusions.

Susan Strate, MD, chair of the council on socioeconomics for the Texas Medical Assn., said using claims data alone often can lead insurers to penalize a physician or a group practice unfairly.

"I know of one case where an insurer said a certain group was more costly than other groups in the area," Dr. Strate said. It turned out that the issue wasn't related to quality or use of services.

"When they really looked at [all] the information, they found out they had been more successful in negotiating contracts," she added.

Physicians have a valid point about relying solely on claims data, said Shirley Lady, Blue Cross Blue Shield Assn.'s executive director for business informatics/Blue Health Intelligence. She said the company's chief medical officer has worked with physician groups to determine more effective tools.

"Claims is a good starting point," Lady said. "It's the most cost-effective and efficient means to collecting information. Is it the best answer? Probably not."

Many physicians have ideas about what would make the situation better, but it's a matter of getting all parties to the table.

Dr. Strate said there should be some type of data extraction from the patient's medical record to add to the information from the claims data.

Allan Goldstein, MD, president of the Medical Assn. of the State of Alabama, said that instead of using claims data to determine quality of care, more meaningful measurements should include emergency department visits, hospitalizations and unscheduled office visits. That's because using claims data alone could rate a physician as a poor performer because claims data don't look at the totality of treatment.

"What they need to look at is outcomes," Dr. Goldstein said.

Lady said she agrees that outcomes represent a key component to determining quality of care. She said Blue Health Intelligence officials will be working with physician groups to come to agreement on appropriate measures for outcomes.

The Blues are not alone in using claims data to generate conclusions about health care. For example, UnitedHealth Group mines data from nearly 27 million lives covered by its plans. The insurer uses the information to track how physicians treat patients by monitoring tests, prescriptions and office visits.

UnitedHealth spokesman Tyler Mason said physicians receive a customized report that identifies patients who may have stopped taking an important medicine or may have skipped an important preventive service or test.

But United's moves have not been without controversy. The AMA and state and local medical associations fought United last year when it tried to use claims data as the basis for rating doctors for a quality-pay plan. United eventually agreed to scrap its program and to work with doctors to create a new one that used more extensive data.

Even as insurers continue the practice of data mining, the Ambulatory Care Quality Alliance, a group representing the American Academy of Family Physicians, the American College of Physicians, America's Health Insurance Plans, and the Agency for Healthcare Research and Quality, is working to agree on a strategy for measuring performance, collecting and aggregating data, and reporting meaningful information to consumers, physicians and other stakeholders.

Industry experts say the desire to build huge databases has largely been sparked by employers putting pressure on insurance companies to do more to cut costs. But Eric Grossman, worldwide partner with Mercer Human Resource Consulting, said single carriers, such as United and the Blues plans, don't have the critical mass with their own data to yield the credibility that employers would like to see.

That's why Mercer pulled together a group of employers and insurers in 2003 to look at ways of aggregating claims data to achieve more desired results.

After years of planning, the Care Focused Purchasing initiative, a group of 50 employers and seven insurers, including Aetna and Humana, began collecting claims data.

Care Focused Purchasing became fully operational in July and is expected to yield its first set of results in the first quarter of 2007.