Washington doctors sue Blues plan over performance standards

Physicians say Regence BlueShield gave them poor quality ratings using bad data. Regence says it uses professional standards and wants to collaborate on improvements.

By Amy Lynn Sorrel — Posted Oct. 16, 2006

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The Washington State Medical Assn. is suing Regence BlueShield, claiming the health plan defamed physicians when it told thousands of patients that their doctors didn't meet the "quality and efficiency" standards needed to be included in the insurer's new performance-based network.

As the national movement toward quality improvement gains ground, the lawsuit reflects doctors' push for more involvement in creating quality measures to ensure that they are fair and do not interfere with the doctor-patient relationship.

In the lawsuit filed Sept. 20 in King County Superior Court, the WSMA and five individual doctors claim that Regence's move to exclude 500 doctors from its Select Network was based on inaccurate and outdated information from claims data. They also say that the insurer breached its contract with physicians by arbitrarily dropping them from the network and telling patients they would have to find a new doctor.

Regence's new plan, announced in a letter to doctors and patients in May, affects about 8,000 patients who are members of the Society of Professional Engineering Employees in Aerospace.

"The problem is that there was flawed data and physicians did not have a chance to react or use the appropriate information to improve it," said internist W. Hugh Maloney Jr., MD, WSMA president-elect. The information that Regence used was not corroborated with patients' medical records and, in many cases, was based on information more than 4 years old, Dr. Maloney said.

He explained that one doctor received a low quality rating because he did not order a mammogram for a patient who had had a double mastectomy. Another doctor was downgraded for failing to order a cervical cancer screening for a patient who had already undergone a hysterectomy, according to the complaint.

In a number of instances, "there was an egregious misapplication of data that has affected physicians' reputations, their livelihoods and their relationships with their patients," Dr. Maloney said.

Bellevue internist Michael Schiesser, MD, one of the individual doctors suing the company, discovered that Regence rated his quality and efficiency in the 12th percentile. One year earlier, though, the health plan graded him in the 90th percentile and gave him an award. Regence based both ratings on data from the same timeframe in 2002 and 2003, Dr. Schiesser said.

"Obviously there's a problem with their methodology," he said.

He added that other data also were "botched," noticing that Regence downgraded him for not ordering diabetes tests for patients who did not have diabetes.

"If they had said, 'Hey, you might want to check into this,' I would have considered that a useful heads up," instead of being labeled a "bad doctor," Dr. Schiesser said.

Regence delays program's start

Jeffrey Robertson, MD, executive vice president for health care services for the Regence Group, did not directly respond to allegations in the lawsuit. But he said the information they used to grade doctors was gleaned from claims data, and the quality ratings were based on national professional standards for cost efficiency and adherence to evidence-based practices.

Regence weighted quality and cost equally, he said.

"We know that the data is not perfect, but it's only as good as what the doctors send out," said Dr. Robertson, a retired family physician.

After hearing about the mistakes from doctors and patients and meeting with the WSMA, Regence sent follow-up letters to its members in June, apologizing for the "[implication] that health care professional(s) who were not invited to participate in the Regence Select Network do not provide quality care. That was neither our intent, nor our perspective, and we regret any misunderstanding."

The health plan also has delayed implementing the Select Network for one year, until July 1, 2007, to rectify any "errors in communication," Dr. Robertson said.

The WSMA's Dr. Maloney says that does little to fix the problem of correctly measuring quality and leaves the door open for it to happen again, which is why doctors filed the lawsuit.

The WSMA wants to collaborate with Regence to establish the performance network, he said, and "evidence-based practice and the appropriate use of the quality improvement process is the way to make care for patients better."

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Case at a glance

Washington State Medical Assn. et al. v. Regence BlueShield

Venue: King County Superior Court, Seattle
At issue: Whether a health plan defamed physicians and breached contracts with them when it excluded doctors from a performance-based network based on poor quality ratings that physicians say came from inaccurate data.
Potential impact: Doctors say that they should be involved in developing evidence-based quality measures that are fair and do not interfere with the doctor-patient relationship. The health plan says its ratings are based on national professional standards and will help improve health care.

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