Texas Blues plan agrees to stop grading physicians on how much they charge

The insurer pledged to permanently discontinue its "affordability" measurement.

By Emily Berry — Posted April 27, 2009

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Texas Attorney General Greg Abbott has pushed the state's Blues plan to abandon a cost-based physician rating program that doctors argued amounted to economic credentialing.

The agreement is the latest of many involving large health plans rating doctors based on cost but casting that score as a quality measure, a practice the AMA has fought for years.

New York Attorney General Andrew Cuomo in late 2007 secured agreements with many of the country's largest health plans -- those that happened to do business in New York -- to base physician tiering or ratings on legitimate quality measures, not cost.

Those agreements were followed by the announcement April 1, 2008, of an AMA-endorsed Patient Charter for Physician Performance Reporting and Tiering Programs, drafted by the Consumer-Purchaser Disclosure Project and signed by several national health plans. Its provisions were similar to the Cuomo agreements.

Neither BlueCross BlueShield of Texas, nor its parent, Chicago-based Health Care Service Corp., were among those who signed on to the patient charter.

But April 10, following an investigation by the state attorney general's office, the Texas Blues signed an agreement pledging to permanently leave behind its Risk-Adjusted Cost Index methodology, once used to determine physicians' "affordability" ratings published in the plan's physician directory.

In the same agreement, the plan promised not to kick doctors out of its network as retaliation for referrals to out-of-network specialists. The company denied ever doing so, despite allegations by the attorney general's office to the contrary.

The plan launched its scoring system in May 2007 but took down its RACI-based affordability scale in July 2008 following discussions with physicians and other groups, spokeswoman Margaret Jarvis said.

"There were other types of methodology on the horizon we were already taking a look at, indicators that were more at the forefront than that one," she said.

The plan continues to award dark blue or light blue ribbons to physicians based on compliance with "evidence-based guidelines" as measured through claims data.

"We are careful not to call that a 'quality' rating, because it's really not synonymous," Jarvis said.

But Texas Medical Assn. President Josie Williams, MD, a gastroenterologist who is co-director of the Rural and Community Health Institute at the Texas A&M Heath Science Center, said the plan was very clearly trying to cast its flawed measurements, past and current, as quality ratings.

"What they were doing was what a lot of the other insurance companies were doing across the country," Dr. Williams said. "They thought it was OK because everybody else was doing it, and employers and consumers wanted a ranking system."

Patricia Gunter, MD, a gynecologist practicing in Austin, Texas, challenged the Blues' ranking of her practice after learning that her "affordability" score excluded her from the network for a low-cost insurance plan called BlueChoice.

Dr. Gunter and her employees were all enrolled in that plan, so she ended up an out-of-network doctor for her own staff.

But more importantly, patients enrolled in BlueChoice were faced with paying out-of-pocket for care from Dr. Gunter and hoping to get reimbursed a portion of the cost -- or switching doctors. Many chose the latter.

"I had patients crying at the window coming to pick up their records to go somewhere else," Dr. Gunter said.

Later she got a letter saying she had earned a dark blue ribbon designation from Blue Cross, indicating she was a high-quality physician.

But because it's based on claims data, she said she doesn't know what to think about her ribbon. "Is that really something to brag about? Is that really reliable? I don't know."

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