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Quality reporting program loses backing of California Medical Assn.

CMA walked away from a two-year collaboration, claiming Blue Shield wasn't acting on concerns that physician ratings were based on flawed data.

By Pamela Lewis Dolan — Posted May 10, 2010

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A physician ratings program soon will go into effect in California -- but without the support of the state medical association.

The "Blue Ribbon" program, set to begin June 1, is the culmination of nearly two years of work by the California Cooperative Healthcare Reporting Initiative. Its members include Blue Shield of California, the Pacific Business Group on Health -- a 50-member coalition of purchasers -- and other health plans, physicians and medical organizations. The California Medical Assn. was part of the coalition until it pulled its support for the project the same week in April its launch was announced.

"The bottom line is that if they [Blue Shield] were willing to really sit in there and at least try to address some of the significant concerns before publishing, we might have stayed in the room," said Armand Feliciano, CMA associate director for medical and regulatory policy.

CMA's concerns are centered around the use of claims data to rate doctors on quality measures. The medical society says physicians could be penalized if patients don't adhere to physician advice, or if patients choose to see another physician for a recommended service.

The CMA said physicians also were concerned their scores could be reduced if a patient does not receive specified care, even if that care is inappropriate. For example, they feared a physician could be penalized for not recommending cervical screening to a patient who had undergone an hysterectomy.

Blue Shield is defending its decision to use claims data, saying the measures "all reflect evidence-based medicine and embody services and tests the patients should receive, as agreed upon by the wider medical community."

Michael-Anne Browne, MD, Blue Shield's medical director for quality, said the specific data, which do not include cost information, won't be used to penalize physicians and won't even be made public. Rather, it's a way to recognize those physicians who can report good outcomes, she said.

Beginning June 1, physicians who score 50% or higher on these measures will be recognized with a blue ribbon icon placed next to their names in the plan's physician directory.

But "this is a process that won't end with blue ribbons," said Andrew LaMar, CMA spokesman. "This is just the start of something, and we don't know where it will lead. If you're going to start something, start it right."

Melanie Matthews, executive vice president and chief operating officer of Manasquan, N.J.-based Healthcare Intelligence Network, said an increasing number of payers are using quality reporting as they move toward performance-based reimbursement. Some medical entities are tracking and reporting the measures themselves as an improvement tool, she said.

Those performance measures are not just derived from claims data, Matthews said, but also from a variety of measures, including self reports from patients.

A recent study by the RAND Corp., funded in part by the U.S. Dept. of Labor, looked at outcomes of a mock profiling program using claims from four Massachusetts health plans. It found that the program misclassified physicians 22% of the time. The American Medical Association used the study's findings to reiterate its long-held position that cost-profiling programs aren't a reliable method of determining performance.

Blue Shield said it did take some of CMA's criticisms under consideration and made changes to the rating system. The plan addressed the attribution concern by giving credit to all physicians on a patient's care team for each recommended service performed, regardless of who recommended it and who performed it.

Physicians also were given the chance, before the score was calculated, to review the data and submit supporting documentation on why certain tests or procedures were not recommended.

By the end of the process, CMA felt the fundamental problems with using claims data still existed, Feliciano said. For example, CMA supported the opportunity for physicians to review the records. But the idea of physicians going through hundreds of patient files within a three- to four-day deadline was unrealistic. Feliciano said the changes to the attribution logic also were good on paper, but the process was still flawed. (See Clarification)

"We had doctors coming back to us saying, 'That's not my patient,' " he said.

The two groups also remained at odds over whether physicians should be penalized if patients are nonadherent.

"The art of medicine incorporates the ability to communicate effectively with patients and to convince them of the importance of evidence-based care," Blue Shield's Dr. Browne said. "There is a difference in a doctor's ability to appropriately engage their patients and get them with the program, and we need to reward doctors who are better able to engage their patients."

CMA believes there's only so much a physician can do.

"It's just not within the realm of believability that a physician could spend every significant portion of every day with every patient making sure the patient is doing what he or she needs to do. That's just not practical," LaMar said.

Despite CMA's withdrawal from the program, the physicians for whom data were collected remain a part of the program. There is no opt-out option, Blue Shield said, and 22,000 physicians -- mostly primary care -- are included.

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