Managed Care De-selection and Further Implications of Financial and Quality Report Cards

Owen Dahl, consultant, The Woodlands, Houston, TX; and Altamash Rahman, administrative fellow, Oncology Consultants, Houston, TX

Dahl opened the session with a review of why a practice should be concerned with de-selection, explaining that the Internet plays a large role. Website action is critical in the long run, he stated. A recent survey in New York found returned results from physicians who said 27% of their patients find their providers online, that 46% of them use a health plan website to do so, and that 31% of them are commercial (eg, WebMD, Health Grade).

The speaker explained that Angie’s List has a component for rating physicians based on bedside manor. “If you do a survey and 95% of your patients are satisfied, what are the other 5% doing?” he asked, adding that they could be writing poor reviews on such sites. WebMD helps patients find doctors to “partner” with, based on things like availability; United Health Care takes 30 specific clinical observations from 5 United patients and gives a physician or practice one or two stars, the former related to quality, and the latter related to cost-effectiveness; and although Aetna and Cigna are not quite as developed, physicians should “watch out for them,” he noted. “Get your staff to check out Angie’s list periodically to see if you’re on there before your patients start dropping off and you don’t know why,” Dahl warned.

Rahman continued the session by providing a case study of Oncology Consultants’ experience with Blue Cross Blue Shield (BCBS)’s Blue Solutions Plan. The plan was developed because rising US healthcare costs stressed employers ability to provide adequate healthcare benefits, and managed care was placed under pressure to then provide cost-effective plans. Rahman next provided an outline of the plan:

• Physician participation is contingent upon two aspects

1. Appropriate credentialing

2. Maintaining RACI score at the pre-determined threshold of 1.00

• Physicians are compared amongst peers in the same specialty to determine cost utilization pattern

• Physicians with high resource utilization patterns may not be eligible to participate in the plan

Because of the plan, on September 17, 2007, Oncology Consultants received a notice of ineligibility from BCBS due to a RACI (economic profile that looks at cost instead of clinical evidence) score higher than 1.00. Their score: 1.05. The RACI score is determined by dividing the total allowed cost of qualified episodes for the attributed physician by the total expected cost for episodes in the same episode group, based on what BCBS thinks it should be.

Attribution, Rahman explained, is given on a tiered basis, that looks like this:

•The episode is attributed to

1. The physician or professional provider who bills the greatest total Relative Value Units (RVUs) in that episode

•When no physician or professional provider is identified by total RVUs, then the episode is attributed to

2. The physician or professional provider billing the greatest number of evaluation and management services (E/M)

•When no physician or professional provider is identified by total RVUs or number of E/M services, the episode is attributed to

3. The physician or professional provider with the highest allowed cost

The presenter moved on to how Oncology Consultants’ view of co-morbidities and cancer severity differed from that of BCBS. In the BCBS Blue Solutions Report Guide, the following was said about co-morbidity: “A linear relationship does not exist between Co morbidity group and episode cost.” Basically, explained Rahman, “it doesn’t matter how sick patients are, that shouldn’t affect cost” according to BCBS. BCBS also didn’t take staging into account, and severity levels were based on simplistic, over-generalized definitions.

So, BCBS picked 12 random patients for RACI calculation, without Oncology Consultants having any idea if they were representative of their patient population. They then processed claim data associated with the patients for a pre-selected time period. And, BCBS considered an episode of care as any encounter that occurred from the first office visit until death or remission, even if there was an encounter outside the practice for something completely unrelated to their cancer, such as a sprained ankle.

Once BCBS determine the score of 1.05 for Oncology Consultants, they sent the letter informing the practice that it was out of the network, without putting any thought into it; it was strictly based on numbers.

Oncology Consultants did its own work and found that what BCBS allowed was actually more than what they had spent per patient, so they challenged BCBS’s assumptions by running their own correlation. They found a direct association between comorbidity and costs, but not necessarily between staging and costs, because the latter the stage of cancer, the less aggressive the treatment and the fewer treatment options there are, explained Rahman.

The session moved back to Dahl, who closed the presentation with some recommendations. He reiterated that all BCBS had were claims data “there were no brains used,” he added. Oncology Consultants asked to see the data, and it took BCBS 2 months to get back to them to go over it. Oncology Consultants asked them to explain it, and they couldn’t. “Challenge them!” exclaimed Dahl, who was backed up by an attendee who noted that a practice she knows of had and EMR and was easily able to use it to challenge United Healthcare when they tried to kick them out of their network; the practice actually had better and more data. BCBS, said Dahl, told Oncology Consultants, “OK, you win, you’re back on the network.” BCBS has now put a freeze on the Blue Solutions plan, Dahl noted, adding that they don’t let them forget what they did.

The recommendations Dahl provides in order to keep from being dropped from the network are to prepare and internal audit of cost utilization that is concurrent with, for example, BCBS; perform an internal investigation of the validity of RACI in its application toward your practice; develop a self model of quality of care by utilizing pre-existing standards of care in your specialty.

Practices need to recognize de-selection as an issue, utilize “claims” information to develop their profile internally, utilize an EMR to really define and develop their profile; establish an awareness and corresponding training program of all physicians and staff; and recognize that patients WILL use Internet sources to find physicians and that this will be an issue for the future, concluded Dahl.