cross blue

Insurers not happy with concierge medicine

Mon, 17 Mar 2008 07:59:56 -0400

A number of insurers aren't too pleased with the small but growing trend of "concierge medicine." For an annual retainer fee, patients can have more personalized care, which may include house calls and more access to their physician. By charging the up-front fee, doctors can afford to cut their caseload and spend more time with fewer patients.

But United Healthcare and Cigna both say the concierge model violates their contracts, and United Healthcare is dropping four Texas physicians because of the practice. Insurers say that doctors may charge patients for co-payments or co-insurance, but not additional fees. Some practices have cut insurance out entirely, while others still have patients relying on insurance to cover most of their visit, which the insurers don't like that at all. However, Aetna, Humana and Blue Cross Blue Shield of Texas say they will accept the concierge model as long as patients don't expect reimbursment for their doctor's retainer fee.

For more on the concierge/insurer conflict:
- read this article from the Houston Chronicle

Related Articles:
Firm rethinks concierge practice approach. Report
Florida public hospital goes five-star route. Report
Impact of concierge practices examined. Report

BCBS of MI promoting coverage pool for individuals

Fri, 29 Feb 2008 06:59:55 -0500

Blue Cross Blue Shield of Michigan has been spending big bucks to promote what it considers to be a perfectly reasonable proposal--to create a health insurance coverage fund for people who have been denied coverage elsewhere. The pool would be run by the Blue plan, which would cover its initial financing, but after two years all of the state's insurers serving the individual market would have to kick in as well. The pool would be created by legislation currently pending in the Michigan legislature. But other insurers aren't so happy with notion. They say that BCBS of Michigan, which already enjoys big financial advantages as not-for-profit, should stop complaining about its losses on the individual market and dig into its $2.8 billion in reserves.

A lot is at stake here, given that by some estimates, a full 25 percent of the state's residents may need individual policies in less than a decade. It will be interesting to see whether BCBS pulls this off; if so, it may provide a back-door solution for health plans across the U.S., who currently are under fire for aggressively dropping sick patients with individual coverage.

To learn more about the pending legislation:
- read this Chicago Tribune piece

Related Articles:
Health plan industry addressing policy cancellations. Report
L.A. sues Health Net over cancellations. Report
Health Net set goals, bonuses based on policy cancellations. Report
CA regulators plan limits to health policy cancellations. Report
BC of California fined $1 million for cancellations. Report

Without Blue plan, P4P stumbling in Arizona

Tue, 12 Feb 2008 06:59:55 -0500

While pay-for-performance programs are proliferating in some states, they're stumbling in Arizona, according to a new report. The report, by HealthLeaders-Interstudy, found that until state leader Blue Cross Blue Shield of Arizona kicks off P4P programs, the programs launched by less-dominant competitors aren't going to get a lot of traction. True, it's not as though the other players aren't headed this way: for example, UnitedHealth and Aetna also offer programs. UnitedHealth, for its part, is offering incentives to doctors who meet general criteria. Aetna, through the Bridges to Excellence coalition, is offering specialty care incentive programs focused on diabetes and cardiac care. Until the Blue plan leaps in, however, such programs are "a tough sell," according to analyst and report author Heather Wicks. "Support from area physicians [is] minimal, as some do not see how pay-for-performance improves patient care."

To learn more about these programs:
- read this Healthcare Finance News piece

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Aetna, WellPoint refuse payment for serious errors

Tue, 15 Jan 2008 06:59:58 -0500

As expected, large private health insurers are beginning to follow Medicare's lead in cutting off reimbursement for care resulting from serious errors. Aetna and WellPoint have begun to include provisions in some contracts that they won't pay for (or let patients be billed for) care related to 28 "never events" compiled by the National Quality Forum, including the death of a mother in a low-risk pregnancy, leaving instruments in patients after surgery and using contaminated devices. Aetna is including provisions in contracts with hospitals which bar payment for all 28 never event. WellPoint, meanwhile, is starting on a more limited basis, refusing payment for four of the 28 items in the list for insureds in Virginia.

Aetna and WellPoint aren't alone. Other big insurers, including UnitedHealth Group and Cigna are considering moves, as are all 39 members of the Blue Cross Blue Shield Association. Meanwhile, hospitals in Minnesota and Massachusetts have voluntarily agreed to not charge for all or at least some of the 28 never events identified by the NQF.

To find out more about this trend:
- read this piece from The Wall Street Journal

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Another two health plans agree to NY doctor-rankings system

Wed, 21 Nov 2007 06:59:57 -0500

It's becoming a stampede. Two more health plans operating in New York state have joined CIGNA, Aetna and Empire Blue Cross Blue Shield in agreeing to follow physician ratings guidelines set by the state's Attorney General, bringing the total to five over just a few months. Group Health Inc. and United Healthcare will now follow a model established by state AG Andrew Cuomo for ranking physicians, one which, among other things, requires health plans to disclose how they develop the rankings and how much weight they give physician costs in their system.

Like the other plans, Group Health and United Healthcare have also agreed to adhere to nationally-accepted quality ranking standards, make sure ratings are adjusted for risk and that sample sizes are reasonable, and hire a "ratings examiner" (essentially, an auditor) to make sure their numbers are kosher.

To learn more about the announcement:
- read this piece from The Business Review (of Albany)

Related Articles:
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Aetna strikes doctor-ratings deal with NY. Report
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The fuss over physician ratings. Report
Restaurant ratings firm Zagat, WellPoint rate doctors. Report
TX doctors slam quality ratings system. Report

MGMA: MI group wins at pay-for-performance

Wed, 31 Oct 2007 07:59:55 -0400

Today, everyone's wondering how to make pay-for-performance worth their trouble. For one Michigan medical group, managing a pay-for-performance incentive program successfully is calling for a mix high-tech skills and old-fashioned process changes. IHA of Ann Arbor, a 130-physician group with more than 248,000 patients and 27 office locations, has been involved with P4P incentives offered by Blue Cross Blue Shield of Michigan for several years, according to Carlotta Gabard, MBA, DPH, vice president for administrative services. Gabard, who spoke at the Medical Group Management Association's Annual conference, says that over time, IHA has done very well with the BCBS program, generally receiving 85 percent to 90 percent of the bonus offered.

In building its P4P efforts, IHA has focused on a few key areas of concern, including chronic illness care, developing cost-effective prescribing patterns and increasing electronic information access. Health IT has been critical to addressing some gaps. For example, the firm used its practice management system to identify patients with relevant diagnoses, then used these profiles to build practice-wide disease registries. Nurses use the registries to monitor patients and schedule necessary preventive care for patients. IT staff also produce reports on how each individual office is performing by patient population and disease category, as well as by individual provider.

Even without adding an electronic medical record into the mix--and one is on the way--the practice had to take the costly step of boosting its IT staff from six to 15 members just to support the added technology infrastructure. Fortunately, however, not all changes IHA made to support its P4P objectives required big investments. For example, IHA boosted generic drug prescriptions by printing up prescription pads which featured easy-to-use lists of high-volume generics.

To learn more about IHA:
- visit its Web site

Related articles:
NY health plans launching physician P4P project. Report
Trend: Number of P4P programs increasing rapidly. Report
Study: P4P definitions, incentives still 'incomplete.' Report
Physicians question CMS P4P effort. Report
CMS extends pay-for-performance program. Report
Health IT not playing key role in P4P. Report
Trend: Medicaid programs offer P4P incentives. Report
Exclusive: How to make P4P work. Interview

CA managed care plans lack in preventive care

Fri, 19 Oct 2007 06:59:54 -0400

A new report suggests that California's managed care plans aren't doing a great job when it comes to preventive care. The California Office of the Patient Advocate has issued a report comparing how often the plans meet 31 clinical quality standards, such as appropriate rates of infant immunization and adult cancer screening, concluding that the health plans' compliance is low in some areas. For example, the report noted that almost one-third of middle-aged women hadn't had a mammogram within the last two-years and that half of members over 50 hadn't had colorectal cancer screens, though both are necessary in catching related cancers early and saving lives.

When rated on this basis, several of the states health plans were rated two out of four stars by the agency, including Aetna Health, Blue Cross, Blue Shield, Cigna, PacifiCare and Western Health Advantage. The plans have since said that they're improving their processes and encouraging physicians to boost their compliance with pay-for-performance programs. Physicians have long argued that it would also help to better reimburse them for time spent on prevention (and lifestyle discussion, too).

To learn more about the report:
- read this piece from the Los Angeles Times

Related Articles:
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California officials plan PPO 'report card.' Report

DC investigates CareFirst provider contracts

Thu, 18 Oct 2007 06:59:56 -0400

The D.C. attorney general's office has begun investigating whether metro DC-area health plan CareFirst has structured its contracts with providers to give it an unfair advantage over competitors. The health plan's CareFirst Blue Cross Blue Shield network serves 1.2 million consumers in the District, Northern Virginia and two Maryland counties.

DC Attorney General Linda Singer is particularly focused on whether CareFirst is making improper of a contract clause--generally known as a "most favored nation" provision--which demands that CareFirst automatically get any low rates providers negotiate with competing health plans. To research the question, Singer has asked a judge to order CareFirst competitor Kaiser Foundation Health Plan to turn over information on its rates. (I'll bet Kaiser execs were thrilled.)

To find out more about the investigation:
- read this article in The Washington Post

Related Article:
MedChi protests CareFirst rate cuts. Report

Texas doctors fight back in MD ratings dispute

Tue, 04 Sep 2007 06:59:57 -0400

Concerned about several health insurers' decision to rate and rank physicians, a Texas medical group has decided to fire back with ratings on insurers. The Harris County Medical Society, working with the University of Houston-Clear Lake, is conducting a survey of physicians to gather their opinions on several insurance companies working in the state. The study only applies to small practices in which the physician or staff deal directly with insurers.

Health plans targeted by the study, which include Aetna, Blue Cross Blue Shield, CIGNA, Humana, Unicare Health Plans and United Healthcare, have all begun using their own physician-rating systems. The Society's leaders say that while they meet with health plans, they're generally not in the loop when it comes to overall performance of the health plans, nor on processes that are working or not working for physicians. They say that their goal is to recognize good performance and find issues that health plans should address, particularly questionable reimbursement practices.

To find out more about the survey:
- read this Houston Business Journal piece

Related Articles:
Texas doctors slam quality ratings system. Report
MDs sue health plan on quality ratings. Report
New York officials demand halt to doctor-rating plan. Report

BCBS tests imaging with Michigan hospitals

Mon, 09 Jul 2007 20:01:34 -0400

Blue Cross Blue Shield of Michigan has struck a partnership with 21 Michigan hospitals under which the group will work to better leverage coronary computed tomography angiography (CCTA). The idea is to see whether CCTA could someday replace the use of standard cardiac catheterization. In the past, the BCBS plan hadn't covered CCTA, but starting this month, hospitals participating in the program will be reimbursed for the test if they're part of the plan's PPO, Point of Service or Blue Care Network plans. To participate in the program, hospitals in the study are required to use a 64-slice CT scanner and meet quality and staff training standards.

The initiative is being funded by the Blue plan, and managed by the Advanced Cardiovascular Imaging Consortium, whose leadership includes physicians from the University of Michigan and Saint Joseph Mercy Health System.

To find out more about the program:
- read this BCBS of Michigan release