Cutting costs Dr. Sanchez says BCBSTX is pleased with the early results of its Bridges to Excellence recognition programs. An early return- on-investment analysis found that the programs produced sav- ings of about $37 per member per month. “We’ve done a second ROI, and the numbers are closer to $100 per member per month reduced cost but better quality care with BTE-recognized physicians delivering the care versus non-BTE-recognized physicians doing the care,” he added. BCBSTX completed an assessment of 12 months of data comparing care delivered by Bridges to Excellence-recognized physicians and nonrecognized physicians. Their findings show that patients cared for by Bridges to Excellence-recognized physicians are receiving care in their physician’s office, are get- ting appropriate testing, and have fewer inpatient admissions and emergency department visits. BCBSTX may add other Bridges to Excellence programs, Ms.
Brooks says, possibly for depression or low back pain. Mr. Brown of HCI3 says Bridges to Excellence works with major health plans across the country on similar recognition programs. “From our perspective it’s improved quality overall,” he said. “It’s recognizing physicians for providing better care, but it also is suggesting that they continue to provide that bet- ter care through the offering of incentives.”
He says the BCBSTX study shows that patients seeing
Bridges to Excellence-recognized physicians means lower costs for the health plan but better care for patients. For example, the fewer inpatient admissions and lower emergency department uti- lization of patients of Bridges to Excellence-recognized physicians reduced costs for the carrier. BCBSTX is the only insurer of-
fering rewards for Bridges to Excel- lence recognition at this time. Dr. Sanchez says he would welcome other plans here to get involved in the program. Mr. Brown says Aetna had a similar program in Texas that was limited to the Austin area, but an Aetna spokesperson said the com- pany does not offer the Bridges to Excellence recognition pro- gram here. And Dr. Sanchez says employers also should see lower health insurance costs as a result of the program. “If we are seeing a $1,200 per year lower cost, a case can be made that employers will see a lower cost if more of their employ- ees went to BTE-recognized physi- cians rather than non-BTE recog-
nized physicians,” he said. “For us, it has been a win-win on multiple fronts.”
TMA is working with both BCBSTX and Bridges to Excel- lence to raise awareness of the program among TMA members. Among the ideas considered are seminars or webinars to ex- plain the program and checklists on how to gain recognition and share program expectations. Dr. Ehrlich says program participation has not necessarily
improved the quality of care she and her partners are provid- ing. They scored pretty high on their Bridges to Excellence evaluations, she says. “My partners and I were all doing the things that were re-
quired for care of our diabetics,” she said. “But one of the four of us didn’t do as good a job at documentation. So this has pro- vided an impetus to make sure those things are in the chart.” But she says the incentive payments certainly could be a big incentive for doctors who scored low to improve their care. “This is definitely an incentive for physicians to do that.” And, Dr. Crow says physicians who fail to gain recognition need to take a hard look at what they’re doing. “If you don’t meet the criteria, then you need to change.” n
Ken Ortolon is senior editor of Texas Medicine. You can reach him by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at
ken.ortolon@texmed.org.
HOW TO APPEAL YOUR HEALTH PLAN RANKING
Health insurance plans continue to use rankings of physicians to lower the cost of care. TMA believes physicians should be aware of their health plan rankings and use TMA-backed legislation passed in 2009 to appeal them, if necessary. Genevieve Davis, director of TMA’s Payment Advocacy Department,
says physicians should review their ratings, request the patient-specific data used to develop those ratings, review the data, and appeal to the Texas Department of Insurance (TDI) if they disagree with the rating. Among ranking programs health plans currently use in Texas are the
UnitedHealthcare Premium Designation program, Aetna Aexcel, CIGNA’s Care Designation program, and Blue Cross and Blue Shield of Texas’ Blue Compare program. TMA staff developed a two-page guide (
www.texmed.org/ratings_
toolkit) to help you appeal a health plan ranking or tiering. The guide is based on House Bill 1888, passed by the Texas Legislature in 2009, which authorized the TDI appeals process. If you have any other issues with reimbursement from insurers, email TMA’s reimbursement specialists at
paymentadvocacy@texmed.org.
October 2011 TEXAS MEDICINE 21
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