Features Archive

Email A Friend

More Features

August 9, 2021
The Property Claims Investigation

July 29, 2021
The Examination Under Oath as a Tool to Defeat Insurance Fraud

July 28, 2021
Liability Insurance Is

January 16, 2021
Insurance HR Manager Who Participated in U.S. Capitol’s Duck Dynasty Insurrection Loses His Job

Of all the aphorisms one hears on the medical front, we can look to US statesman and financier Bernard Baruch to set us straight on the contemporary whys and wherefores of what HMOs are up to in California. He said, in 1924, “There are no such things as incurables, there are only things for which man has not found a cure.”

Right now, it’s Blue Cross of California that is taking the lead on how to straighten out part of its own mess as a major player in the Health Maintenance Organization industry. Always looking for a cure, Blue Cross immodestly claims it is taking the lead role in making medicine better for you and me—not to mention its employees and constituent medical groups.

Medical research and development aside, the preponderance of health care professionals have known for some time that patient satisfaction is the most important factor in medical relationships. Blue Cross, which is a division of Thousand Oaks-based WellPoint Health Networks Inc., has in fact utilized a point system for “indicators” of quality heath care delivery since 1994.

Ostensibly, the points-indicator system—reportedly assiduously utilized by a fourth to one-third of all Blue Cross medical groups—just didn’t practice all it preached.

And so it came to pass that Blue Cross (California’s fourth largest HMO with 5.6 million members) has introduced a bonus program that will reward physicians groups that meet certain scorecard criteria. On July 11, it gathered the press to announce “a major restructure to pay for and reward” its medical groups for amping up quality care—hence, patient satisfaction, according to Jeff Kamil, MD, the HMO’s medical director and vice president of medical policy and quality.

Saying the updated program focuses “exclusively on quality of care,” Kamil emphasized, “We believe this change is necessary for out market. (We are going) to restage and reformat health care delivery in California,” moving from what was formerly cost-containment-driven issues to the new mantra: Quality care.

Kamil said Blue Cross employees, patient members and the medical providers themselves are all in accord on the “reformatting, ” which will stress “quality in the right way, at the right time and in the right place.”

He also denied that the timing of the announcement had anything to do with the universal Patients’ Bill of Rights bill, which includes particulars on how to sue HMOs and is now under consideration in Congress.

Michael Belman, MD, Blue Cross staff vice president, averred that his HMO has set the standard for quality by its “quality scorecard” system, but promised to increase the scale (based on a factor of 200 points) because “change is required.”

Also appearing at the press conference was Tom Rosenthal, MD, a true heavyweight carrying the imprimatur of UCLA (per usual, regarded as among the top five hospitals in the US) who is director of the physicians HMO group at the university. Rosenthal said his team, consisting of 1,000 physicians and a patient base of 80,000, supports the “ideals in this and supports in particular the items that have been selected to be incentivized.” From the physicians group perspective, he said, the “patient’s own reporting of their health care experience is an extremely important measurement of quality of care…”

In its official press release, Blue Cross said the restructuring plan is “in response to feedback from both consumers and physicians. Recent surveys among medical groups in California have shown that physicians who receive rewards for superior performance related to clinical care and patient satisfaction are more satisfied with their work and are better appreciated by their patients.”

Acting upon the feedback of physician partners and with the endorsement of their external Physician Relations Committee, Blue Cross dubbed the new program “Primary Care Physician (PCP) Quality Measurement and Bonus Systems” with a customized “quality scorecard.”  The scheme awards points to physician groups, which have an internal process for measuring the quality and clinical performance of each doctor and a system for disbursing award bonuses to those practitioners who score well.

“The quality measures, which are determined by each medical group, may include such items as patient satisfaction surveys, waiting times for appointments, number of complaints and grievances, peer and staff reviews and patient turnover. In addition, the measurements will also include physician performance in managing chronic diseases such as asthma or hypertension and adherence to screening guidelines for breast and cervical cancer.  Blue Cross of California believes it is the first health plan to formally recognize physician groups who use these evaluation tools,” the HMO said.

“We commend Blue Cross of California for this important advance in rewarding delivery of high quality health care and patient service by its physician groups,” said Peter Lee, president of Pacific Business Group on Health. “Collecting and reporting data significantly affects performance; we believe the new PCP Measurement category is an important element in promoting physician accountability and member satisfaction."

Also, under the revised quality scorecard, more than half of a medical group’s score will now be based on patient health outcomes and patient satisfaction.

Dr. Robert Crocker, WellPoint’s senior vice president of health care quality assurance and clinical affairs, stated, “This system of measurement is a direct response to our members, employer groups and market demand for more accountability to be focused on their medical care.  If our medical groups can be successful in achieving the appropriate health outcome, then cost savings will be an automatic byproduct of the process.  We know that the best care is that which is given in the right place at the appropriate time.  This also happens to be the most cost-effective care.”

From another perspective, “Neither physicians or patients are satisfied with the current focus of cost and utilization controls,” observed Steve McDermott, CEO of Hill Physicians Medical Group.  “With its new quality scorecard, Blue Cross is working to shift the focus where it belongs—on quality of care and patient satisfaction.”

Blue Cross noted that the new incentive program will be implemented continuously as new contracts are renegotiated with each medical group in its HMO network.

Many other HMOs are expected to follow Blue Cross’ counterattack to what has often been criticized as a ponderous and sometime onerous way to run a business, medical or otherwise.

Is it too soon to say, “My body (and peace of mind) thanks you, Blue Cross”?