Health Care Transparency

State lawmakers are back in Austin and as they begin their work, one word permeates the health care discussion: transparency. Everybody wants it, but no one knows exactly what it is. Health plans and business groups list it at the top of their legislative wish lists while both President Bush and Gov. Perry have called for more of it. The hospital lobby seems to think it’s a good idea, but then they were instrumental in killing a transparency bill in the last Legislature. This time around they join physician groups in approaching a more robust push for transparency with a dose of skepticism. Physicians argue that if transparency is good for some players in the health care game, it should be good for all, leading one prominent health care columnist to call the whole thing a high-stakes contest of “you show me yours, I’ll show you mine.”

Lt. Gov. David Dewhurst assured a spot for the topic on the state’s agenda by issuing a charge to the Senate State Affairs Committee to “evaluate health care cost transparency by health care providers and access to that information by patients.” When the committee met last summer to hear testimony on the charge, committee chair Robert Duncan, R-Lubbock, put the question to a crowded hearing room: “I’d like to hear from everybody today, what is the purpose of transparency? What is the policy goal, what are we trying to accomplish with transparency?” Over the next few hours, he got a wide variety of answers.

To understand what health care transparency is really about, it’s important to know who’s pushing for it. Employers are tired of suffering sticker shock each year when they renew their employees’ health insurance policies and they want a better understanding of where those premium dollars go. To them, it’s Business 101. They want to know the cost per unit of health care service and the level of quality for that service so they can make informed decisions about what to buy.

According to Marianne Fazen, Ph.D., executive director of the Dallas-Fort Worth Business Group on Health, employers aren’t only interested in price transparency. She says they want to know which doctors are performing the right tests and treatments for their employees with chronic diseases. “You can’t make a decision based on price alone, nor can you make a decision based on quality alone. You need the two together so you can make a value decision.”

Her group has been working with employers and health plans to pilot quality measurement demonstration projects on work site diabetes and cardiac disease management, among others. “What we’re finding is quality means something different to everybody.” Fazen says employers have accepted adherence to evidence-based medicine standards as a valid measurement for rating physician performance.

“All I know is that employers are pushing for this,” she says. “They’ve seen some of the health plans posting prices on their Web sites and they’ve seen premium networks, so they know it’s possible to have some greater transparency in quality and price. Everyone’s had a taste of it and they’re hungry for more.”

While physicians embrace evidence-based medicine as an excellent way to improve the quality of care they deliver, employers and health plans are turning the standard on its head to make judgments about physician care without a fair method of measurement. TAFP’s director of public affairs, Tom Banning, says they are using “flawed claims data” rather than clinical data from patient charts to determine whether physicians are adhering to evidence-based medicine. “It’s junk science. Business and health plans view transparency through a one-way mirror and they’re perverting evidence-based medicine for financial gain. It’s nothing more than economic credentialing to control networks and limit patient access, and that is not good for patients and it is not good for physicians.”

At the root of the drive for transparency is the trend toward consumer-directed health care. Proponents argue that if consumers had more “skin in the game,” they would make better choices about the care they seek, shopping for the best value and avoiding expensive services they don’t need. High-deductible plans and health savings accounts are designed to shift more of the cost burden onto patients, who need price and quality information to be smart shoppers.

In August 2006, President Bush gave a boost to the transparency movement by releasing an executive order to promote quality and efficient health care, calling on agencies to make available price and quality measurements to enrollees of federal health programs. Secretary of Health and Human Services, Mike Leavitt, told a group of employers at a national summit on health care transparency: “The only force strong enough to change the course of health care is consumer choice, a market based on consumer value.”

Whether or not consumer-driven care can reshape America’s health care system, high-deductible plans and increased employee cost-sharing promise lower health premiums for employers, and that’s what they want most of all.

A Question of Quality?

Late last year, Blue Cross Blue Shield of Texas sent a letter to patients of TAFP Treasurer Robert Youens, M.D., of Weimar, saying that as of Jan. 1, 2007, he would no longer be included in the BlueChoice Solutions network, a “high-performance” network designed to offer cost savings to employers. BlueChoice Solutions providers must have a risk-adjusted cost index rating that falls below a threshold set by the health plan. In other words, they can’t cost the plan too much money. As of Jan. 1, they must also meet what the plan has determined to be an acceptable level of adherence to evidence-based medicine.

Youens also received a letter from Blue Cross informing him that he would receive a gray ribbon designation in the plan’s new online physician quality rating tool, BlueCompare. According to the Blue Cross Web site, physicians receiving a dark blue ribbon are recognized for “the strongest performance compared to peers in doing the right things for various conditions.” A light blue ribbon designates satisfactory quality and a gray ribbon means that either the plan doesn’t have enough claims data on the physician in question to make a judgment or the physician doesn’t meet the quality threshold.

At his request, Blue Cross sent Youens a lengthy report on his performance based on their claims data, which included examples of how he had not made the grade. The report showed that only a small percentage of his patients who take statins had been administered liver screenings. Youens used his electronic health record to pull chart data on all those patients and found that all of them had indeed been administered the test. Why the discrepancy? Youens can’t be certain because the information from Blue Cross didn’t detail whom the patients were or what specific liver screening was being questioned, but he can take a guess.

Many of his patients taking statins have multiple conditions, so they received a metabolic profile, a comprehensive panel of tests that includes a liver screening. Youens says that the plan probably didn’t recognize that fact and counted those patients against him.

Another example from the report dealt with how regularly Youens’ patients received Pap smears. “They don’t provide us any data or guidelines to suggest who these people are,” Youens says. “I mean, if this is a 19-year-old girl, a high school athlete with a knee injury, we’re not going to do a Pap smear.”

The information Blue Cross sent Youens regarding his exclusion from the BlueChoice Solutions network boiled down to a determination that he billed for more moderately complex office visits than his peers. In essence, he was too expensive. “I would argue that it’s a thoroughness issue. With BlueCompare, we’re being dinged for a lack of thoroughness whereas in the BlueChoice Solutions, we’re being dinged for our thoroughness.”

Youens is not alone. Many physicians received similar news from Blue Cross before the end of the year. Acting on physician complaints, TAFP worked with AAFP and the Texas Medical Association to express concerns to the plan over both the BlueCompare program and the recent expulsion of physicians from the BlueChoice Solutions network. TMA and TAFP collaborated on a month-long, Web-based survey to identify physicians harmed by the plan’s actions. As of now, Blue Cross has decided to postpone its BlueCompare program, so the physician rating tool on its Web site has not been activated. However, the plan is still marketing the program.

A board-certified family physician in practice since 1979, Youens understands the importance of evidence-based medicine and of measuring quality. “But I also know that what we do has a component of judgment involved and things that work well in studies maybe don’t work well for individual patients. I think you have to be very careful of holding physicians to a standard that’s not necessarily relevant to an individual patient.”

Physician organizations have been working on standards for quality measurement for years. Physicians argue that chart reviews and patient outcomes data offer a more reliable assessment of quality than claims data collected by health plans, but chart reviews are expensive and labor intensive. In the absence of an efficient and mutually agreeable method of quality measurement and reporting, health plans have begun to include quality and affordability ratings for physicians on their Web sites at the behest of employers. United Healthcare gives physicians one, two or no stars for quality and efficiency. Aetna has its Aexcel physician ranking program, which doesn’t currently include primary care physicians. Humana offers quality and price comparisons through a set of “provider transparency tools” on their members-only Web site. Experts agree that the amount and range of information reported by health plans is sure to increase.

“Transparency is wrapped in the illusion of reasonableness and accountability. Who wouldn’t want cost and quality information?” Banning says. “Yet, the lack of transparent clinical guidelines or standards the plans are using to determine cost, quality or efficiency is by far the most significant threat to clinical autonomy and the economic independence of medical practice since the invention of managed care. The plans control the data and are using it to run physicians out of networks and shift cost to patients.”

Last year, the Washington State Medical Association and six physicians filed suit against Regence BlueShield of Washington saying the plan had defamed physicians by telling their patients that they did not meet the quality and efficiency threshold to participate in the plan’s high performance network and that the patients would have to find other physicians. A story in the Seattle Post-Intelligencer reported that the plan’s actions would have affected approximately 8,000 patients and 500 physicians before the network change was postponed for a year.

According to a WSMA press release, one physician received an unacceptable ranking for not performing a mammogram on a patient who had already undergone bilateral mastectomies. Another physician was excluded from the network for not administering diabetes treatment to patients who didn’t have diabetes. In an editorial to the Tacoma News Tribune, WSMA President W. Hugh Maloney, M.D., asks the seminal question: “Is the objective to save money or to improve care?”

Price Matters

When a consumer wants to buy a car, he or she can search the Internet to find out what the dealership paid for that car, what amenities are available and what the expected price should be before ever walking into the showroom. Employers and health plans argue that with price transparency, consumers should be able to approach health care purchases in the same way. That logic makes sense when consumers consider elective surgeries, outpatient procedures and MRIs, but when a patient is sick and needs to see a doctor, the same logic doesn’t hold true. How can a physician know what services will be needed and what level of visit he or she will submit to a health plan before seeing the patient?

“Physician services are not homogeneous,” says Steve Neorr, chief operating officer for the Medical Clinic of North Texas. “For a plan to put a fee schedule out on the Web really does not provide much value to the patient. Low fee schedules do not necessarily mean cost savings to patients.”

Neorr says that when plans use cost-based rankings to narrow physician networks and to exclude physicians from high-performance networks, physician practices suffer. “Up here in Dallas, basically you’ve got Aetna, United, Cigna and Blue Cross. You have four plans. I guarantee that makes up 50 to 60 percent of most practices. So if all of a sudden, you’re cut out of one of these networks, that could be 20 percent of your practice that you see shrivel up and go away.”

In general, family physicians are not opposed to publishing their charges, but what they charge has little to do with what they are paid. As AMA board member Edward Langston, M.D., has stated in an AMA release on transparency, “Gone are the days when a doctor posts fees and patients pay the doctor directly. Now, it’s third-party payers—insurers and the government—who set prices.”

TAFP President Doug Curran, M.D., agrees. “If you came to me and said, ‘Dr. Curran, what does Blue Cross pay you for a level three visit,’ well technically I can’t tell you that. I can give you a range, but I can’t really give you details on that.” Physician fees are dictated by “take-it-or-leave-it” contracts with health plans and if physicians disclose what one plan pays them for a service, other plans will want the same price if they’re paying more.

“As far as patients knowing what I charge,” Curran says, “man, I want them to know what I charge because I’m the best deal in town.” Curran believes that if price transparency is implemented in a way that is fair to physicians, patients will see what researchers have been saying for years: primary care offers patients the best bang for their buck.

Robert Youens is confused by the idea that health plans are arguing for price transparency. “It’s not like the insurance companies don’t already have all of this data. They know exactly what I charge and they know exactly what they pay. They could care less what I charge. … If I were any more transparent, I wouldn’t have to buy clothes.”

What’s Good for the Goose …

TAFP is committed to the goal of health care transparency, Banning says, but equal measures of transparency should be applied across the board. Where price is concerned, simply publishing charges for common physician services doesn’t give patients the information they need—what will their out-of-pocket expenses be, exactly what services are covered by their plan and what is the current amount left on their deductible.

Patients see their physicians as experts on their health plans, and it’s understandable that they would think if their physicians don’t know what services were covered by their plan, then surely they can find out with the click of a mouse. When the Senate State Affairs Committee held its hearing on transparency last July, Karen Kennedy, CEO of the Medical Clinic of North Texas caught the senators’ attention as she explained just how false that assumption is.

Kennedy works with Steve Neorr at the Dallas-Fort Worth practice. She told the senators that her physician group operates under 79 contracts with third-party payers, which translates to approximately 5,000 different sets of benefit plans. “We’re spending over $20,000 a month in additional staff for a 90-physician practice just to try to get the correct information so we can enter that information into the electronic medical record so the physician can have a conversation with the patient in the exam room of what’s covered and what’s not covered,” Kennedy said.

If health plans issued “smart cards” to their members, like ATM cards, physicians could swipe the cards as patients signed in and have immediate access to real-time coverage information. This technology could streamline patient admission and claims processing while giving physicians the information they need to have meaningful discussions about treatment options with patients and what those options will cost them. Smart cards could also eliminate the specter of unexpected medical bills showing up in patients’ mailboxes long after care has been delivered.

“Getting accurate information from the health plans is critical to us in reducing cost and decreasing the frustration of the patients,” Kennedy told the senators.

Whether through smart card technology or through reliable Web portals, real-time verification of benefits may be on the horizon. Jared Wolfe, executive director of the Texas Association of Health Plans, says there is a trend among health plans to implement such technology. “I’ve always thought that the biggest value anybody could deliver to the provider community would probably be real-time benefits verification,” he says, adding that in the past year, Aetna, United Healthcare, Cigna and Humana have all begun experimenting with the technology. The most significant obstacles are the upfront costs of making the change and the fact that the plans do not want to forgo their ability to establish the legitimacy of claims, he says.

Wolfe believes the role of health plans in transparency is to make very complex data understandable to the average consumer. Part of that is reporting physician quality and Wolfe acknowledges that claims data alone doesn’t tell the whole story. “We’ll have to get better at that, and that’s going to entail us working with the provider community.”

“I think that there’s a pretty broad recognition among the plans that the worst of all worlds would be to have 25 different plans with 25 different definitions of what constitutes quality,” he says, adding that most plans agree that a standard measurement system is needed. The plans’ hesitation is about what happens after the metrics are established. “Are we still going to have control about how we develop our particular system? I think they view that as a way of competing with other health plans.”

A Look Into the Crystal Ball

As of yet, no transparency legislation has been filed, but you can bet that with all of the attention the subject has received, there will be soon. TAFP’s Tom Banning predicts that there will probably be a bill requiring hospitals and ambulatory surgical centers to publish a list of prices for common procedures. There’s likely to be some balanced billing legislation that will require health plans, physicians and hospitals to inform patients they may be cared for by an out-of-network physician and be financially responsible for the cost of that care. Additionally, legislation will be filed to require health plans to be more transparent with their financial data and there will be a bill to require plans to implement processes for real-time verification of benefits, Banning says.

As the 80th Texas Legislature began work, the Senate State Affairs Committee released its report including its recommendations on health care issues. On the topic of transparency, the committee recommended that the Legislature implement a process for publishing market value information for health care services and continue discussions on the possibility of publishing health plans’ cost data and financial information. The committee also recommended “encouraging the increased use of ‘smart cards’ for enrollees of health plans.”

On another front, Gov. Perry announced an executive order in advance of the legislative session. The order created an 11-member panel called the Texas Health Care System Integrity Partnership to help establish a “public-private collaborative,” the mission of which would be to “promote a safe, high-quality, transparent and efficient health care system.” Among the duties listed in the governor’s executive order is one directing the new authority to provide “consumers with access to information on the price and quality of health care goods and services, and health care products.”

Of the 11 members appointed by the governor to serve on the panel, there are only two physicians and one consumer advocate. “The panel is dominated by representatives of the business and health plan lobbies,” Banning says. “We will have to be vigilant in tracking the actions of this panel to ensure that the best interests of Texas’ patients are not compromised.”

Physician and patient advocates expect that employers and health plans will continue to push their version of transparency, but TAFP President Doug Curran remains optimistic. “If we play our cards right through the transparency process, we’ll come out as a really valuable asset for health care in Texas.”