Quality Payback for Physicians

CLINICIAN'S ROUND TABLE - TRANSPARENCY IN THE BRIDGES TO EXCELLENCE HEALTH PLAN CERTIFICATION PROGRAM

Transparency is the sound byte of the day. You can't have a conversation without mentioning the word. I feel like <_____>, but without it, can industry, employers, insurance companies, and physicians groups work together in a win-win program. You are listening to ReachMD XM-157, the Channel for Medical Professionals. Welcome to the Clinician's Round Table.

I am Dr. Bill Rutenberg, your host, and with me today is Mr. Francois deBrantes. Mr. deBrantes is the CEO of Bridges to Excellence, a not-for-profit organization that designs and creates programs that encourage physicians and physician practices to deliver safer, more effective and efficient care by giving them financial and other incentives to do so. Mr. deBrantes serves on the board of directors of Maspro, the advisory board of the University of Connecticut, School of Health Administration and E-Health, Connecticut, Connecticut Health Information Exchange.

DR. BILL RUTENBERG:

Welcome Mr. de Brantes.. Thanks for joining us at the Clinician's Round Table.

DR. DEBRANTES:

Thank you.

DR. BILL RUTENBERG:

Bridges to Excellence recognizes and rewards healthcare providers who demonstrate that they have implemented comprehensive solutions in the management of patients. Do you expect the same from health plans?

DR. DEBRANTES:

Well we do and that might be ambitious on our part, but I do think that the health plans and health plan executives with whom we dialogue on a regular basis truly want to respond to employer demands and employer needs in driving better quality and better performance in physician care.

DR. BILL RUTENBERG:

I was recently at a Council of Economics meeting at our local medical society and we had a presentation from Blue Cross Blue Shield and they had a whole list of things in their profiling system that the doctor's office should call patients for this test and that test, and I said to them, you guys have the computer systems, why aren’t you taking the responsibility for contacting them? Is that is something Bridges of Excellence might expect from on insurance company, to get people for their mammography, colonoscopy, stop smoking?

DR. DEBRANTES:

Well really there are a couple of things that we look at in certifying or designating health plan implementation. It is a pay-per-performance program and some of this in response to the activities that Attorney General, Cuomo has had in New York State and I am going to segment it into really 2 parts, 1 is what kind of data are they using to measure and assess the quality of physician care and what methodologies are they using to determine efficiency or relative efficiency of physician care, and on the quality side what we are really truly looking for is whether or not they are using our recognition status as a key indicator and the reason why we are looking for that is because it is based on medical record information, not claims information and so as a result of which it is more reliable and more credible. On the cost side, what we are looking at is, whether or not they are not falling into the trap of small sample sizes, that the methodology is rigorous and standarized, they there are some emerging national standards on all of this.

DR. BILL RUTENBERG:

On March 28, 2008, Bridges to Excellence announced certification of CIGNA, Aetna, and CareFirst Blue Cross Blue Shield. What did they do to meet this criteria. How did they earn certification.

DR. DEBRANTES:

Well the single biggest thing they've accomplished is really harmonization and standardization in the way the look at measure and we word quality performance of physicians, and here is why this is important. When you think about the number of payers that you have in your practice, the different demands from each payer. If each one of them comes with slightly different quality programs and incentives that vary from program to program, it is virtually impossible to figure out what to do and what we found is that in order to motivate physicians to change, in order to give them the ability to quantify the benefits of change, there needs to be a harmonized signal and so that means you know standardizing on quality measures, sending a very strong signal to the physicians that say, if you do X, you will get Y in rewards.

DR. BILL RUTENBERG:

So the goal then is that each of the health insurers will follow a single set of criteria in evaluating the physician performance.

DR. DEBRANTES:

That's correct and that really is one of the commitments that they've made.

DR. BILL RUTENBERG:

Now on the web site again, I am sort of playing a devil's advocate, it says the designation is achieved after a rigorous review of the health plans program and its adherence to a set of core principles that are foundational to Bridges To Excellence's mission. What constitutes a rigorous review?

DR. DEBRANTES:

Well you know, I have been asked this for a fair amount of time and we spend a lot of effort looking at the specific methodologies that the plans are using. We look for the telltale signs of, you know what I would consider to be good versus adequate or bad, and you know it really isn't very complicated. The first step is to look at sample sizes. So if sample sizes aren’t at least greater than 30, the methodology is simply not going to be good enough for us.

DR. BILL RUTENBERG:

And that will be 30 per physician?

DR. DEBRANTES:

30 per physician exactly, right. And you know what, many plans do not reach that basic level of criteria and so that gets amount of our gain.

DR. BILL RUTENBERG:

You wouldn’t even have any power for analysis of the sample size.

DR. DEBRANTES:

Well that's correct, but you have to remember that for many of them, the goal of the assessment isn't necessarily to, I mean, it is partially to create rewards, but is also to create indicators for their plan members and so, you know, since our programs are really designed to look at dollars, we want the precision to be much higher.

DR. BILL RUTENBERG:

Okay, that was the first, what other things are you looking at then?

DR. DEBRANTES:

The other thing we are looking at is the extent to which they are using the right types of case mix adjustors, the extent to which the pure comparison for the right ones, so several elements that aren’t super complicated, but really are telltale signs of good versus simply average.

DR. BILL RUTENBERG:

How will you monitor their compliance over a period of time.

DR. DEBRANTES:

Well right now, the designations really are yearly designations, so they are valid for 1 year based on the programs that the plans have today and so next year we will reevaluate what they are doing.

DR. BILL RUTENBERG:

Are there criteria for revocation of a certificate?

DR. DEBRANTES:

Well, I guess the revocation would happen if they change their methodology mid stream and so far, you know, we have no inclination that they would do that.

DR. BILL RUTENBERG:

But there are monitors?

DR. DEBRANTES:

Yeah we do monitor this and we look at it carefully and you know, these are health plans that we have good relationships with, that we talk to very often.

DR. BILL RUTENBERG:

I would like to welcome those who are just joining us at the Clinician's Round Table on ReachMD XM-157, the Channel for Medical Professionals. I am Dr. Bill Rutenberg, your host, and I am speaking today with Mr. Francois deBrantes, CEO of Bridges to Excellence, and we are discussing transparency in the Bridges To Excellence Health Plan Certification Program.

What is the cost to a health plan of getting certified?

DR. DEBRANTES:

There really is no cost. I mean these plans are existing if you are customers of Bridges to Excellence because we license to them the right to use our programs. So we do this really as a way to inform providers and as a way to inform purchasers, employers about the rigor with which a plan is designing and implementing a basic performance program.

DR. BILL RUTENBERG:

So an insurance company can license the Bridges to Excellence program and utilize it without achieving certification. Certification means that they have complied to your standards.

DR. DEBRANTES:

That's correct. Now you know, the programs themselves have certain principles and certain rules associated to them, that the plans have to adhere to, but the way they use them and blend them, and mix them into their existence incentive programs, really is up to them. However, if they do it, you know, what we would say, they do it the right way, then that is when we would give them our designations.

DR. BILL RUTENBERG:

There was an article in the March 6, 2008, Los Angeles Times, health insurers get poor marks from hospital. United HealthCare Group received an unfavorable opinion of 91% from hospital executives. WellPoint was second worst with 48% unfavorable and CIGNA 47% unfavorable. WellPoint owns Blue Cross - Blue Shield of California and Allan Korn, Senior Vice President, Chief Medical Officer of Blue Cross - Blue Shield is on your board. Shouldn’t this make me a little bit vary of what's going on with the utilization of the Bridges to Excellence program and certification by Bridges To Excellence of these plans.

DR. DEBRANTES:

We look really exclusively at what they are doing on the physician side, so we don’t monitor what they are doing on the hospital side, ours are programs that are really designed for physician incentives, not hospital incentives.

DR. BILL RUTENBERG:

Let me go 1 step further then, again I was at a recent meeting of our council of medical economics, and Blue Cross - Blue Shield of Illinois unveiled their physician profiling program which is entirely based on claims data. Shouldn’t Dr. Korn sort of step in and say, hey hold it guys, I am on Bridges to Excellence and this claims data isn't so good.

DR. DEBRANTES:

You know I think there is broad recognition that claims data are overall inadequate to robust the measure of physician performance. The challenge is that, they are ubiquitous and so it is the type of data that is the most accessible and most used by plans because they have it. Getting data from medical records is complicated. So the challenge of adding different types of data, medical record data to assessment of physician performance is clearly a goal I think of most plans, but the problem is getting a hand on enough data to make the measurement valid and so part of our discussion with health plans has been and continues to be that they should always offer physicians an option. And option A is claims because that is what exists in massive amounts. Option B is medical records and the answer from the physicians can't always be no and no. Because performance assessment is something that is absolutely critical to the employer and consumer communities. So the question really isn't how not be measured more than how can measurement be done in a more robust fashion and that is one of the things that we really look at in our designation and so the extent to which the plans are using our data, medical record base to performance assessments, then they can achieve that certification. If they are not, they won't.

DR. BILL RUTENBERG:

So I guess what I have missed or now I am understanding is that Bridges to Excellence is really a physician-centered program and the health plan certification is not looking at the health plans in terms of the way they are running themselves, but it is really how they are relating to their contracted physicians.

DR. DEBRANTES:

Well that's exactly right and again I mean I think going back to the statements of and the actions from Attorney General, Cuomo, the big issue really is about transparency. What methods are you using to assess performance. Are they robust enough, do they stand the basic tests of reasonableness and what options are you providing physicians in order to both look, understand, and potentially contest the validity of the performance assessment and so I think that's a lot of what we are doing in our designations. We are looking at the methodologies. We are trying to make sure that the methods are fair and equitable and we are forcing……………Incomplete dictation.