A coalition of 35,000 California physicians Monday angrily withdrew its participation from Blue Shield's new "Blue Ribbon" rating system saying it will harm the reputations of good practitioners by giving patients misleading and faulty data about their care.
In a statement, the California Medical Association said the system, the California Physician Performance Initiative (CPPI), scheduled to go public June 1, will provoke doctors "to order tests or procedures that have already been done," and will score doctors on data that often is not relevant because it is based only on billing claims.
"For instance, physicians who don't order cervical cancer screening tests for their patients, even if the patients have already had hysterectomies, would get a lower rating," the CMA says.
Some 13,000 high-volume physicians would be scored on evidence-based healthcare quality standards.
"We're being ignored and our concerns aren't addressed. No point in participating if they're going to publish and not make an honest effort to address our concerns," says Andrew LaMar, CMA spokesman. "I don't know what the end result is if patients and payers and physicians and everybody who is supposed to benefit from this don't have confidence that these are reasonable ratings that use a process that's accurate and fair."
The system also would reduce scores for doctors whose patients saw an out-of-network, non-contracting provider for their pap smears and didn't tell their primary care physicians. That physician "would be penalized because there would be no pap smear claims data submitted to the health plan," according to the CMA.
LaMar says the CMA blasted the rating system the same day that Blue Shield announced the program would be the "largest initiative in California history to measure physician performance."
Blue Shield officials took strong exception to CMA's criticism saying that the scoring template was worked out over years with numerous stakeholders in the interests of transparency.
"We want to get individual information about physicians, and people want to know which providers have a tendency to follow evidence-based guidelines," says Blue Shield spokesman Aron Ezra. He added that CMA's concerns that a doctor might not do a test on a patient for legitimate reasons are ill-founded.
"It's not like one specific example would throw off the data," Ezra says.
The CMA had worked for two years to produce the system, along with health plans, purchasers, consumers, and health data experts affiliated with the Pacific Business Group on Health, a coalition of 50 purchasers and the nonprofit Blue Shield. The initiative began in 2006.
In a news release Monday, PBGH President and CEO David Lansky said "we know that the doctor-patient relationship is at the core of our healthcare system. That's why the CPPI is so important to California's employers and families ¬to help patients make the best decisions about where to seek care."
Groups that support CPPI are the American Association of Retired Persons, the California Public Employees' Retirement System, the Service Employees International Union, the California Health Care Coalition, the California School Employees Association, and Southern California Edison.
CMA's concerns
In an April 15 letter to Blue Shield President and CEO Bruce Bodaken and Lansky, the CMA listed a number of other concerns:
The quality metrics used in the score do not capture patient outcomes, and only offer a "cursory view of the overall care provided by a physician."
On April 16, in a letter to CMA Chief Executive Officer Dustin Corcoran, Blue Shield of California's Chief Medical Officer Meredith Mathews, MD, defended the rating system.
"We strongly disagree with your statement that CPPI data is not reliable enough to use since it is based on claims data," he wrote. "The CPPI measures all reflect evidence-based medicine and embody services and tests the patient should receive, as agreed upon by the wider medical community. They measure a range of services that are critical to achieving favorable outcomes for cancer patients, diabetics, and patients with heart conditions."
He also wrote that physicians can correct data before it's published, that physicians "are not penalized, only acknowledged for superior performance" and said that if another doctor provides a patient's service, other doctors that delivered care to that patient would get credit for that service.
He added that "quality transparency is critical and long overdue. Californians have access to quality information on hospitals and medical groups, but currently have no information on their individual physician."