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Risk Adjusted Cost Index – Blue Cross in Texas Agrees to not terminate physician contract for referring to physicians outside ne

Posted Apr 12 2009 11:51pm

If this is not risk management by insurance companies calling the shots for healthcare, I don’t know what is, and stands to completely work to image disintegrate the doctor-patient relationship, not to mention the insurance company doctor relationship.  It seems like every week there’s some new risk management guideline established that is something we need to be aware of.  Last week, for example, those with Blue Cross in Michigan are out of luck for insurance if they have had a sex change.  I have no opinion on the individuals one way or another, but the point being made here is what’s the next group to be ruled out, and yet there’s a ton of money being invested in Blue Cross Venture Capital, so and thus far the investments appear it be promoting software companies that an even perhaps drill down further into the analysis processes, so the business intelligence software with health insurance companies continues and by the way, the organization in Michigan is part of the VC venture.  

You can read more about the AMA and their questioning of how business intelligence software is being used with the recent Senate testimonies relative to Ingenix, which was used by many major carriers and the company, a subsidiary of United Health Care made 1.3 billion last year doing this.  Senator Rockefeller has asked for reports from 20 carriers on how they used the service, etc.  Recently Blue Cross was told to suspend 2 Part D plans.   The California Medical Association has stepped in here too.   

Prescriptions risk score used to deny health insurance

Docs Outraged across the US at Blue Cross Request

Doctor's Outrage: Asked to Rat on Patients?

This is also part of the reason we have this:  Desperate Hospitals – March 2009 Update

It just seems to appear that there’s a whole ton of money out there to invest, but not enough to pay claims, which I believe to be the basis of the business, correct?    Risk management loves medical devices too that can track everything so they can have documented proof, and there’s a time and place for some of this, but the pendulum is swinging too far as if left unmanaged you will be wearing a device some day that will record the day you conceive, they want proof on everything.  Insurance companies already are trying to institute such an approach with devices that are human audit trails , if the employer has employees tied to devices and they get proof, well they get a discount.  If left unmanaged and uncontrolled as it is today, this will grow behind the scenes and one day it will hit the fan and everyone will wonder “how did this happen”.    We can’t forget we are human and risk management appears to see nothing wrong with getting more information in which ever fashion they come up with next, being all the way down to devices that are human audit trails.  Device manufacturers too are targeting insurance companies for sales of such devices as well, as publicized on the internet.

If you are a senior driver, Allstate has “brain fitness” software too to help in the evaluation process of what you pay, so it’s creeping into other areas of insurance as well.  There are great tools with many medical devices, but to purely administrate for the use to risk management only is a crime and much of this is being marketed as health tools in disguise,  when in reality the bottom line is not education but rather audit trails with devices to enhance risk management business intelligence.  I am all for enhancing healthcare intelligence for better knowledge and there’s a bit of a fine line on how and where devices should function here with implementation for one and regulatory control for a second as there is none for many of them and nothing that discusses human rights relative to their use.      BD   

AUSTIN - Texas Attorney General Greg Abbott on Thursday resolved the state's probe into a Blue Cross Blue Shield of Texas' (BCBS) physician rating program that used cost-based indicators to rank doctors. Under today’s Assurance of Voluntary Compliance, the health insurance company agreed to refrain from using its Risk Adjusted Cost Index (RACI) – to rate doctors as more or less affordable in providing quality medical treatments and achieving a desired health outcome for patients.

Today’s agreement also resolved investigation into Blue Cross’ handling of so-called out-of-network referrals. According to state investigators, Blue Cross threatened to terminate physicians solely on the basis of referring their patients for medically needed treatments from qualified specialists that were outside the Blue Cross provider network.

"It is not appropriate to interfere with the protected doctor-patient relationship by terminating a doctor solely for making good faith out-of-network referrals for necessary care," said Attorney General Abbott.

Under the agreement, BCBS agreed to stop publishing and using its RACI methodology to assign doctors’ ratings. The company also agreed not to terminate or threaten to terminate doctors for solely for making referrals for medically necessary care outside the BCBS network.

Texas Attorney General

Related Reading:

Physicians are not a real happy group today - survey

The 2 New Hot Words in Healthcare: Algorithms and Whistleblowers

Doctors fight balance-billing ban on out-of-network costs to survive
Will Greed lead to Meltdown of the Health System?
“Beware of Geeks Bearing Formulas”…Warren Buffett
Blue Cross Blue Shield No Longer Covering Gender Reassignment - Michigan
The AMA and the California Medical Association file legal suit – WellPoint and Ingenix

Health Insurance Underwriting procedures – Data Mining to Cherry Pick and some are listed on the Web

The search for John Doe – Who’s running the queries (Algorithms) and wants to know

The Ingenix Inquisition – Hearing Requested by Senator Rockefeller

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