Stanley Feld M.D.,FACP,MACE
I have mentioned mistrust by physicians of the insurance industry, the government and hospitals. I have also pointed out the invaluable potential of the Ideal EHR in helping physicians increase the quality of care delivered without being penalized by the insurance companies and government. This mistrust is part of the reason for delayed adoption of information technology by physicians.
Steven Petak M.D., J.D.,FACE, FCLM, current AACE(American Association of Clinical Endocrinologists) President wrote an important editorial in First Messenger (the Newsletter for the AACE) illustrating the danger Information Technology presents as a tool against doctors by Blue Cross/Blue Shield of Texas.
BC/BS of Texas data collection resulted in a defective value judgment of Dr. Petak’s quality of care. BC/BS information technology system made that judgment measuring the wrong thing. BC/BS clearly did not understand the use of a specific drug. Dr. Petak is an excellent doctor as are others in his group. Blue Cross/Blue Shield of Texas did not bother to ask Dr. Petak why he did not practice evidence-based medicine while using the drug metformin.
BC/BS of Texas simply awarded Dr. Petak with a gray ribbon (which is bad) for the whole world, his patients, and potential patients who have insurance with BC/BS of Texas, to see. A dark blue ribbon in the Texas Blue Compare program of Texas Blue Cross/Blue Shield stands for excellent. A light blue ribbon is defined as good or average. How would you, as a patient, like to be going to a bad or average doctor? You wouldn’t!
The ribbon classification is available for all the BC/BS of Texas insured patients. It is an attempt at quality transparency for the benefit of their insured members. The coveted dark blue ribbon would indicate to the world that physicians have mastered applying evidence-based medicine and cost efficiency to their patients. Dr. Peak states “ The dreaded gray ribbon would only communicate my shame and wanting to the world. Although a gray ribbon is defined as not being able to provide a measure because of insufficient data for the physician or specialty or their threshold was not met, I knew my hard won reputation for excellence would now be lost”.
What did Dr. Petak do wrong? He failed to meet the evidence-based requirements concerning diabetes care. He did not do enough eye exams, HbA1c, and urine microalbumin assessments. Metformin is used to treat diabetes. Dr. Petak does not treat Diabetes Mellitus and had so informed BC/BS. He did not submit the claim form with a diagnosis of Diabetes Mellitus. He sees many patients with Insulin Resistance Syndrome (Metabolic Syndrome). Metformin is used in the treatment of Metabolic Syndrome by many specialists. Many female patients with Metabolic Syndrome do not ovulate. When the insulin resistance is treated they can ovulate and become pregnant.
Patients can buy metformin for $4 per month at Wal-Mart. If they had a successful ovulatory cycle and became pregnant, the patient has avoided the multiple tests and procedures of in-vitro fertilization. The saving to the patient in stress, anxiety and money is enormous. The savings to the entire cost to the healthcare system is great.
What was BC/BS of Texas’ problem? The problem was a lack of understanding of medical care. They did not evaluate Dr. Petak with accurate or useful information. Their computer system did not search for the diagnosis of Diabetes Mellitus. They assumed he was treating Diabetes Mellitus. They did not ask Dr. Petak why he used metformin. They simply penalized him. They only evaluated him with one of the elements of quality care. They simply used the tests that should be performed at a given interval in treating a diabetic. BC/BS was only interested in showing the world they are a great company protecting their patients from bad doctors. They had no concern for the physicians’ reputation or the physician-patient relationship.
There are other of examples of insurance companies evaluating quality care with the wrong criteria and presenting physicians with report cards that seem meaningless to me. This is part of the reason there seems to be such resistance to the Pay for Performance. It is simply mistrust by the patients of the insurance companies and the government. Both have declared they want to gain our trust. However, they continually act in a way that creates an environment of mistrust.
Bravo, Dr. Petak for publishing this example. The ideal EHR must be set up so it is physician friendly and a physician extender. It should not be a weapon to be used against the physician.