OAKLAND, Calif. (CN) – The California Medical Association has filed a 7-count class action against Blue Shield of California. The CMA claims the insurer’s “Blue Ribbon Recognition Program,” which “rates” doctors is an “economic profiling scheme that inaccurately and unfairly ‘rates’ the physician plaintiffs and members of the physician class through the use of an inherently flawed methodology.”
The CMA claims the insurer’s rating system cannot possibly measure physicians’ quality of care because Blue Shield does not review medical charts to determine if proper care was given, does not evaluate patient outcomes, makes no allowance when a patient has more that one doctor, uses only 1 year of claims data, and limits its date to patients eligible for only 16 procedures.
The CMA adds that its member doctors are given “woefully inadequate” opportunities to review and correct the “error-fraught” data.
The CMA claims Blue Shield worked up its Blue Ribbon Recognition Program with two other big insurance companies in a cooperative effort called the California Physician Performance Initiative.
“In addition to portraying its network physicians in an unfair and inaccurate manner, the Blue Ribbon Recognition Program also fails to provide adequate explanations and disclosures regarding the basis for its ‘ratings’ and the fact that not all physicians are even eligible to receive a blue ribbon,” according to the complaint.
The class claim the Blue Ribbon Recognition Program is a scheme designed “to inject HMOs or insurers squarely into the physician-patient relationship.”
“Economic profiling schemes, at bottom, are intended to cause a physician who is more expensive for an HMO or insurer to pay to receive less patient traffic than physicians who provide patient care at a lower cost to HMOs or insurers,” the complaint states.
The CMA claims that “numerous physician groups” throughout California have complained about errors in the program, but “rather than drop the program or start over after correcting the fundamental flaws in its program, however, CPPI tried to shift the burden of identifying and correcting errors to individual physicians through a multi-step, time-consuming process that was poorly explained and communicated to physicians.”
The CMA and lead plaintiffs Drs. Lisa Asta and Richard Stern want Blue Shield ordered to stop the program and inform the public about the “wrongfulness or inherent limitations” of the ratings.
The class also seeks damages for violations of California Business and Professions Code and breach of contract. It is represented by Raymond Boucher with Kiesel Boucher Larson in Beverly Hills.
(Editor’s note: Blue Shield replied to this CNS story with a long email defending its Blue Ribbon program.
(Blue Shield said: “The performance results are drawn from data collected by the California Physician Performance Initiative (CPPI), a multi-stakeholder initiative run by physician organizations, health plans, purchasers, consumers and health data experts to measure and report on the performance of California’s physicians. Started in 2006 and managed by the Pacific Business Group on Health, CPPI aggregates claims data covering more than 5 million patients and 63,000 physicians to generate a reliable set of quality metrics.
(“The Blue Ribbon program provides disclosure to physicians and our members about the methodology used. It does not consider cost and does not penalize physicians.”)