Health & Welfare | Daily Report

Blue Shield's rating system appears on the individual pages for each doctor.

For anyone who has had a common cold, an ongoing debate between a major California health insurer and the group that represents doctors is one to watch.

At the heart of the battle is whether the practice of medicine can be graded like a student’s performance on a test. Insurers want to rate doctors; doctors are pushing back.

All of this is coming to a head as soon as tomorrow when Blue Shield of California is expected to ask an Alameda Superior Court judge to dismiss a lawsuit filed by a doctors' group over a controversial rating system.

Here’s how the battle found its way into court:

In June, Blue Shield of California unveiled a website rating hundreds of doctors and major medical groups throughout California.

The ratings are steeped in a movement called “evidence-based medicine.” It’s a school of thought that acknowledges that doctors can pick a prescribed course of action that is widely accepted as beneficial or potentially harmful or unduly costly. The New York Times magazine wrote a long and fascinating profile of one doctor's efforts to bring this movement to life in a Utah hospital system.

Along those lines, Blue Shield created scores that are a mash-up of measures that conventional medicine has come to accept. They include measures of whether doctors are handing out antibiotics for the common cold, a move considered problematic since it is unnecessary and can give rise to antibiotic resistance.

The doctor rating website also looks at whether doctors are giving asthma patients medicine (good), testing diabetic patients annually for kidney function (good) and giving MRIs to back-pain patients (bad). The latter is considered inefficient because lower back pain tends to resolve just as well without expensive medical care, according to studies.

Also included in the ratings are measures of efficiency, which look at doctor use of generic medicines (efficient) and use of emergency rooms (inefficient).

The ratings were controversial, though, even before they were unveiled. The California Medical Association withdrew its support from the stakeholder input phase of the project in April and aired its distaste.

The association described what it called “serious and disturbing flaws” in the rating system. They include an increase in costs if doctors start duplicating tests that aren’t captured in the rating data. The rating might not count care that patients get out of the physician networks that are being evaluated. And the ratings fail to account for instances when patients refuse recommended care.

"Publishing erroneous information will only serve to confuse patients, increase costs and unjustly destroy the reputations of many fine doctors," the group's president, Dr. Brennan Cassidy, said in a statement issued in April.

The medical association soon followed with a lawsuit alleging that Blue Shield “has touted its Blue Ribbon Recognition Program as identifying physicians in California supposedly providing superior care,” but it is actually “an economic profiling scheme.”

In other words, the doctors' group is accusing the insurer of rewarding doctors that are helping the insurer pad its bottom line. The lawsuit, filed in September in Alameda Superior Court, criticizes Blue Shield for creating a system that does not include review of individual patient medical records and looks at only one year of billing data.

Blue Shield has responded to the allegations [PDF] in press statements and in court. The insurer said in a statement that their rating system “does not consider cost and does not penalize physicians.”

The insurer’s response said the ratings are drawn from industry-standard measures of quality care. It also said doctors were given ample opportunity to review patient records and submit information to correct any problems with the data.

Blue Shield enjoys the support of several organizations in the project, including the Service Employees International Union, California Healthcare Coalition and the AARP.

Jeannine English, a member of the AARP board of directors, told the trade publication Fierce Healthcare “that her organization sees publicizing doctor performance statistics as ‘empowering’ to patients and that doing so encourages them to ‘take a more active role in their healthcare.’”

For now, the rating system is still posted at the Blue Shield website, along with detailed explanations of how it works.