Since QualityAffordability.com launched in the summer of 2009, we have received a steady stream of feedback from our visitors on a variety of issues. Our goal is to answer every message. Below, we've summarized some recent comments, questions, complaints, and shared our responses.

Choose a topic:
Health Reform
Alternative Quality Contract Pay for Performance
Premium Prices and Benefits

Health Reform

Question: What do you think about proposals for a government run health plan?

Reply:
Blue Cross Blue Shield of Massachusetts, along with many others in the health care industry, believes a government sponsored health insurance plan is not needed to accomplish national health care reform. Here in Massachusetts, we expanded coverage to more than 400,000 previously uninsured residents without a government option. We believe that market changes and system reforms would accomplish the same goal with far less disruption to the health care delivery and payment system.

We are also concerned about cost shifting. The federal government is the largest payer for health care in the nation. Historically, the government has consistently underpaid doctors and hospitals for their services. According to Milliman Inc., an independent actuarial and consulting firm, this cost shifting adds $1,788 dollars to the annual cost of the average American family's insurance policy. A government option would increase cost shifting to the private sector and cause private health insurance costs to rise. Furthermore, health insurers in our state, including Blue Cross Blue Shield of Massachusetts, are consistently ranked among the best in the nation for quality of service. A public plan would threaten the good work of high-quality, single-state, non-profit health plans like those in Massachusetts, by forcing them to unfairly compete with large, national, for-profit insurers and the federal government.

Finally, a strong private insurance system is integral to designing and implementing the necessary delivery system reforms to ensure that we have a high-quality, high-value health care system. The private market has the ability and agility to innovate unencumbered by political pressure or changing administrations.

Alternative Quality Contract Pay for Performance

Question: How do we determine quality?

Reply:
We evaluate quality using nationally recognized, widely accepted, validated measures. Wherever possible, we use measures that have been endorsed through a national consensus process, such as the National Quality Forum. And we go beyond this to ensure that the sample sizes available to us for each measure meet high standards for reliability and stability. We include patient experience, as well as measures of clinical care processes and clinical outcomes, in evaluating quality. Patient care experiences are also evaluated using nationally accepted measures that are based on the Agency for Healthcare Research and Quality family of measures, including ambulatory and inpatient measures that address the quality of clinician-patient communication, access to care, staff responsiveness, and integration of care.

Question: Couldn't your Alternative Quality Contract lead to doctors providing less care?

Reply:
One of the innovations of our Alternative Quality Contract (AQC) is that it rewards providers for how their patients do with treatment. Doctor's would not be able to achieve the quality measures that lead to incentive payments by withholding care. Many of the nationally accepted measures included in the AQC involve patient outcomes. Patients cannot have a positive outcome if appropriate care is NOT provided. For instance, providers are rewarded for providing disease screenings as recommended by medical research, or for performing regularly scheduled wellness visits for infants and adolescents. Learn more about our AQC.

And while the AQC ensures patients get the care they need, Blue Cross Blue Shield of Massachusetts is working diligently to make sure our members get the care they need. Be sure to check out What We're Doing About Overuse, Underuse, and Misuse to learn more about the steps we're taking to reduce health care waste.

Question: How will this model allow for payment of outpatient physical therapy services in private practices?

Reply:
Our Alternative Quality Contract will not change the payment to providers of your specialty in private practices. Your fee schedule will continue as stated in your contract. What may change, however, is the number of visits and volume of referrals you may receive as primary care providers (PCPs) operating under our Alternative Quality Contract, evaluations of the clinical effectiveness of the services provided by specialists and therapists to whom you refer your patients. The PCPs who refer patients to you may also require more detailed progress notes and want those notes more often then currently provided.

Our Alternative Quality Contract is designed to improve the quality and effectiveness of care our members receive. Instead of paying providers for more tests, more visits, and more procedures, it rewards doctors and hospitals for meeting nationally accepted standards of quality and for their patients' outcomes. Our AQC also makes the PCP responsible for managing and coordinating the care his or her patient receives, which is why PCPs may ask for enhanced documentation of their patient's progress.

If you haven't read it already, view a detailed description of our Alternative Quality Contract.

Premium Prices and Benefits

Question: Why is my individual premium going up/so high?

Reply:
Our premiums reflect the cost of heath care services. About 90 cents of every premium dollar we collect is used to pay for these services. Health care costs are being driven by two main factors. One is the rising unit price of care. For example, the cost of a doctor's visit or prescription this year compared to last year. The second factor is the growing use of health care; more people are getting more health care than in the past, and intensity of health care services is increasing. An example of that would be our growing reliance on high-tech health care such as MRIs over X-rays.

So the growth in the actual price of health care and increases in the use and intensity of that care is what is driving your premium.

We are working hard to control this. According to the Institute of Medicine, as much as 30 percent or more of what we spend on health care as a nation is wasted through the overuse, underuse, and misuse of health care. We are working to reduce and eliminate this waste. The first and most important step is to change the way we pay for health care so we start rewarding the quality of care, not just the quantity of care. If you haven't already, please read about our Alternative Quality Contract.

We are also working with doctors and hospitals on this issue. You can learn more by reading What We're Doing About Overuse, Underuse, and Misuse.

You can find out just how much we can save by eliminating the overuse, underuse, and misuse of health care services by visiting the New England Health Care Institute. Their research documents examples of waste and their costs to the health care system.

Question: Why aren't certain prescription drugs (like Allegra D^®'' 24) covered?

Reply:
One of the ways we manage the rising costs of health care for our members is to encourage the use of generic and over-the-counter medications. Because over-the-counter, non-sedating antihistamines (like Claritin^®'' and Zyrtec^®'') are widely available and are as effective as prescriptions drugs, we no longer cover non-sedating antihistamines that require a prescription. Your doctor should be aware of this change, and should be able to recommend an over-the-counter medication that will work best for you.

The changes we have made to our pharmacy benefit that promote the use of generic and over-the-counter medications have been successful in reducing the cost of health care for our members. Any changes we make to our pharmacy benefit are made after a thorough review by our Pharmacy and Therapeutics Committee, which includes independent doctors and pharmacists not employed by Blue Cross Blue Shield of Massachusetts.