The national Blue Cross and Blue Shield Association released a set of clinically oriented guidelines earlier this month out of what it called "a sincere desire" to foster better communication and trust between the nation's physicians and its 45 member plans, which cover 80 million Americans.
Skeptics, however, said the document is simply another self-policing promise designed to head off the passage of federal patient-protection regulations, which could greatly restrict managed-care practices and increase insurers' liability. The guidelines are voluntary, so individual Blues plans are not required to adhere to them to maintain their Blues licenses.
The 10 recommendations address issues surrounding the role of doctors in clinical decisionmaking-a topic that has long been a source of tension between physicians and insurers. Guideline No. 1, for instance, recommends that health plans involve network doctors in clinically oriented committees and tasks such as credentialing providers, developing formularies and medical policies, and hearing member appeals.
"Most of us believe that managed healthcare has taken a wrong turn when it comes to physician relations," said Scott Serota, president and chief executive officer of the Chicago-based Blues association. "The good news is, we jointly believe the guidelines can help us get back on track in improving relationships."
The guidelines are based on a set of policies that the American Medical Association introduced to its 290,000 member physicians in December 1998 and later shared with the Blues association as part of ongoing talks between the groups.
Key provision dropped
The two sets of guidelines are very similar, with one key exception: The Blues' version leaves out a provision that urges healthcare providers to "be accountable to their peers for professional decisions based on accepted standards of care."
Some suggest the guideline was omitted because it hints at the thorny issue of insurer liability. Providers have long argued that health plans should be held just as legally accountable for their coverage decisions as doctors are for their medical decisions.
Insurers are shielded from malpractice lawsuits by the 27-year-old Employee Retirement Income Security Act, which prohibits patients from suing their HMOs in state courts or collecting damages in federal suits.
Skeptics also point out that the Blues association announced its guidelines at a time when health insurers are combating not only heightened criticism but the threat of greater industry regulation. Blues plans, in particular, have been under fire for pursuing for-profit conversions and mergers, moves that consumer advocates complain are compromising patient care for the sake of greater company profits.
"Much of this is a public relations tool, a `we care' statement designed to ward off the more onerous prospect of patient-protection legislation," said Ronald Pollack, executive director of Families USA, a consumer healthcare group in Washington. "These sentiments have been voiced before, with very few results."
`Code of conduct' similarities
Indeed, the guidelines are highly reminiscent of the "code of conduct" trumpeted in 1996 by the American Association of Health Plans, which represents more than 1,000 insurers, including several Blues plans. Although the AAHP made its code mandatory in 1997 and vowed to oust any member that failed to comply with the code's 12 provisions, not a single plan has ever gotten the boot.
Both the AAHP's code and the Blues' new guidelines address the controversial issue of "gag clauses." The AAHP's code states, "Nothing in any health plan policies or contracts ... should be interpreted as prohibiting physicians from discussing treatment options with patients." The Blues' guideline No. 4 likewise states that, although health plans make coverage decisions, "participating network physicians must be able to discuss all treatment alternatives with their patients."
The organizations' directives also overlap on issues of utilization management, quality assessment, practice guidelines, drug formularies, credentialing and member appeals (See chart).
"They're nice statements of sentiment, but so far they've been much ado about very little," Pollack said.
For its part, the AMA is viewing the Blues' adoption of the guidelines with cautious optimism.
"It's a step in the right direction, and we applaud that," said Donald Palmisano, M.D., a member of the AMA's board of trustees. "But it's one thing to recommend a policy and quite another to follow through on it. We'll have to wait and see if the guidelines are acted on."
And despite the AMA's endorsement of the new guidelines, Palmisano added, Blues plans and physicians remain at odds over federal patients' rights legislation.
The Chicago-based AMA has been adamant in its support of legislation that would allow patients to sue health plans, including those of self-insured employers, for damages. The Blues association, on the other hand, argues that lawsuits would increase healthcare costs and that coverage disputes should be settled though external review and arbitration.
The AMA is backing at least two lawsuits involving Blues plans-one filed by patients against Blue Shield of Maryland and the other filed by doctors against Blue Cross and Blue Shield of Georgia.
Still, the new guidelines are an important first step toward finding common ground, said Allan Korn, M.D., the Blues association's chief medical officer.
"We all recognize that the guidelines do not address all of the issues between us," Korn said. "Our hope is that these recommendations will serve as a way to open the dialogue between us and create more opportunities for collaboration to benefit the membership of both organizations."
