Two Insurers Pushing Evidence-Based Medicine

Article excerpt

CHICAGO -- In a trade-off designed to encourage Tennessee physicians to use evidence-based medicine, one insurer is paying for phone calls, e-mails, and other services that are not usually reimbursed.

In the first phase of the project, BlueCross BlueShield of Tennessee will pay doctors in five participating practices for services that physicians say will help them practice better medicine including phone calls, online visits, and group visits. Patients included in the pilot must meet predefined clinical criteria for diabetes, congestive heart failure, or hypertension and be BlueCross BlueShield members. And the physicians in the pilot must agree to use evidence-based medicine guidelines in treating their patients.

Further financial incentives may be provided later in the project.

"There are really only two things that work when it comes to changing human behavior--one of them is incentives, and the other is restrictions," Dr. Steven Coulter, senior vice president and chief medical officer for BlueCross BlueShield of Tennessee said at a conference sponsored by America's Health Insurance Plans. "We got to thinking maybe it's time to focus a little more on the incentives side of that 'how do you change behavior' equation."

So the insurer convened a workshop of employers, hospital executives, physician groups, and others to come up with solutions. "The physicians admitted to not using guidelines, but the reason is that nobody paid them to," he said. "In fact, we create barriers within our payment structures."

The health plan is measuring clinical outcomes, patient and physician satisfaction, and total medical cost, Dr. Coulter said. "We're holding the physicians accountable for the process, but we're holding the program accountable for the outcomes. Physicians see patients one at a time, and all they can do is do the right thing."

Process measures for the diabetes pilot project include the rate of ordering hemoglobin [A.sub. …