Blues plans are creating a giant claims database

Physicians are concerned about the ways insurers use such information and about reliance on claims data alone for making cost and quality decisions.

By Jonathan G. Bethely, AMNews staff. Sept. 11, 2006.

For years insurers have been creating databases to warehouse the details of claims data. Insurers have also used the same claims data to assess quality and efficiency designations, a practice many physicians say is notoriously unreliable.

With Blue Health Intelligence, a HIPAA-compliant claims database with information from 20 Blues plans, Blue Cross Blue Shield Assn. is joining the list of insurers using claims data to track medical trends. The database compiles treatment details, minus the patient's name, of 79 million people nationwide.

Blues officials say the data are expected to provide a peek into how people use the health care system, part of an ongoing industry trend to provide more transparency. But physicians say insurers, including the Blues plans, are using claims data to cut costs. They also say insurers have often used claims data to unfairly guide patients to physicians identified as the cheapest.

"Claims data are for doctors to get paid," said Larry Fields, MD, president of the American Academy of Family Physicians. "It's not for insurance companies to try to direct patients to low-cost facilities or physicians. It certainly has nothing to do with quality, and insurance companies should not try to disguise their use [of claims data] as quality measurers."

Dr. Fields said insurers have relied on claims data because they already have this information at their fingertips. He said insurers haven't been as ready to use evidence-based quality guidelines because physicians would have to be paid to report that kind of information.