Regence and CareCore: Flawed at the CORE!
The Regence Blue Cross Blue Shield CareCore (TRCC) program affects clinics in Oregon and Washington, but the ramifications affect all outpatient physical therapists.
The program is administered by a utilization management company called Landmark Healthcare. Customers of Landmark are health insurance companies that are looking for ways to reduce medical costs. TRCC’s rationale for introducing this program is to address increasing charges for physical therapy services. The primary function of TRCC is to reduce utilization of physical therapy treatments. TRCC has been put into place to restrict and limit access to physical therapy.
Providers were notified that the TRCC program would rate clinic and practitioners strictly on claims history over the past year, though Regence and CareCore do accept comments from providers on an ongoing basis.
TRCC takes the claims history and assigns clinics and therapists a Tier level. Tier A is assigned to “premier” clinics, while Tiers B and C are for those who utilize more visits and units of care. Tier A is assigned to clinics that bill for less patient visits and units per session.
TRCC does not incorporate any components that measure outcomes, quality of care, or complexities of patients. Simply, the less visit units billed for any reason equates to a better rating. In my conversation with a representative of CareCore on November 21, 2014, they are planning to one day incorporate some means to measure value.
When Regence rolled out TRCC in November 2013, all their members (our patients) were required to be preauthorized for physical therapy treatment. Many of us have vast experience with this challenging dilemma of wanting to help clients while having to spend inordinate amounts of time completing authorizations that are imperative to be paid for services rendered.
The rollout of TRCC was poorly organized in all facets from the website to clinical education and preparation. TRCC started as a complete fiasco and a year later has improved by 15 to 20 percent due to some improved systems thanks to considerable efforts put forth by the APTA, clinicians, and Regence members. It continues to be a giant administrative bottleneck. There has been little regard for the additional time of therapists and concomitant additional administrative costs.
One example of an administrative bottleneck is TRCC’s inability to fax us updates on authorizations completed for the first 9 months. It took almost an act of Congress with significant lobbying efforts by us and the Northwest Rehab Alliance (NWRA) that this finally was addressed. Addressing this issue took at least 60 hours of our administrative time to complete. As a group, we might consider including language in contractual agreements that reimburses us for unproductive foibles for which we are not responsible in the future.
The program does not have any positive benefits for consumers or clinics. Quality clinics are interested in ways to reduce costs to all parties while improving value. Consumers are buying products and services that fulfill their needs and offer value. The definition of value is that the product or service being purchased will be a worthwhile investment of time, effort, money.
TRCC comes with significant cost to Regence. Is this being paid for from administrative funds or patient care funds? I have not been successful in clarifying this with Regence or CareCore. Will the cost of TRCC produce savings or turn out to be useful to any or all parties involved?
I am going to take the liberty to discuss one of the challenges of Regence and other insurers in the ever changing health care system. Regence is one of a number of for-profit insurers. As a clinic owner, I am also looking for a reasonable level of profitability and viability. Where is the incentive of Regence or any insurer to look for quality and long term health improvements for their member groups and individuals? Some purchase health care strictly on cost while others are looking for value. Many individuals have no choice but the plan(s) their companies offer them. One must respect and be aware of this conundrum. Entire books have been written on this topic.
From a physical therapy provider perspective, any quality provider is interested in providing quality cost effective care to those clients who chose their facility. I believe that the vast majority of physical therapy providers not only offer such care, but are concerned over the cost of such care to both the clients and payers’ such as Regence. We look at each new client for the long term. We are hoping that when and if they need physical therapy services in the future that we will be chosen. We are hoping if the customer has a positive experience, they will refer their network of friends, family and colleagues. Are Regence and other health care insurers concerned with long term benefits?
Historically, there has been value in being a Regence provider. We provided quality care effectively and efficiently. Payment for services rendered was made in a timely manner. The administrative costs to bill and collect were reasonable. Until November 2013, it did not take an act of Congress to be able to work with the Regence members. My relationship with Regence has always been of mutual respect, even during implementation of the TRCC program. I also like and respect the relationship I have developed with my CareCore contact, Ms. Vycki Rupakus PT, DPT, MS, who is the director of therapy services for TRCC.
The Regence members and those companies who chose to purchase such a plan believed they would be able to access health care in a reasonable manner without arbitrary restriction. Unfortunately, TRCC is a program based on restricting care to members while simultaneously more than quadrupling the administrative costs to authorize these patients.
Thus, like any intelligent business owner and concerned therapist, I investigated the tier parameters. TRCC has been helpful in explaining how they determine tiers and the information utilized in making such determinations. In November 2014, TRCC utilized updated clinical outcomes for assessing a tier.
My clinic continues to be Tier B. We are in the process of appealing this secondary to the following figures from the CareCore. TRCC compares your numbers with a peer standard. We feel we might have a case due to our patient visits per episode being 5.2 versus the peer standard of 7.1. Our modality use is 0 versus the peer value of .4 units per session. Number of units of exercise and manual therapy units per session is the third measurement. We are 3.3 units versus the peer standard of 1.3 units per session. It appears we are being penalized for spending one-on-one time with patients in which we average 3.5 units per patient visit to the peer standard of 3. 4. I have offered the TRCC our values from Care Connections. We do not use physical therapy aides or assistants. We are not a Tier A clinic due to averaging .1 more units per session of care.
Regence could have chosen to utilize and incorporate available outcome measurements. Physical therapists are collecting such data through a number of statistical analyses such as Care Connections, FOTO and others. One of the major reasons I recently joined the Northwest Rehab Alliance is because they ask providers to measure functional outcomes. We invest monthly to measure these outcomes.
PTPN, another provider network, is presently utilizing such metrics with their members. PTPN presented their data at the recent PPS conference in Colorado Springs on Friday November 7, 2014. The title of their presentation was, “Outcomes=Income: Is your practice making the most of Healthcare’s Alphabet Soup. “ Their top clinics earn bonuses for achieving certain outcome measures.
Fortunately, the APTA, OPTA, NWRA, private practices, therapists, consumers and many others are fighting back. TRCC has made some minor changes, but there are many more that need to be made.
Regence should cease this program until the program incorporates outcomes. Collaboration between the interested parties could do this in a timely manner. The definition of value is quality effective, efficient care with qualified outcomes.
Is this an example of a large corporation taking undue advantage of clinicians and their paying members? Is this corporate warfare against physical therapy and those we treat? Is this a way for Regence to get a grip on over utilization of physical therapy services by some providers? Are there other ways that could satisfy all parties in the long term or short term? These are all questions for one to contemplate. The solution is not black and white.
Below are a few ideas that we continue to suggest to Regence members and other physical therapists as a way of working through this challenge.
- We take the time to explain to members that care is being restricted.
- Physical therapists and clinics can call Care Core to discuss what can be done to improve the systems.
- Patients can call Care Core directly. Regence prefers they call them directly at 800-676-2583.
- Contact the Oregon Insurance commission; Phone: 503-947-7984, Fax: 503-378-4351, 888-877-4894 (toll free), firstname.lastname@example.org, www.insurance.oregon.gov.
- Contact elected officials.
- Contribute to the Oregon PAC (Political Action Committee) and PT-PAC so we can have the necessary political clout to fight back and protect ourselves.
Isn’t it time for us stand up as a united physical therapist front? Are we going to let Regence or any insurance provider dictate care while demeaning the physical therapy profession? Our choices are to be aware, get involved and take action. We as a profession can be involved on all levels or expect a gradual decline of earning potential with the concomitant reduction of the ability to provide quality care necessary for long term positive outcomes. It is time to stand up and be heard. We must do it now and then continue to be proactive!
Keith Glasser PT, MS, Cert MDT
Chief Executive Officer of Optimal Results Physical Therapy