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Related Experiment Videos

Paying the physician's fee: Blue Shield and the reasonable charge.

T L Delbanco, K C Meyers, E A Segal

    The New England Journal of Medicine
    |December 13, 1979
    PubMed
    Summary

    Physician control over Blue Shield fee negotiations led to significant increases in medical procedure costs, particularly for surgeries. Greater transparency and public oversight are needed to reform these payment systems.

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    Area of Science:

    • Health Policy
    • Medical Economics
    • Public Health

    Background:

    • Physician fees and income are subjects of ongoing debate.
    • Blue Shield plans and programs have evolved to determine physician payment structures.
    • Medicare's "reasonable-charge" formulas influenced Blue Shield's "usual, customary, and reasonable" (UCR) payment models.

    Purpose of the Study:

    • To describe the evolution of Blue Shield physician payment systems.
    • To analyze the impact of UCR protocols on physician fees.
    • To examine the role of physicians in controlling fee-setting committees and boards.

    Main Methods:

    • Review of Blue Shield's historical fee-payment protocols.
    • Analysis of fee adjustments for surgical procedures in the Washington, DC area over a three-year period.
    • Examination of board composition and committee majorities for Blue Shield plans nationally.

    Main Results:

    • Blue Shield UCR protocols allowed for substantial increases in allowances for selected surgical procedures (29-75%) within three years.
    • Specific examples show significant fee hikes for procedures like coronary-artery bypass.
    • Physicians dominate Blue Shield boards and fee-setting committees, controlling payment formulas.

    Conclusions:

    • There is limited justification for the secrecy surrounding physician fee-payment protocols.
    • Physician control over Blue Shield boards and committees influences fee determination.
    • Increased public debate, representation, and accountability are crucial for monitoring and reforming these programs.

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