Paying the physician's fee: Blue Shield and the reasonable charge.
At a time of debate over physicians' fees and income, we describe the evolution of Blue Shield plans and programs to pay physicians' fees. We review how Medicare's "reasonable-charge" formulas fostered Blue Shield "usual, customary, and reasonable" (UCR) contracts. In a three-year period in the Washington, DC, area, Blue Shield UCR protocols permitted "customary" allowances for selected surgical procedures to rise 29 to 75 per cent; charges by two physicians increased allowances for coronary-artery bypass from $2000 to $3500. We find little justification for secrecy in fee-payment protocols. Physicians dominate the District of Columbia Blue Shield Board and its committees, and they control fee-payment formulas. Nationally, 61 per cent of Blue Shield boards have majorities of health-care providers; approximately two thirds of fee-related committees have physician majorities. We urge increased public debate, public representation, and accountability in monitoring and reforming the programs that we describe.
D054598:Blue Cross Blue Shield Insurance Plans / Q000191:economics* / Q000458:organization & administration; D004219:District of Columbia; D005245:Fee Schedules; D005251:Fees, Medical; D006801:Humans; D007357:Insurance, Physician Services / Q000191:economics*; D006278:Medicare / Q000191:economics; D013514:Surgical Procedures, Operative; D014481:United States