Biomaterial Database

Paying the physician's fee: Blue Shield and the reasonable charge. 1979

T L Delbanco, and K C Meyers, and E A Segal

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.

UI	MeSH Term	Description	Entries
D007357	Insurance, Physician Services	Insurance providing benefits for the costs of care by a physician which can be comprehensive or limited to surgical expenses or for care provided only in the hospital. It is frequently called "regular medical expense" or "surgical expense".	Physician Services, Insurance,Services Insurance, Physician,Insurance Physician Service,Insurance Physician Services,Insurances, Physician Services,Physician Service, Insurance,Physician Services Insurance,Physician Services Insurances,Service, Insurance Physician,Services Insurances, Physician,Services, Insurance Physician
D004219	District of Columbia	A federal area located between Maryland and Virginia on the Potomac river; it is coextensive with Washington, D.C., which is the capital of the United States.	Washington, D.C.,Washington, DC
D005245	Fee Schedules	A listing of established professional service charges, for specified dental and medical procedures.	Fee Schedule,Schedule, Fee,Schedules, Fee
D005251	Fees, Medical	Amounts charged to the patient as payer for medical services.	Fee, Medical,Medical Fee,Medical Fees
D006278	Medicare	Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)	Health Insurance for Aged and Disabled, Title 18,Insurance, Health, for Aged and Disabled,Health Insurance for Aged, Disabled, Title 18,Health Insurance for Aged, Title 18
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D013514	Surgical Procedures, Operative	Operations carried out for the correction of deformities and defects, repair of injuries, and diagnosis and cure of certain diseases. (Taber, 18th ed.).	Surgical Procedures,Ghost Surgery,Operative Procedures,Operative Surgical Procedure,Operative Surgical Procedures,Procedure, Operative Surgical,Procedures, Operative Surgical,Surgery, Ghost,Surgical Procedure, Operative,Operative Procedure,Procedure, Operative,Procedure, Surgical,Procedures, Operative,Procedures, Surgical,Surgical Procedure
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.
D054598	Blue Cross Blue Shield Insurance Plans	Prepaid health and hospital insurance plan.	Blue Cross,Blue Shield,Blue Crosses,Blue Shields,Cross, Blue,Crosses, Blue,Shield, Blue,Shields, Blue