CHICAGO -- In a trade-off designed to encourage Tennessee physicians to use evidence-based medicine, one insurer is paying for phone calls, e-mails, and other services that are not usually reimbursed.

In the first phase of the project, BlueCross BlueShield of Tennessee will pay doctors in five participating practices for services that physicians say will help them practice better medicine, including phone calls, online visits, and group visits. Patients included in the pilot must meet predefined clinical criteria for diabetes, congestive heart failure, or hypertension and be BlueCross BlueShield members. And the physicians in the pilot must agree to use evidence-based medicine guidelines in treating their patients.

Further financial incentives may be provided later in the project.

"There are really only two things that work when it comes to changing human behavior--one of them is incentives, and the other is restrictions," Dr. Steven Coulter, senior vice president and chief medical officer for BlueCross BlueShield of Tennessee said at a conference sponsored by America's Health Insurance Plans. "We got to thinking maybe it's time to focus a little more on the incentives side of that 'How do you change behavior?' equation."

So the insurer convened a workshop of employers, hospital executives, physician groups, and others to come up with solutions. "The physicians admitted to not using guidelines, but the reason is that nobody paid them to," he said. "In fact, we create barriers within our payment structures."

The health plan is measuring clinical outcomes, patient and physician satisfaction, and total medical cost, Dr. Coulter said.

"We're holding the physicians accountable for the process, but we're holding the program accountable for the outcomes," he said. "Physicians see patients one at a time, and all they can do is do the right thing."

Process measures for the diabetes pilot project include the rate of ordering hemoglobin [A.sub.1c] (Hb[A.sub.1c]) tests, the rate of emergency room visits, the rate of hospitalizations, the rate of ordering diabetic eye exams, the rate of ordering cholesterol tests, the proportion of patients who received an influenza vaccine, and the rate of ordering microalbuminuria tests.

On the outcomes side, the health plan will evaluate how many patients showed improvement in their Hb[A.sub.1c] levels from baseline, how many had an LDL cholesterol of less than 100 mg/dL, and how many had systolic blood pressure of less than 130.

In the congestive heart failure project, the health plan will measure the percent of patients who are on an ACE inhibitor, the number of emergency room visits, the rate of hospitalizations, and LDL cholesterol levels of less than 100 mg/dL.

BlueShield of Tennessee isn't the only insurer who is offering incentives for evidence-based medicine. Independent Health, a not-for-profit health plan based in Buffalo, N.Y., offers bonuses to its member physicians for improving outcomes.

About 7 years ago, Independent Health launched the Quality Management Initiative Award, which provides incentives to primary care physicians who meet evidence-based criteria for mammography, cervical cancer screening, immunizations, colon cancer screening, chronic disease management, patient satisfaction, and timely access to care.

The health plan collects information from physicians through claims data and self-audits of charts.

Early on in the program, physicians get paid just to review and self-audit their charts. Later, they are paid for their performance, said Dr. Michael Cropp, executive vice president and chief medical officer for Independent Health.

Unlike the BlueCross BlueShield plan, Independence Health weights outcomes more heavily than process measures.