Change Incentives to Promote Better Care

Blue Cross and Blue Shield of Alabama

Alabama Health Improvement Initiative

Blue Cross and Blue Shield of Alabama partnered with healthcare providers and employers statewide to establish the Alabama Health Improvement Initiative (AHII), a collaborative approach to rewarding physicians who deliver high-quality care.  The first phase of the program, which focuses on diabetes care, rewards general and specialty physicians identified through the National Committee for Quality Assurance's (NCQA) Diabetes Physician Recognition Program.  Later phases of the program will recognize superior performance among physicians in other care areas.  After receiving NCQA recognition, each qualified physician is publicly recognized, receives a $1,500 recognition reward and becomes eligible for annual incentives of up to $20,000 per year or a maximum of $50,000 over a three-year period.

Alabama Hospital Quality Initiative

Blue Cross and Blue Shield of Alabama launched the Alabama Hospital Quality Initiative (AHQI) to reduce hospital-acquired infections (HAIs) and promote appropriate antibiotic use.  HAIs affect an estimated 90 million lives each year, or nearly six percent of admitted patients.  In collaboration with the Alabama Hospital Association and a key vendor, hospitals are able to identify potential real-time warning signs of an infection outbreak, track and quantify nosocomial infection trends, share best practices and evaluate the effectiveness of infection control interventions.  AHQI promotes nursing unit-level goal setting to reduce infections, defines and standardizes best practices statewide and enhances transparency through timely, electronically transmitted hospital data regarding different and specific sources of infection and corresponding strains' susceptibility to antibiotics.  The statewide initiative positively influences care from the hospital board to bedside nursing care.  Among the program's results:

• 100 percent of Alabama hospitals participate in AHQI.
• Since 2004, HAIs have fallen by 25-30 percent.
• Peer-to-peer hospital transparency, which promotes the dissemination of best practices, is an important element of this quality initiative.

Blue Distinction®

Blue Cross and Blue Shield of Alabama is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Hospital Tiered Network

Jan. 1, 2009, marked the beginning of the fourth year of Blue Cross and Blue Shield of Alabama's Hospital Tiered Network.  The network was launched in response to healthcare consumers' request for a network that focuses on both cost and quality.  Hospitals receive a tier ranking based on three primary components, including fiscal, quality and patient safety performance.  The Hospital Tiered Network has provided a way to encourage and reinforce improvements in healthcare transparency and quality. Among the most recent successes:

• Prior to July 1, 2006, there were 35 (or 34 percent of) hospitals in the state utilizing a rapid response team (RRT).  In 2008, 93 (or 92 percent of) facilities have confirmed the implementation of the RRT methodology.  An RRT is a group assembled by each healthcare facility that responds immediately to patients who exhibit signs of cardiac arrest.  RRTs' goal is to reduce the number of cardiac arrests that take place outside of the ICU.
• In 2007, hospitals were asked to have employees complete a version of the Agency for Healthcare Research and Quality (AHRQ) Employee Culture of Safety Survey, which enables hospital employees to provide anonymous feedback to management about the perceived culture of safety at their facility.  As a result, 98 hospitals participated, and over 18,000 surveys were entered.  These data helped identify medication reconciliation and patient hand-offs as potential areas for statewide improvement.
• The 2008 Tiered Network Criteria asked hospitals to enroll in the Institute for Healthcare Improvement's (IHI) 5 Million Lives Campaign.  The national campaign aims to reduce the incidence of preventable patient harm.  In 2006, 38 (or 37 percent of) state hospitals were enrolled in the campaign.  As of 2008, 94 (or 93 percent of) hospitals have confirmed enrollment in the campaign and are listed on the IHI website.  For 2009, hospitals have been asked to increase their level of engagement in the campaign.

Premera Blue Cross Blue Shield of Alaska

Blue Distinction®

Premera Blue Cross Blue Shield of Alaska is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Generics Yes! A Smart Choice

Premera Blue Cross Blue Shield of Alaska created the Generics Yes! A Smart Choice program to raise awareness of the safety, efficacy and affordability of generic drugs.  The multi-faceted educational campaign uses colorful and informative brochures, posters and mailings to inform consumers of their prescription drug options.  In 2007, 63 percent of Premera’s prescription drug orders were filled with generics, compared with 60 percent for Medco, the Plan’s pharmacy benefits manager.

Three-Tier Incentive Formulary

Premera Blue Cross Blue Shield of Alaska’s three-tier prescription formulary promotes the use of cost-effective medications by offering lower co-pays for generic and preferred brand-name drugs.  Premera’s Pharmacy and Therapeutics Committee, which creates formulary tiers using current scientific data, meets six times per year to update the list of preferred drugs.  The program not only saves members money through lower co-pays but also raises awareness of the comparable effectiveness of less expensive generic drugs.  Furthermore, members continue to have access to the broadest possible selection of prescription drugs.

Blue Cross and Blue Shield of Arizona

Blue Distinction®

Blue Cross Blue Shield of Arizona is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

State Legislation to Address Rising Healthcare Costs

Blue Cross Blue Shield of Arizona championed state legislation (SB 1098) that allows health insurers to offer rewards or incentives to members participating in qualified wellness programs.  The bill's passage was a key step toward encouraging healthy lifestyles and curbing rising healthcare costs through better management of chronic conditions such as asthma, diabetes and obesity.

Arkansas Blue Cross and Blue Shield

Blue Distinction®

Arkansas Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Anthem Blue Cross

Blue Distinction®

Anthem Blue Cross is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

HMO Quality Scorecard Program

Anthem Blue Cross’s HMO Quality Scorecard Program provides physician bonus incentives for medical groups demonstrating improved quality of service and patient care in HMO plans.  The awards are based on providers’ performance in managing chronic diseases such as asthma, diabetes and heart disease; adhering to screening guidelines for breast and cervical cancer; and achieving high-quality patient outcomes and service satisfaction scores.

IHA Rewarding Results

Anthem Blue Cross participates in the Integrated Healthcare Association’s Rewarding Results program, a California-based coalition of health plans, physicians, healthcare systems, purchasers and consumers designed to maintain a public scorecard to compare physician group performance.  Since the program’s implementation, every quality measure has seen improvement, with increased patient visits, reduced hospitalizations and better management of chronic diseases.  The program relies heavily on technology to track and improve care quality.

 

Patient-Centered Medical Homes

The patient-centered medical home, a model currently under consideration by Anthem Blue Cross, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are also being developed by Anthem Plans in Colorado, Maine, New Hampshire, New York and Ohio.  Additional programs are being discussed and considered in Missouri, California and Wisconsin.

PPO Pulse P4P Program

Anthem Blue Cross’s PPO Pulse program offers a Web-based index of physician performance information based on a common set of clinical measures designed to improve and reward quality care for patients.  Physicians who meet qualifying standards receive an increase in their reimbursement based on their performance.

Quality Insights Hospital Incentive Program

Anthem Blue Cross’s Quality Insights Hospital Incentive Program (Q-HIP^SM) is a hospital quality program involving the voluntary reporting of nationally vetted and recognized evidence-based quality indicators in three categories: patient safety, patient health outcomes and member satisfaction.  In addition, the program incorporates quality metrics and P4P incentives for important patient safety initiatives and operates under a transparent review process.  The Plan audits and externally validates the submitted hospital all-payer data, helping ensure the reporting hospital is promoting high-quality and safe healthcare for all patients.

Blue Shield of California

Blue Distinction®

Blue Shield of California is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Generic Prescription Co-pay Reduction Program

To improve patients’ adherence to their medication regimens and lower prescription drug costs, Blue Shield of California developed the generic prescription co-pay reduction program.  Employer groups with more than 50 workers are eligible to participate in the program, which waives members’ co-pay on generic prescriptions and creates a financial incentive to switch from brand name therapies.

Pay-for-Performance Program

Blue Shield of California participates in a statewide pay-for-performance program that offers a uniform incentive structure for California physician groups and a publicly accessible scorecard on provider performance.  The initiative promotes high-quality, affordable healthcare by focusing on clinical performance, patient experience, health IT use and other criteria developed by the Integrated Healthcare Association (IHA).

For example, Blue Shield’s program uses the IHA standards to track physician groups’ performance on factors such as adolescent immunization rates, blood sugar monitoring for diabetics and the use of effective control medications for members with asthma.  In 2007, the Plan awarded more than $31 million in bonuses to medical groups across its network for implementing best practices to improve healthcare delivery and patient outcomes.

Anthem Blue Cross and Blue Shield (Colorado)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Patient-Centered Medical Homes

The patient-centered medical home, a model currently being tested in a multi-payer pilot that includes Anthem Blue Cross and Blue Shield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are also being developed by Anthem Plans in Maine, New Hampshire, New York and Ohio.  Additional programs are being discussed and considered in Missouri, California and Wisconsin.

PPO Pulse P4P Program

Anthem Blue Cross and Blue Shield’s PPO Pulse program offers a Web-based index of physician performance information based on a common set of clinical measures designed to improve and reward quality care for patients.  Physicians who meet qualifying standards receive an increase in their reimbursement based on their performance.

Promoting Healthcare Quality Program

Anthem Blue Cross and Blue Shield’s Promoting Healthcare Quality (PHQ) program was launched in 2003 under a basic assumption: If hospitals are offered incentives to improve quality outcomes and meet certain performance standards, the quality and safety of care for patients would improve.  Anthem was the first health benefits company in the state to introduce this kind of program and has since been recognized as a leader in expanding reimbursement for clinical excellence and improved medical outcomes, rather than limiting it only to delivery of medical services.  PHQ offers hospitals various incentives – including financial – for achieving measurable improvements in patient safety and health outcomes, using such measures as pneumococcal vaccination rate, provision of aspirin and beta blockers for patients suffering a heart attack, computerized physician order entry systems and ICU staffing.  Success is measured by assigning values for compliance with recommended patient safety standards, implementation of systems and processes to meet these standards and improvements in clinical outcomes.

Anthem Blue Cross and Blue Shield (Connecticut)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Quality Insights Hospital Incentive Program

Anthem Blue Cross and Blue Shield’s Quality Insights Hospital Incentive Program (Q-HIP^SM) is a hospital quality program involving voluntary reporting of nationally vetted and recognized evidence-based quality indicators in three categories: patient safety, patient health outcomes and member satisfaction.  In addition, the program incorporates quality metrics and pay-for-performance incentives for important patient safety initiatives, and its review process is transparent.   The Plan audits and externally validates the submitted hospital all-payer data, helping to ensure that the reporting hospital is promoting high quality and safe healthcare for all patients.

Blue Cross Blue Shield of Delaware

Blue Distinction®

Blue Cross Blue Shield of Delaware is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Continuity of Care Audit

Blue Cross Blue Shield of Delaware’s Quality Improvement nurses perform annual chart audits of primary care physicians to monitor the coordination of care and effective communication between hospitals or Ambulatory Surgery Centers and the patient’s PCP.  Facilities that meet or fall below the average rates of information exchange are encouraged by BCBSD to review practices and develop steps to enhance communication in order to improve care coordination and patient outcomes.  Care centers with a communication rate of 100 percent are asked to share best practices with lower-ranked facilities to ensure the effective exchange of patient information across the care continuum.

Blue Cross and Blue Shield of Florida

Blue Distinction®

Blue Cross and Blue Shield of Florida is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Patient-Centered Medical Homes

Blue Cross and Blue Shield of Florida’s patient-centered medical home (PCMH) demonstration project, currently in the planning phase, aims to promote patient-physician collaboration and care coordination by explaining the role of specialists, suggesting appropriate and compassionate treatment options and answering questions about illnesses.  The PCMH encompasses care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  The model also empowers consumers to access healthcare options appropriate to their situation and make healthier lifestyle choices.

Recognizing Physician Excellence Program

Blue Cross and Blue Shield of Florida introduced its physician recognition program, Recognizing Physician Excellence (RPE), in September 2004 in an effort to recognize and reward physicians committed to delivering quality care and excellent service to their patients.  RPE assesses performance through extensive metrics, which are categorized into two components:

• Clinical Quality – Outstanding and improved performance on clinical quality metrics based on nationally accepted evidence-based guidelines
• Process Improvement – Enhanced patient relationships through the use of e-capabilities, training and education programs and patient safety and satisfaction initiatives

Eligible physicians include primary care specialists such as family practice, general practice, internal medicine, pediatrics, geriatrics and OB-GYN providers who participate in NetworkBlue and treat a high volume of members.  Physicians participating in the RPE program are identified in the Plan’s online provider directory by the RPE icon.

Blue Cross and Blue Shield of Georgia

Blue Distinction®

Blue Cross and Blue Shield of Georgia is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Quality Care Providers, Inc.

Since 1995, Blue Cross and Blue Shield of Georgia and Quality Care Providers, Inc. (QCPI) have maintained their commitment to quality and affordable healthcare coverage in a number of ways, including a physician quality program for more than 900 primary care physicians participating in the BlueChoiceSM network in the Atlanta area.  This program is based on preventive health measurements, patient satisfaction and quality goals, including mammography screening rates, proper testing and follow-up for diabetic patients, vaccination rates among children and seniors and appropriate use of antibiotics.    Network physicians’ performance is reviewed on an annual basis.

Quality Insights Hospital Incentive Program

Blue Cross and Blue Shield of Georgia’s Quality Insights Hospital Incentive Program (Q-HIP^SM) is a hospital quality program involving voluntary reporting of nationally vetted and recognized evidence-based quality indicators in three categories: patient safety, patient health outcomes and member satisfaction.  In addition, the program incorporates quality metrics and pay-for-performance incentives for important patient safety initiatives, and its review process is transparent.   The Plan audits and externally validates the submitted hospital all-payer data, helping to ensure that the reporting hospital is promoting high quality and safe healthcare for all patients.

Quality Physician Performance Program

Blue Cross and Blue Shield of Georgia’s Quality Physician Performance Program (QP-3SM) is an incentive-based performance program for physicians.  The program incorporates effectiveness measures using nationally recognized or endorsed quality measures from groups such as:

• National Quality Forum
• National Committee for Quality Assurance
• Joint Commission
• Ambulatory Quality Alliance
• American Medical Association’s Physician Consortium for Performance Improvement

Where there are no nationally recognized quality metrics, the program works directly with medical societies to develop performance and monetary metrics.  In the clinical category of heart disease, for example, QP-3 teamed with the American College of Cardiology and the Society of Thoracic Surgeons to define evidence-based clinical indicators for cardiac care and created the QP-3 scorecard.

Blue Cross and Blue Shield of Hawaii

Blue Distinction®

Blue Cross and Blue Shield of Hawaii is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Hospital Quality Service and Recognition Program

Hoping to motivate hospitals to improve care quality and service excellence, Blue Cross and Blue Shield of Hawaii developed the Hospital Quality Service and Recognition Program, which offers financial incentives to top-performing facilities. After evaluating hospitals on clinical quality metrics and service satisfaction rates, the program provides tools to help facilities improve their performance, including software with patient-level information about complications. The program also distributes detailed performance reports with an executive summary that highlights key areas for improvement.

Blue Cross of Idaho

Blue Distinction®

Blue Cross of Idaho is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Hospital Quality Incentive Program

Blue Cross of Idaho partnered with the Idaho Hospital Association to launch the Hospital Quality Incentive Program, which measures patient safety and clinical outcomes and rewards participating facilities based on their performance.  In addition to tracking rates of hospital-acquired infections and surgical complications, the initiative evaluates hospitals’ adherence to evidence-based measures known to improve health outcomes among patients with pneumonia, heart attack, congestive heart failure and diabetes.  Providers that meet the program’s safety, quality and affordability goals receive financial incentives and are presented with the Hospital Quality Award at Blue Cross of Idaho’s annual Hospital Quality Conference.

Regence BlueShield of Idaho

Blue Distinction®

Regence BlueShield of Idaho is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Regence Activate

The Regence self-managed plan, Activate, gives members the opportunity to earn points for engaging in healthy behaviors.  These points convert to “Member Choice Funds,” which can be used to pay deductibles or other out-of-pocket medical expenses.  Choosing from a list of qualifying wellness activities, members can earn points by participating in weight loss programs or activities such as running, skiing, attending a health club, receiving an annual flu shot or participating in a nutrition or healthy cooking class.  This plan includes a variety of programs at no additional cost to help members make the best use of these choices, including:

• Health Coach – Provides members with a personal connection to someone who can help them assess their current habits, set goals to achieve better health and monitor their progress along the way.  Using a toll-free number, members can call upon the coach for education, goal-setting, encouragement and support.
• myRegence.com – Empowers members to take charge of their healthcare.  This interactive tool provides advice, navigation and rewards to promote proactive behavior on the part of the member.
• CareEnhance® – Provides confidential, 24/7 access to information and advice.  Members can talk or correspond via e-mail with a registered nurse any time of day or night.  In addition, an AudioHealth Library provides general health information on nearly 1,200 topics.  The audio library is also available online.
• Special Beginnings – Offers personalized monitoring of an expectant mother’s care throughout her pregnancy, along with 24-hour, toll-free telephone access to registered nurses who specialize in working with mothers and newborns, including a full set of educational tools.
• Regence Advantages program – Features discounts on items and services such as hearing aids, fitness club memberships, weight management programs, contact lenses and LASIK procedures
• No network, just tiers of coverage – With self-managed plans, Regence members do not need to check to see if their doctor is in or out of a network.  All are covered at some level.

For more information, please visit www.selfmanagedplans.com or view Regence’s press release by clicking here.

RegenceRx Generic Incentive Program

The voluntary RegenceRx generic incentive program allows members taking certain generic medications to receive up to a 30-day supply at no cost.  Over 25 generic medications are part of this program.  Previously, members could only receive samples of branded medications supplied by pharmaceutical manufacturers to their physicians.  Now, members can try a generic medication with no initial financial obligation before filling the balance of their prescription.   Each one percent increase in generic utilization represents a savings of approximately $12 million.

The RegenceRx Generic Incentive Program hopes to encourage physicians to cut costs by prescribing generic medications when available and gives members the encouragement to ask for generic medications specifically at their physician’s office and pharmacy.  For more information, please click here.

Blue Cross and Blue Shield of Illinois

Asthma Action Plan

In an effort to improve outcomes for asthma patients, Blue Cross and Blue Shield of Illinois (BCBSIL) offers a financial incentive to HMO medical groups and independent practice associations based on the percentage of asthmatics receiving a written asthma self-management plan.  According to follow-up data from the program, members who received asthma plans for several years had fewer asthma ER visits and fewer asthma admissions than those who received no asthma plans or just one asthma plan over the same time period.  In 2008, the program expanded to include systematic assessment of asthma control in accordance with the 2007 National Asthma Education and Prevention Program Guidelines.

Blue Distinction®

Blue Cross and Blue Shield of Illinois is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Diabetes Checks and Balances in Bloomington-Normal, Ill. Diabetes Prevention

Through a partnership with employers and providers in the Bloomington-Normal, Ill., area, Blue Cross and Blue Shield of Illinois’s (BCBSIL) Diabetes Checks and Balances program motivated local residents with diabetes to get four key tests, including HbA1c, LDL cholesterol, an eye exam and screening for kidney disease.  As part of the program, BCBSIL identified local members with diabetes and sent them information about the program.  Local physicians also became actively engaged in improving the care of diabetics, and BCBSIL hosted diabetes screenings in the workplace and elsewhere in the region.  The program generated impressive results, including a one percent reduction in HbA1C levels, a significant decrease in ER visits and admissions and annual cost savings of more than $900,000.

Diabetes Flowsheet Project Diabetes Prevention

Blue Cross and Blue Shield of Illinois (BCBSIL) offers a financial incentive to HMO medical groups and independent practice associations based on the percentage of diabetic patients for whom physicians systematically track diabetes care using one-page summary flowsheets.  These sheets track indicators such as blood sugar levels, eye exam compliance, LDL cholesterol, blood pressure and medical attention for nephropathy.   Since the program’s inception, diabetes screening and control rates have improved substantially.  Research also indicates that members who control their diabetes risk factors over time have significantly lower ER visit and inpatient admission rates than those whose conditions are not controlled.  The flowsheet program has been replicated for coronary artery disease, another condition for which preventive services can reduce the likelihood of future complications.

HMO Quality Improvement Fund and Blue Star Medical Group Report

Blue Cross and Blue Shield of Illinois’s HMO Quality Improvement Fund and Blue Star Medical Group Report reward and publicly recognize physician groups that meet annual clinical performance targets.  These targets are revised annually and include preventive services such as childhood immunizations, influenza vaccinations and cancer screenings, as well as chronic disease management for asthma, diabetes, hypertension and cardiovascular disease.  Physician groups that meet established thresholds earn additional compensation, and those with superior performance are publicly recognized in the Blue Star Medical Group report, which is available at www.bcsbil.com.

Hospital Quality Program

To increase the transparency of hospitals’ quality performance and identify opportunities for improvement, Blue Cross and Blue Shield of Illinois (BCBSIL) assesses multiple aspects of hospital quality using both internal data and publicly available information.  Each contracted Illinois hospital receives an annual Hospital Profile summarizing the results and providing comparison data for similar hospitals.  In addition, the Plan publishes summaries of hospitals’ quality and safety performance in its Blue Star Hospital Report, which includes structural, process, outcome, member survey and efficiency results.  Members may access the report at www.bcbsil.com.

Anthem Blue Cross and Blue Shield (Indiana)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Hospital Quality Program

Anthem Blue Cross and Blue Shield crafted a hospital quality program to help reduce variation in practice patterns and outcomes among network hospitals.  The program has evolved to include an incentive payment for quality, electronic data submission and enhanced sharing of best practices.  Now called the Midwest Hospital Quality Improvement Program, it includes 357 hospitals in Ohio, Kentucky, Indiana and Missouri.  As part of the program:

• An annual Request for Information (RFI) is sent to each network hospital.  The RFI consists of 10 core measures, developed in collaboration with participating hospitals, accrediting bodies and quality organizations.  Once the RFI is completed, data are entered into a confidential database, aggregated and analyzed.
• Hospitals receive a report card with their overall score, as well as comparisons to their peer hospitals, matched by size for ease of comparison.  The Midwest Hospital Quality Improvement Program changes its measures in response to national and regional trends to incorporate more contemporary approaches for measuring or improving clinical quality.
• Starting in 2003, incentives were paid to high-performing hospitals, while lower-performing hospitals were approached about remediation.  However, the goal of this program is not to punish lower-performing hospitals but to work with hospitals in a collaborative fashion to improve care quality.
• Further collaboration is sparked by the annual Hospital Quality Program meetings.  Beginning in 2003, hospitals were asked to submit an abstract of a “successful practice,” which is judged by an impartial panel of Quality Improvement Directors from other regions.  Winning practices are presented at the Hospital Quality Improvement meetings, allowing for an exchange of ideas among competing hospitals.

Quality Health First®

Anthem Blue Cross and Blue Shield participates in the Quality Health First program, a service of the nonprofit Indiana Health Information Exchange.  The program was developed by physicians, hospital networks, health insurers, the Regenstrief Institute, the Employers’ Forum of Indiana, the Indiana State Medical Association, the Indiana Department of Health and the Indianapolis Medical Society to provide better patient information.  It builds upon a system that securely aggregates and accurately delivers patient information such as lab results, reports, medication histories and treatment histories in a standardized, electronic format across all providers.  This program helps physicians manage patients with chronic diseases, supports preventive care efforts and serves as Anthem’s quality reporting tool for primary care physicians in the nine-county Indianapolis area.

Wellmark Blue Cross and Blue Shield of Iowa

Blue Distinction®

Wellmark Blue Cross and Blue Shield of Iowa is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants. New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development. The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care. To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Incent and Reward Best Practices Program

Wellmark Blue Cross and Blue Shield of Iowa’s Incent and Reward Best Practices program rewards physicians who demonstrate a commitment to providing diabetes care and patient education that aligns with national standards and other care quality measures.  Clinicians who meet clinical performance and patient outcome targets are eligible to receive special recognition and potential financial rewards from the Plan.  Participating providers also agree to share their performance information with members, employers and other clinicians, and starting in the second quarter of 2008, clinic-level performance data for primary care physicians was posted online.

Patient-Centered Medical Homes

Wellmark Blue Cross and Blue Shield of Iowa’s patient-centered medical home (PCMH) demonstration project, which is currently in progress, aims to promote patient-physician collaboration and care coordination by explaining the role of specialists, suggesting appropriate and compassionate treatment options and answering patients’ questions about illnesses.  The PCMH encompasses care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  The model also empowers consumers to access healthcare options appropriate to their situation and make healthier lifestyle choices.

Blue Cross and Blue Shield of Kansas

Blue Distinction®

Blue Cross and Blue Shield of Kansas is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Anthem Blue Cross and Blue Shield (Kentucky)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Hospital Quality Program

Anthem Blue Cross and Blue Shield crafted a hospital quality program to help reduce variation in practice patterns and outcomes among network hospitals.  The program has evolved to include an incentive payment for quality, electronic data submission and enhanced sharing of best practices.  Now called the Midwest Hospital Quality Improvement Program, it includes 357 hospitals in Ohio, Kentucky, Indiana and Missouri.  As part of the program:

• An annual Request for Information (RFI) is sent to each network hospital.  The RFI consists of 10 core measures, developed in collaboration with participating hospitals, accrediting bodies and quality organizations.  Once the RFI is completed, data are entered into a confidential database, aggregated and analyzed.
• Hospitals receive a report card with their overall score, as well as comparisons to their peer hospitals, matched by size for ease of comparison.  The Midwest Hospital Quality Improvement Program changes its measures in response to national and regional trends to incorporate more contemporary approaches for measuring or improving clinical quality.
• Starting in 2003, incentives were paid to high-performing hospitals, while lower-performing hospitals were approached about remediation.  However, the goal of this program is not to punish lower-performing hospitals but to work with hospitals in a collaborative fashion to improve care quality.
• Further collaboration is sparked by the annual Hospital Quality Program meetings.  Beginning in 2003, hospitals were asked to submit an abstract of a “successful practice,” which is judged by an impartial panel of Quality Improvement Directors from other regions.  Winning practices are presented at the Hospital Quality Improvement meetings, allowing for an exchange of ideas among competing hospitals.

Blue Cross and Blue Shield of Louisiana

Blue Distinction®

Blue Cross and Blue Shield of Louisiana is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Imaging Authorizations Program

Use of high-tech imaging studies (CT, MRI, PET, nuclear cardiology) grew at a rate of 37 percent nationwide in 2005. Based on national data, nearly 30 percent of these tests may be unnecessary, inappropriate or redundant. Focusing on the right test for the patient at the right time reduces unnecessary radiation exposure, increases productivity, reduces unwarranted disparities in healthcare and saves time - as well as helps keep insurance affordable for Louisianians.

In 2007, Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc., (HMOLA), its wholly owned subsidiary, contracted with American Imaging Management, Inc. (AIM) to administer a review program for elective outpatient high-tech imaging studies. AIM, an independent company that provides review and prior authorization program services, is a recognized leader in clinical appropriateness, decision support, education and review in the field of advanced diagnostic imaging. This phase was the first step toward Blue Cross’ conversion to a Full Utilization Review program on Jan. 1, 2008.

Blue Cross and Blue Shield of Louisiana’s imaging authorizations program is built on clinical guidelines and medical policies designed to evaluate and direct the appropriate use of high-tech imaging services. Ordering physicians contact AIM to complete a review for outpatient, non-emergent imaging services such as CT scans, MRIs and PET scans. The Plan has made the request process as easy as possible for providers by linking the AIM application to its free online provider service, iLinkBLUE.

Quality Improvement Projects

Blue Cross and Blue Shield of Louisiana’s (BCBSLA) Health & Quality Management Department develops Quality Improvement Projects (QIPs) to address specific high-risk populations, severe chronic illnesses and/or areas where extra effort might have a large impact on a sizeable population. Two examples of recent QIPs are initiatives to increase lipid screening rates in the diabetic population and to improve colorectal cancer screening rates.

Comprehensive Diabetes Care: Increasing Lipid Screening Rates in the Diabetic Population
During a review of 2005 data, BCBSLA medical staff noted that diabetic lipid screening rates were approximately 20-25 percent lower than the NCQA Quality Compass National and South Central Benchmarks. Louisiana has one of the highest prevalence rates for diabetes in the United States, translating into a high rate of diabetes-related claims for the Plan.

Heart disease and stroke account for about 65 percent of deaths in people with diabetes. Improved control of cholesterol or blood lipids can reduce cardiovascular complications by 20-50 percent, according to the CDC. The QIP to increase lipid screening rates is designed to resemble previous successful QIPs that improved rates of microalbumin and HbA1c screening in a similar population.

Improving Colorectal Cancer Screening Rates
Since the incorporation of this measurement in Blue Cross and Blue Shield of Louisiana’s 2004 reporting year data, the company’s rates have been lower than the BCBSA and NCQA South Central benchmarks. The Plan’s 2005 measure in total colorectal cancer screening rates was 16.4 percentage points lower than the Blue Cross and Blue Shield Association (BCBSA) benchmark. However, BCBSLA medical staff noted that the Plan achieved a modest increase in the colorectal cancer screenings after nurse interventions including chart reviews and reminder messages. This led to the decision to make colorectal cancer screening a formal QIP early in 2006.

The American Cancer Society (ACS) estimated in 2005 that about 145,000 people would be diagnosed with colorectal cancer. Overall, 91 percent of new cases and 94 percent of deaths from colorectal cancer occur in individuals older than 50. Although the ACS and other health organizations recommend that colorectal cancer screening begin at age 50 for individuals at average risk, less than 50 percent of people age 50 or older in the United States have had a recent test.

There is a 90 percent chance of survival five years beyond diagnosis if a patient is diagnosed with cancer at the earliest, most treatable stage; however, only 39 percent are diagnosed at the earliest point. Some 55,000 people were expected to die in 2006, and half could have been saved with the appropriate testing.  This QIP was designed to encourage and remind specific at-risk members to receive one or more of the appropriate screenings for colorectal cancer: fecal occult blood test, flexible sigmoidoscopy, double contrast barium enema and/or colonoscopy.

Both of these QIPs are wrapping up as of first quarter of 2009, and final results will be available soon.

Requiring Accreditation for Diagnostic Imaging Providers

Blue Cross and Blue Shield of Louisiana implemented a credentialing and accreditation requirement as a condition for network participation for all freestanding diagnostic imaging providers and the equipment used to perform the following modalities: magnetic resonance imaging (MRI), computed tomography (CT), positron-emission tomography (PET) or nuclear cardiology. The company requires that all freestanding diagnostic facilities be accredited by either the American College of Radiology (ACR) and/or the Intersocietal Accreditation Commission (IAC) for any or all of the aforementioned modalities. If providers perform these services and are not accredited or fail to remain accredited, they will be removed from all Blue Cross networks in which they participate. The only exception will occur if the freestanding diagnostic imaging provider no longer performs a modality that requires accreditation or performs another modality that does not require accreditation.

In October 2008, Blue Cross began requiring accreditation as a condition of participation for all newly contracted freestanding diagnostic imaging providers. All freestanding diagnostic imaging providers currently in the Blue Cross networks must be accredited for all of the modalities they perform by Dec. 31, 2009, in order to remain in its network(s). Blue Cross reviews each provider’s accreditation status during the provider’s regularly scheduled recredentialing cycle, which is every three years.

Anthem Blue Cross and Blue Shield (Maine)

Anthem Quality Insights® (AQI®) Incentives Programs

Anthem Blue Cross and Blue Shield’s Primary Care Quality Incentive Program rewards participating physicians for excellent performance based on standards of quality, clinical outcomes, patient safety and administrative processes designed to enhance patient care.  The Quality Incentive Program for Cardiology and Obstetrics/Gynecology rewards performance for specialty care services based on industry standard measures of quality, including process measures, technology measures and pharmacy measures.

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Patient-Centered Medical Homes

The patient-centered medical home, a model currently being tested in a multi-payer pilot that includes Anthem Blue Cross and Blue Shield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are also being developed by Anthem Plans in Colorado, New Hampshire, New York and Ohio.  Additional programs are being discussed and considered in Missouri, California and Wisconsin.

Quality Insights Hospital Incentive Program

Anthem Blue Cross and Blue Shield’s Quality Insights Hospital Incentive Program (Q-HIP^SM) is a hospital quality program involving voluntary reporting of nationally vetted and recognized evidence-based quality indicators in three categories: patient safety, patient health outcomes and member satisfaction.  In addition, the program incorporates quality metrics and pay-for-performance incentives for important patient safety initiatives, and its review process is transparent.   The Plan audits and externally validates the submitted hospital all-payer data, helping to ensure that the reporting hospital is promoting high quality and safe healthcare for all patients.

CareFirst BlueCross BlueShield

Blue Distinction®

CareFirst BlueCross BlueShield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

CareFirst Quality Rewards

CareFirst Quality Rewards (CQR) is a voluntary program designed to recognize and reward physicians for delivering effective, affordable healthcare services.  The program promotes physician adoption of quality improvement processes, including:

• Adhering to standards of practice established by national guidelines;
• Remediating care processes that fall short of national standards; and
• Improving patient care and outcomes.

Physicians taking part in CareFirst Quality Rewards can receive up to 107 percent of standard CareFirst reimbursement rates for meeting nationally recognized measures for quality and affordability.

Blue Cross and Blue Shield of Massachusetts

Alternative Quality Contract

Creating a firm link between clinical performance and provider reimbursement, Blue Cross and Blue Shield of Massachusetts (BCBSMA) recently introduced its optional Alternative Quality Contract, an innovative approach to improving the quality and appropriateness of care.  With an estimated 30 percent of care considered unnecessary or duplicative, BCBSMA’s AQC aims to ensure that patients receive the right treatment from the right provider at the right time.  To accomplish its goals of improving patient care, rewarding high-performing providers and controlling premium cost growth, the Plan worked closely with providers to restructure the traditional fee-for-service (FFS) payment system, which compensates caregivers based on the quantity rather than the quality of the services they deliver.  Unlike the standard FFS model, the AQC offers a blend of two kinds of reimbursement: a global, risk-adjusted, fixed payment per patient – with annual increases in line with inflation – and performance-based incentives linked to nationally recognized quality, efficiency and patient experience measures.  Patients also have access to providers’ scores on key performance measures, enabling them to select physicians and facilities that deliver high-quality, cost-effective care.  Furthermore, providers are encouraged to reinvest cost savings into more efficient care systems, a feature that BCBSMA expects to drive ongoing improvement.

Blue Distinction®

Blue Cross and Blue Shield of Massachusetts is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

 

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

 

Bridges to Excellence Program

Blue Cross and Blue Shield of Massachusetts participates in the Bridges to Excellence (BTE) program, a national initiative developed by employers, physicians, providers, researchers and other industry stakeholders to improve care quality.  The program recognizes and rewards physicians who meet stringent quality standards set by the National Committee for Quality Assurance and adopt comprehensive strategies for providing safe, timely, effective, efficient, equitable and patient-centered care.

eRx Collaborative Program

Formed by Blue Cross and Blue Shield of Massachusetts (BCBSMA) and other healthcare stakeholders, the eRx Collaborative promotes e-prescribing by subsidizing physicians’ adoption costs.  BCBSMA also has an incentive program to encourage providers to obtain and use the technology.  To date, the collaborative has achieved impressive results.  For example:

• Researchers estimate that e-prescribing resulted in the prevention of approximately 724 potential adverse drug events (ADEs).
• The cost savings related to avoiding these potential ADEs is estimated to be $630,000 in healthcare utilization.
• 71 percent of eRx Collaborative prescribers say e-prescribing saves time for office staff, with the majority saving one to two hours daily.
• 81 percent of eRx Collaborative prescribers would recommend e-prescribing to a colleague.
• In 2006, BCBSMA e-prescribers saved five percent on drug costs relative to BCBSMA prescribers not using the technology.
• BCBSMA members saved approximately $800,000 in co-payments on their prescriptions.

Hospital Performance Incentive Program

Blue Cross and Blue Shield of Massachusetts’s (BCBSMA) Hospital Performance Incentive Program (HPIP) is designed to link payment to performance on a set of nationally recognized quality indicators involving clinical outcomes, clinical processes, patient experience and hospital governance.  Hospitals receive payment for performance as well as for improvement.  In 2007, 64 hospitals earned a total of $104 million through the HPIP.  Taking the initiative one step further, the Plan recently said it would require hospitals to implement and utilize Computerized Physician Order Entry (CPOE) systems in order to participate in its incentive programs after 2012.  CPOE systems, which alert doctors when a medication order may pose a dosage, interaction or allergy danger, provide healthcare professionals with broader access to patient information, improve patient safety and streamline workflow.

Primary Care and Group Physician Incentive Programs

Blue Cross and Blue Shield of Massachusetts’s (BCBSMA) Primary Care Physician Incentive Program (PCPIP) and Group Physician Incentive Program (GPIP) reward physicians for meeting nationally recognized quality standards and patient safety goals.  The PCPIP measures performance in chronic disease care, preventive services, clinical outcomes reporting and other areas at the PCP level and enables providers to earn incentive payments on top of their fee-for-service reimbursements.  The GPIP, meanwhile, is a group-level incentive program designed to engage physicians in promoting medical efficiency and quality improvement, with a particular focus on the role of specialists.

Reinforcing the Plan’s emphasis on e-prescribing technology, BCBSMA recently announced that it is requiring physicians who prescribe medications to electronically prescribe in order to qualify for any of its physician incentive programs effective January 1, 2011.  The Plan introduced this initiative in an effort to continuously improve the quality, affordability and efficiency of care for its members.  The new requirement applies to both PCPs and specialists.  Currently, 99 percent of PCPs in the HMO Blue Network and 78 percent of specialists participate in BCBSMA incentive plans.

Blue Cross Blue Shield of Michigan

BCN’s Healthy Blue Living

BCN's Healthy Blue Living was first-to-market in Michigan and the nation with a product structure that encourages employees and their spouses to commit to healthy lifestyles, supported by their primary care physicians and the Blue Care Network (BCN).  The rewards for that commitment - in addition to achieving better health - are lower co-payments and deductibles for members.  The target for savings for employers is an average 10 percent reduction compared with an HMO product without the unique structure.

Members with this coverage have access to care management programs and services.  These include free smoking cessation and weight loss programs, free award-winning health education programs and BCN's disease management programs, which assist members with chronic conditions.  Experienced health coaches also are available to work with at-risk members on an individual basis to help them manage specific health issues.

Blue Distinction®

Blue Cross Blue Shield of Michigan is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Healthy Blue Incentives Program

Blue Cross Blue Shield of Michigan's Healthy Blue Incentives is a PPO product that reduces co-payments and deductibles for members who participate in its wellness program.  After enrolling in Healthy Blue Incentives, members complete a health risk appraisal to identify risk factors such as tobacco use, high body mass index or high blood pressure.  Those with a high risk profile are referred to a health coach to develop a wellness action plan.

Through regular contact with the personal health coach and participation in a tailored wellness program, members become eligible for reduced co-pays and lower deductibles and maintain those enhanced benefit levels by continuing with their wellness program and demonstrating progress toward their health goals.  Additionally, employers are rewarded for their workers' wellness with up to 10 percent cost savings, incentivizing health promotion in the workplace.

Patient-Centered Medical Homes

Partnering with and providing incentives to physician organizations, Blue Cross Blue Shield of Michigan (BCBSM) implemented initiative frameworks to guide the difficult work to re-tool practices so that they can function as patient-centered medical homes (PCMHs).  PCMHs are intended to transform the care delivery model and promote quality, efficiency and coordination.  Clinical teams at PCMHs manage patients' healthcare needs, work with members to identify personal health goals and coordinate care provided by specialists and healthcare facilities.  BCBSM uses its Physician Group Incentive Program (PGIP) to catalyze physician organizations to reorganize their clinical practices to conform to the PCMH model of care delivery.  In 2008, roughly $30 million of the $50 million expected to be distributed by the PGIP will go to physician organizations that are assisting practices to implement the PCMH approach.

Save Lives Save Dollars Initiative

Blue Cross Blue Shield of Michigan participates in the Greater Detroit Area Health Council's (GDAHC) multi-stakeholder Save Lives Save Dollars (SLSD) initiative, which aims to drive quality improvement and achieve cost reductions across southeastern Michigan.  Focusing on coordinated, intermediate and long-term actions, the initiative promotes adherence to evidence-based guidelines and performance metrics for diabetes care, the prevention of surgical site infections and generic drug utilization, as well as heart attack, heart failure and pneumonia care.  SLSD is also involved in the Robert Wood Johnson's Regional Quality Strategy, "Aligning Forces for Quality," as well as efforts to reduce health disparities, promote appropriate ER use and better manage patients' back pain.  The SLSD website is now posting performance information on SE Michigan hospitals, health plans and physician organizations.

Value Partnerships Incentive Programs

Working closely with physician organizations and hospitals, Blue Cross Blue Shield of Michigan launched the Value Partnerships Incentive Programs, which are designed to improve care quality and reduce costs.  These pay-for-performance initiatives foster collaboration among various stakeholders, contributing to the development of a highly functioning, quality-based healthcare system.  They include:

• Physician Group Incentive Program – Offers physician organizations financial incentives to focus on both long-term improvements in systems of care and short-term savings opportunities. PGIP mobilizes physician organizations via an array of initiatives that are focused on areas such as improving pharmacy or radiology cost and use, increasing adherence to evidence-based medicine standards for chronic disease or implementing capabilities that are needed to equip practices to function as patient-centered medical homes.
• Hospital Pay-for-Performance Programs – Provide financial incentives for mid-size and large acute care hospitals, as well as rural facilities, participating in BCBSM Collaborative Quality Initiatives, which promote high-quality, efficient and affordable patient care 

Blue Cross and Blue Shield of Minnesota

Blue Distinction®

Blue Cross and Blue Shield of Minnesota is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Bridges to Excellence Program

Blue Cross and Blue Shield of Minnesota collaborates in the Bridges to Excellence (BTE) program, through Minnesota Community Measurement, a Minnesota organization that promotes quality and transparency in healthcare. Spearheaded by the state’s Buyers Health Care Action Group, an employer coalition, Minnesota’s BTE program rewards physicians for providing high-quality diabetes and cardiovascular disease care. Blue Cross and Blue Shield of Minnesota was the first health plan to align measures with BTE and offer joint reporting to providers, streamlining the process and allowing potential rewards from both programs. The Plan continues to investigate additional quality measures with Minnesota Community Measurement, to expand its unique joint reporting relationship with BTE.

Recognizing ExcellenceSM in Clinical Performance and Assisting Smokers to QuitSM

Blue Cross and Blue Shield of Minnesota’s outcomes-based provider incentive program, Recognizing Excellence and Assisting Smokers to Quit, focuses on rewarding superior clinical outcomes, preventive medicine and clinical systems improvement (EMR implementation). The program spans seven specialty areas, including internal medicine, family medicine, pediatrics, OB-GYN, cardiology, spinal surgery and behavioral health. Recognizing Excellence is unique in that providers self-report data from patient charts. This process enhances provider awareness of their patient care and improves accuracy of results. 2009 will be the sixth year of the incentive program.

The tobacco component of Recognizing Excellence rewards clinics that document tobacco use status and refer interested tobacco users to quitting assistance. The Clinic Fax referral program (a Call It QuitsSM project) enables healthcare providers to use a single form and fax number to refer any patient who uses tobacco to quitline support, regardless of insurance status. Clinic incentive payments are tied to the Recognizing Excellence program, based on actual enrollments in an appropriate stop-smoking program. As of December 2008, over 600 clinics have enrolled in the referral program, including medical, dental, behavioral health and public health clinics.

Measurable improvement in diabetes care and offering assistance to quit earned the Plan a “Best of Blue” award from the Blue Cross and Blue Shield Association in 2006.

Blue Cross & Blue Shield of Mississippi

There are currently no plans in this category.

Anthem Blue Cross and Blue Shield (Missouri)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Hospital Quality Program

Anthem Blue Cross and Blue Shield crafted a hospital quality program to help reduce variation in practice patterns and outcomes among network hospitals.  The program has evolved to include an incentive payment for quality, electronic data submission and enhanced sharing of best practices.  Now called the Midwest Hospital Quality Improvement Program, it includes 357 hospitals in Ohio, Kentucky, Indiana and Missouri.  As part of the program:

• An annual Request for Information (RFI) is sent to each network hospital.  The RFI consists of 10 core measures, developed in collaboration with participating hospitals, accrediting bodies and quality organizations.  Once the RFI is completed, data are entered into a confidential database, aggregated and analyzed.
• Hospitals receive a report card with their overall score, as well as comparisons to their peer hospitals, matched by size for ease of comparison.  The Midwest Hospital Quality Improvement Program changes its measures in response to national and regional trends to incorporate more contemporary approaches for measuring or improving clinical quality.
• Starting in 2003, incentives were paid to high-performing hospitals, while lower-performing hospitals were approached about remediation.  However, the goal of this program is not to punish lower-performing hospitals but to work with hospitals in a collaborative fashion to improve care quality.
• Further collaboration is sparked by the annual Hospital Quality Program meetings.  Beginning in 2003, hospitals were asked to submit an abstract of a “successful practice,” which is judged by an impartial panel of Quality Improvement Directors from other regions.  Winning practices are presented at the Hospital Quality Improvement meetings, allowing for an exchange of ideas among competing hospitals.

Patient-Centered Medical Homes

The patient-centered medical home, a model currently under consideration by Anthem Blue Cross and Blue Shield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are being developed by Anthem Plans in Colorado, Maine, New Hampshire, New York and Ohio.  Additional programs are being discussed and considered in California and Wisconsin.

Blue Cross and Blue Shield of Kansas City

Blue Distinction®

Blue Cross and Blue Shield of Kansas City is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants. New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.  Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care. To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Patient-Centered Medical Homes

Blue Cross and Blue Shield of Kansas City (BCBSKC) is evaluating the use of patient-centered medical homes (PCMHs) within its network.  In an effort to improve care delivery, PCMHs foster collaboration between patients and their personal physician and aim to offer a comprehensive system for improving individual wellness and health outcomes.  The model encompasses care for all stages of life, including acute and chronic care, preventive services and palliative care.  Following an evaluation of PCMHs’ impact on care delivery, BCBSKC is planning to implement the model across its network.

Blue Cross and Blue Shield of Montana

Blue Distinction®

Blue Cross and Blue Shield of Montana is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Reducing Unnecessary CT/MRI Tests Program

Recognizing that nearly two-fifths of the CT and MRI procedures recommended statewide fail to meet the American College of Radiology's (ACR) appropriateness criteria, Blue Cross and Blue Shield of Montana (BCBSMT) launched the Reducing Unnecessary CT/MRI Tests Program. As part of this initiative, the Plan collaborated with radiologists and encouraged them to consult with referring physicians about scan appropriateness. BCBSMT also created an incentive structure to ensure compliance, helping drive a 22 percent reduction in CT/MRI utilization.

Blue Cross and Blue Shield of Nebraska

Blue Distinction®

Blue Cross and Blue Shield of Nebraska is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Recognition for Quality Program

To acknowledge and encourage quality improvements across its network, Blue Cross and Blue Shield of Nebraska’s Recognition for Quality program publicly recognizes high-performing hospitals and physicians that participate in nationally established, evidence-based quality improvement programs. For example, the Plan has recognized providers for their participation and success in national initiatives such as the American Heart Association’s Get With The Guidelines program, the Institute for Healthcare Improvement’s 100,000 Lives Campaign and the Blue Cross and Blue Shield Association’s Blue Distinction Centers.  These programs help ensure that patients receive high-quality, evidence-based care and promote adherence to nationally recognized best practices.  To learn more about the Recognition for Quality program, please visit Blue Cross and Blue Shield of Nebraska’s website.

Anthem Blue Cross and Blue Shield (Nevada)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Promoting Healthcare Quality Program

Anthem Blue Cross and Blue Shield’s Promoting Healthcare Quality (PHQ) program was launched in 2003 under a basic assumption: If hospitals are offered incentives to improve quality outcomes and meet certain performance standards, the quality and safety of care for patients would improve.  Anthem was the first health benefits company in the state to introduce this kind of program and has since been recognized as a leader in expanding reimbursement for clinical excellence and improved medical outcomes, rather than limiting it only to delivery of medical services.  PHQ offers hospitals various incentives – including financial – for achieving measurable improvements in patient safety and health outcomes, using such measures as pneumococcal vaccination rate, provision of aspirin and beta blockers for patients suffering a heart attack, computerized physician order entry systems and ICU staffing.  Success is measured by assigning values for compliance with recommended patient safety standards, implementation of systems and processes to meet these standards and improvements in clinical outcomes.

Anthem Blue Cross and Blue Shield (New Hampshire)

Anthem Quality Insights® (AQI®) Incentives Programs

Anthem Blue Cross and Blue Shield’s Primary Care Quality Incentive Program rewards participating physicians for excellent performance based on standards of quality, clinical outcomes, patient safety and administrative processes designed to enhance patient care.  The Quality Incentive Program for Cardiology and Obstetrics/Gynecology rewards performance for specialty care services based on industry standard measures of quality, including process measures, technology measures and pharmacy measures.

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Patient-Centered Medical Homes

The patient-centered medical home, a model currently being tested in a multi-payer pilot that includes Anthem Blue Cross and Blue Shield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are also being developed by Anthem Plans in Colorado, Maine, New York and Ohio.  Additional programs are being discussed and considered in Missouri, California and Wisconsin.

Quality Insights Hospital Incentive Program

Anthem Blue Cross and Blue Shield’s Quality Insights Hospital Incentive Program (Q-HIP^SM) is a hospital quality program involving voluntary reporting of nationally vetted and recognized evidence-based quality indicators in three categories: patient safety, patient health outcomes and member satisfaction.  In addition, the program incorporates quality metrics and pay-for-performance incentives for important patient safety initiatives, and its review process is transparent.   The Plan audits and externally validates the submitted hospital all-payer data, helping to ensure that the reporting hospital is promoting high quality and safe healthcare for all patients.

Horizon Blue Cross and Blue Shield of New Jersey, Inc.

Blue Distinction®

Horizon Blue Cross and Blue Shield of New Jersey is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Horizon Health Rewards

Horizon Blue Cross and Blue Shield of New Jersey offers the Health Rewards incentive program to motivate members to make lifestyle improvements and encourage greater participation in healthcare decision-making.  The program rewards consumers with incentive points for completing a health risk assessment, using healthcare cost calculators, comparing hospital quality performance and reading health-related articles.  Members can redeem points for gift cards from leading retailers, merchandise, travel packages and more.

Hospital/Physician Recognition Programs

Horizon Blue Cross and Blue Shield of New Jersey’s Hospital Recognition Program publicly acknowledges network hospitals for improving safety, clinical outcomes and patient satisfaction and provides financial rewards to facilities with superior performance.  Similarly, Horizon’s Physician Recognition Program rewards network provider groups with financial incentives and public recognition for delivering superior care in nine specialties based on nationally recognized best practices. 

Patient safety criteria are based on the Joint Commission's National Patient Safety Goals and the Institute for Healthcare Improvement’s 5 Million Lives Campaign.  Clinical criteria are based on the Centers for Medicare and Medicaid Services’ process measures for heart attack, heart failure, community-acquired pneumonia and surgical-site infection prevention.

In April 2007, Horizon announced that more than 60 network hospitals will share $6 million in payments in recognition of their superior performance in care quality and patient outcomes.

Patient-Centered Medical Homes

Horizon Blue Cross and Blue Shield of New Jersey is seeing impressive results in its patient-centered medical home pilot, which provides financial incentives to primary care physicians for delivering comprehensive, coordinated patient care, including chronic disease management.  Using claims data to track patient care, Horizon is also able to alert physicians when patients need routine tests and screenings.  Among the results to date:

• In just one year, blood sugar testing compliance rates for patients with diabetes jumped from 40 percent to more than 90 percent. 
• Screening rates for breast, cervical and colon cancers also increased significantly, rising by 25 percent, 19 percent and 15 percent, respectively.

Health Care Service Corporation, a Mutual Legal Reserve Company | Blue Cross and Blue Shield of New Mexico

Blue Distinction®

Blue Cross and Blue Shield of New Mexico is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

BlueCross BlueShield of Western New York and BlueShield of Northeastern New York

Blue Distinction®

BlueCross BlueShield of Western New York and BlueShield of Northeastern New York is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Go Generic – The Smart Choice Incentive Program

To raise providers' and members' awareness of the effectiveness, safety and value of generic drugs, BlueCross BlueShield of Western New York and BlueShield of Northeastern New York launched the Go Generic – The Smart Choice initiative.  Using mailings, Web-based resources and seminars, the program encourages members to consider lower-cost generic drugs.  The campaign also offers financial incentives to physicians and pharmacists who shift their prescribing and dispensing practices toward greater use of generics.  In its first three years, the program has achieved impressive results, boosting the percentage of generic rather than name-brand prescriptions from 38 percent to nearly 52 percent networkwide.  The initiative has made significant strides in reducing healthcare costs while ensuring that members receive appropriate medications.

Patient-Centered Medical Homes

BlueCross BlueShield of Western New York and BlueShield of Northeastern New York are piloting patient-centered medical homes (PCMHs).  The PCMH model fosters collaboration between the patient and physician and is designed to encompass all stages of life, including acute and chronic disease management, preventive services and palliative care.  The model also empowers consumers to access healthcare options appropriate to their situation and rewards physicians for improvements in quality, safety and outcomes.

Provider Incentive Program

BlueCross BlueShield of Western New York and BlueShield of Northeastern New York's Provider Incentive Program offers financial rewards to physicians, hospitals and provider groups that improve clinical quality across the care continuum.  The program measures quality and efficiency based on a set of performance indicators developed collaboratively with network providers.  Some program-driven improvements include: 

• Reduction in time-to-treatment for thrombolytic patients from 80 minutes to 33 minutes
• Reduction in acute myocardial infarction mortality rates from 9.50 percent to 7.15 percent
• 55 percent reduction in cardiac surgery mortality rates from 3.39 to 1.53 per 100 procedures

Empire Blue Cross and Blue Shield (New York)

Blue Distinction®

Empire Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Patient-Centered Medical Homes

The patient-centered medical home, a model currently being tested in a multi-payer pilot that includes Empire Blue Cross and Blue Shield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are also being developed by Anthem Plans in Colorado, Maine, New Hampshire and Ohio.  Additional programs are being discussed and considered in Missouri, California and Wisconsin.

Performance Extra Program

Empire Blue Cross and Blue Shield’s Performance Extra physician incentive program focuses on clinical activities related to the prevention and management of a variety of chronic and acute conditions, as well as quality service and other evidence-based gauges of state-of-the art medical practice.  Wherever applicable, the program uses national benchmarks to assist in defining distinctive and exceptional performance.  Performance Extra provides incentives for superior management of chronic conditions such as asthma, diabetes, high cholesterol, hypertension, and mental health conditions, as well as preventive service delivery, care quality, patient satisfaction and generic dispensing.

Quality Insights Hospital Incentive Program

Empire Blue Cross and Blue Shield’s Quality Insights Hospital Incentive Program (Q-HIP^SM) is a hospital quality program involving the voluntary reporting of nationally vetted and recognized evidence-based quality indicators in three categories: patient safety, patient health outcomes and member satisfaction.  In addition, the program incorporates quality metrics and P4P incentives for important patient safety initiatives and operates under a transparent review process.  The Plan audits and externally validates the submitted hospital all-payer data, helping ensure the reporting hospital is promoting high-quality and safe healthcare for all patients.

Excellus Blue Cross Blue Shield (New York)

Blue Distinction®

Excellus BlueCross BlueShield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Excellus BlueCross BlueShield Quality Improvement Program

Excellus BlueCross BlueShield launched its Quality Improvement Program to encourage the timely delivery of necessary and effective care and improve the health and satisfaction of Plan members.  In addition, the program supports and recognizes practitioner, provider and enrollee efforts to achieve improved functional and clinical health outcomes.

Generic Prescription Incentive Program

To reward physicians who effectively educate patients about generic medication alternatives, Excellus BlueCross BlueShield’s Generic Drug Incentive Program offers financial incentives to providers whose patients subsequently switch to the generic formulary.  In addition, physicians who increase their ratio of generic drug prescriptions by five percentage points are eligible to receive higher reimbursements for patient office visits.

Generics are REAL Community Education Program

After issuing a detailed analysis in December 2005 showing that upstate New York could potentially save more than $880 million by increasing the use of generic rather than name-brand drugs, Excellus BlueCross BlueShield created and launched a multi-faceted, multi-year and region-adjusted public education campaign titled Generics are REAL.

The Plan conducted follow-up analyses in 2006 and 2007 to track generic fill rate increases in upstate New York and to estimate the realized communitywide savings produced by those increases.  In addition, the Plan conducted a consumer survey in early 2007 to assess the public’s perception of generic drugs.  Based on the analyses and survey, Excellus has modified and expanded the Generics are REAL campaign to increase public awareness and acceptance of generics.  Echoing the calls-to-action commonly used in pharmaceutical advertising, the campaign’s core message to consumers is, "Ask your doctor or pharmacist if generic drugs are right for you."  The campaign’s elements include:

• Detailed analyses of benchmarks and potential savings opportunities by region
• Public relations outreach, community events and radio and print advertisements
• Employer group education, outreach and communication tools
• Targeted direct-to-member communications
• Physician education and outreach
• Interactive Web tools available to the public

The generic fill rate for the total upstate New York population went from 53.8 percent to 63.9 percent between October 2005 and October 2007, resulting in projected communitywide savings of more than $350 million.

Patient-Centered Medical Homes

The patient-centered medical home (PCMH), a model currently under consideration by Excellus BlueCross BlueShield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.

Rochester Rewards Results Program

Excellus BlueCross BlueShield’s Rochester Rewards Results program is designed to improve care quality for patients with chronic illnesses.  The initiative encourages quality improvement by using communitywide clinical guidelines and providing financial incentives based on care quality, patient satisfaction and feedback programs.

Blue Cross and Blue Shield of North Carolina

Blue Distinction®

Blue Cross and Blue Shield of North Carolina is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Bridges to Excellence Program

Blue Cross and Blue Shield of North Carolina (BCBSNC), in partnership with the State Health Plan for Teachers and State Employees, completed a three-year Bridges to Excellence pilot program in April 2009. Bridges to Excellence is a national initiative developed by employers, physicians, healthcare providers, researchers and other industry stakeholders to improve care quality. The program recognized physicians who adopted comprehensive strategies for providing safe, timely, effective, efficient, equitable and patient-centered care.

This pilot program rewarded physicians for distinction in three categories: diabetes care, heart and stroke care and physician office management/efficiency, which included clinical information systems, patient education and support and care management. The program recognized 194 physicians at 41 practices statewide for meeting stringent national standards set by the National Committee for Quality Assurance. These physicians received a combined total of $4.2 million in care quality rewards.

Based on the success of the Bridges to Excellence pilot, BCBSNC expects to expand the concept of providing rewards and recognition to doctors meeting quality standards later in 2009.

Co-Pay Waiver for Generics

Blue Cross and Blue Shield of North Carolina launched an initiative to raise members’ awareness of generic drugs as a clinically effective but lower-cost alternative to brand-name treatments.  To encourage members to make the switch, the program waived co-payments for generic prescriptions used to treat chronic conditions such as congestive heart failure, hypertension, high cholesterol and diabetes. Opting for generics under the program saved members an estimated $50 per drug on average.

BlueCross BlueShield of North Dakota

Blue Distinction®

Blue Cross Blue Shield of North Dakota is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

MediQHome Quality Program

MediQHome is Blue Cross Blue Shield of North Dakota’s (BCBSND) patient-centered medical home quality program. The patient-centered medical home is a model of a physician practice that emphasizes readily accessible, comprehensive, coordinated care and active involvement of the patient and family in healthcare decisions. BCBSND believes the medical home concept - which is rapidly gaining traction as a viable tool to improve quality, reduce costs and help eliminate disparities in healthcare access and outcomes - could profoundly improve healthcare in this country.

MediQHome allows providers to focus on their patient’s health outcomes through the use of MDinsight, an interactive decision support tool that helps the provider identify care opportunities by organizing all available patient clinical data (not claims data) to create clinical summaries and quality reports specific to each patient. BCBSND is currently in a “proof of concept phase” and plans to make the program available to all providers in 2010.

Anthem Blue Cross (Ohio)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Hospital Quality Program

Anthem Blue Cross and Blue Shield crafted a hospital quality program to help reduce variation in practice patterns and outcomes among network hospitals.  The program has evolved to include an incentive payment for quality, electronic data submission and enhanced sharing of best practices.  Now called the Midwest Hospital Quality Improvement Program, it includes 357 hospitals in Ohio, Kentucky, Indiana and Missouri.  As part of the program:

• An annual Request for Information (RFI) is sent to each network hospital.  The RFI consists of 10 core measures, developed in collaboration with participating hospitals, accrediting bodies and quality organizations.  Once the RFI is completed, data are entered into a confidential database, aggregated and analyzed.
• Hospitals receive a report card with their overall score, as well as comparisons to their peer hospitals, matched by size for ease of comparison.  The Midwest Hospital Quality Improvement Program changes its measures in response to national and regional trends to incorporate more contemporary approaches for measuring or improving clinical quality.
• Starting in 2003, incentives were paid to high-performing hospitals, while lower-performing hospitals were approached about remediation.  However, the goal of this program is not to punish lower-performing hospitals but to work with hospitals in a collaborative fashion to improve care quality.
• Further collaboration is sparked by the annual Hospital Quality Program meetings.  Beginning in 2003, hospitals were asked to submit an abstract of a “successful practice,” which is judged by an impartial panel of Quality Improvement Directors from other regions.  Winning practices are presented at the Hospital Quality Improvement meetings, allowing for an exchange of ideas among competing hospitals.

Patient-Centered Medical Homes

The patient-centered medical home, a model currently being tested in a multi-payer pilot that includes Anthem Blue Cross and Blue Shield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are being developed by Anthem Plans in Colorado, Maine, Missouri, New Hampshire and New York.  Additional programs are being discussed and considered in California and Wisconsin.

Health Care Service Corporation, a Mutual Legal Reserve Company | Blue Cross and Blue Shield of Oklahoma

Asthma Action Plan

Blue Cross and Blue Shield of Oklahoma developed the Asthma Action Plan to help members better manage and control the disease.  The Plan offers HMO medical groups a financial incentive to work with asthmatic patients, rewarding physicians based on the percentage of patients receiving a written asthma self-management plan, such as guidelines for the use of peak flow meters and controller medications.  The action plan initiative improves health outcomes for members with asthma and reduces ER visits for acute asthma attacks, which can drive up healthcare costs.

Blue Distinction®

Blue Cross and Blue Shield of Oklahoma is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Patient-Centered Medical Home

Blue Cross and Blue Shield of Oklahoma is presently developing a demonstration project of the patient-centered medical home model, designed to create a healthcare setting collaboration between the patient and physician to improve the quality, safety and outcomes of care.  The PCMH model emphasizes and rewards the coordination of care for patients encompassing all stages of life, including acute and chronic condition management, preventive services and palliative care.  The demonstrations are in the early stages of development, but once implemented will empower consumers to access healthcare options appropriate to their situation to make healthy lifestyle choices.

Regence BlueCross BlueShield of Oregon

Blue Distinction®

Regence BlueCross BlueShield of Oregon is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Regence Activate

The Regence self-managed plan, Activate, gives members the opportunity to earn points for engaging in healthy behaviors.  These points convert to “Member Choice Funds,” which can be used to pay deductibles or other out-of-pocket medical expenses.  Choosing from a list of qualifying wellness activities, members can earn points by participating in weight loss programs or activities such as running, skiing, attending a health club, receiving an annual flu shot or participating in a nutrition or healthy cooking class.  This plan includes a variety of programs at no additional cost to help members make the best use of these choices, including:

• Health Coach – Provides members with a personal connection to someone who can help them assess their current habits, set goals to achieve better health and monitor their progress along the way.  Using a toll-free number, members can call upon the coach for education, goal-setting, encouragement and support.
• myRegence.com – Empowers members to take charge of their healthcare.  This interactive tool provides advice, navigation and rewards to promote proactive behavior on the part of the member.
• CareEnhance® – Provides confidential, 24/7 access to information and advice.  Members can talk or correspond via e-mail with a registered nurse any time of day or night.  In addition, an AudioHealth Library provides general health information on nearly 1,200 topics.  The audio library is also available online.
• Special Beginnings – Offers personalized monitoring of an expectant mother’s care throughout her pregnancy, along with 24-hour, toll-free telephone access to registered nurses who specialize in working with mothers and newborns, including a full set of educational tools.
• Regence Advantages program – Features discounts on items and services such as hearing aids, fitness club memberships, weight management programs, contact lenses and LASIK procedures
• No network, just tiers of coverage – With self-managed plans, Regence members do not need to check to see if their doctor is in or out of a network.  All are covered at some level.

For more information, please visit www.selfmanagedplans.com or view Regence’s press release by clicking here.

RegenceRx Generic Incentive Program

The voluntary RegenceRx generic incentive program allows members taking certain generic medications to receive up to a 30-day supply at no cost.  Over 25 generic medications are part of this program.  Previously, members could only receive samples of branded medications supplied by pharmaceutical manufacturers to their physicians.  Now, members can try a generic medication with no initial financial obligation before filling the balance of their prescription.   Each one percent increase in generic utilization represents a savings of approximately $12 million.

The RegenceRx Generic Incentive Program hopes to encourage physicians to cut costs by prescribing generic medications when available and gives members the encouragement to ask for generic medications specifically at their physician’s office and pharmacy.  For more information, please click here.

Blue Cross of Northeastern Pennsylvania

Blue Distinction®

Blue Cross of Northeastern Pennsylvania is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Hospital-Acquired Conditions

Starting January 1, 2009, Blue Cross of Northeastern Pennsylvania will not make additional payments in cases where hospital-acquired conditions occur.  Instead, the case will be reimbursed as if the hospital-acquired condition did not occur, in accordance with Medicare policies that currently include no additional payment for:

• Objects left in during surgery
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infection
• Pressure ulcers
• Vascular catheter-associated infection
• Surgical site infection – mediastinitis after coronary artery bypass graft surgery
• Falls and trauma – fractures, dislocations, intracranial injuries, crushing injuries and burns
• Surgical site infection following certain orthopedic procedures
• Surgical site infection following certain bariatric procedures
• Manifestations of poor glycemic control

Never Events

Beginning January 1, 2009, Blue Cross of Northeastern Pennsylvania will not pay if one of the following occurs:

• Surgery is performed on the wrong body part
• Surgery is performed on the wrong patient
• The wrong surgical procedure is performed on a patient

Pay For Performance

Pay For Performance is a pilot program that Blue Cross of Northeastern Pennsylvania launched with 20 primary care physician groups.  The program rewards the groups for improving their performance on clinical measures, referring and/or enrolling their patients in certain disease management programs and adopting best practices in the use of electronic medical records.

PCP Incentive Program

Blue Cross of Northeastern Pennsylvania’s PCP Incentive Program rewards primary care physicians for delivering high-quality, cost-effective care based on the following factors: preventive and clinical performance measures, utilization measures and services under capitation and data submission and access to care.

Capital BlueCross

Blue Distinction®

Capital BlueCross is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.  Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Collaboration with State on Chronic Care Initiatives

Capital BlueCross is working with the Pennsylvania state government on chronic care initiatives that will grant incentives to physicians to provide care management services and monitor specific conditions. 

Highmark Blue Cross Blue Shield

Blue Distinction®

Highmark Blue Cross Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.  Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Promoting Quality Improvement Programs

• Focus on measuring quality indicators that have been identified by national quality improvement organizations
• Align financial incentives to improvements in these quality measures.
• Provide practice coaching and guidance to physicians and hospitals
• Make education, coaching and incentives available to members to improve their adherence to evidence-based guidelines and their use of preventive care

A key success factor has been the development of collaborative relationships with Highmark’s network providers and its members, rooted in mutually shared goals.

QualityBLUE

QualityBLUE, Highmark's pay-for-performance program, continues to generate positive results by working with hospitals and physicians to save lives and reduce healthcare costs. The following results were the outcome of healthcare provider efforts measured by Highmark for fiscal year 2008-2009:

• MRSA infection reduction: Approximately five patients for every 100 hospital admission results in a healthcare-associated infection. Many of these are caused by staph infections resistant to common antibiotics and are called Methicillin Resistant Staphylococcus aureus (MRSA). QualityBLUE hospitals reduced MRSA infections by 233 infections, which translates to a projected care cost savings of $6.3 million to $8.1 million. Approximately five percent of patients with a MRSA infection die, so by averting 233 infections, potentially 11 lives were saved.
• Central line infections: A central line is an invasive catheter device inserted in a patient and used to monitor the blood circulating through the body, provide nourishment and administer medication. While these catheters are life sustaining, they may place patients at risk for infection. QualityBLUE hospitals have consistently had a lower infection rate than the national average. Comparison of the rates demonstrates that QualityBLUE hospitals prevented 1,020 potential bloodstream infections that resulted in $37.5 million in avoided care costs and, more importantly, saved 122-255 lives.
• Breast cancer screening: For every 1,000 women between the ages of 50-65 screened for breast cancer, 1.8 lives are saved. Internal medicine primary care practices participating in QualityBLUE adhered to recommended screening guidelines at a higher rate than the national average. In doing so, an estimated 174 lives among women over age 50 have been saved.

Independence Blue Cross

There are currently no plans in this category.

Triple S Management Corporation

Maintenance of Certification Incentive Program

Triple-S Management Corporation’s Maintenance of Certification Incentive Program encourages physicians to maintain their specialty certification and recognizes them for doing so by awarding a certificate of participation and offering special designation in the Triple-S network directory.  The Plan also provides reimbursement for registration fees and offers a biannual monetary incentive.  The program is currently in place for internal medicine and its subspecialties, pediatrics and its subspecialty and family medicine.

Patient-Centered Medical Homes

Triple-S Management Corporation’s patient-centered medical home (PCMH) demonstration project aims to promote patient-physician collaboration and care coordination by explaining the role of specialists, suggesting appropriate and compassionate treatment options and answering patients’ questions about illnesses.  PCMHs encompass care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  The model also empowers consumers to access healthcare options appropriate to their situation and make healthier lifestyle choices.

Provider Incentive Models

Triple-S Management Corporation has developed Provider Incentive Models based on the Plan’s Quality Assessment Performance Initiatives.  In addition, Triple-S’s Physician Incentive Plan focuses on chronic disease management and quality management in the general population.

Quality Incentive Program

Triple-S Management Corporation has developed a quality incentive program to promote optimal care delivery.  The program is designed to enhance provider-patient encounters by offering physicians information on key quality measures in their patient base, providing helpful insight into their practices’ quality performance.  The initiative’s pilot phase focuses on two of Puerto Rico’s most prevalent conditions: diabetes and asthma.  In addition, the program offers a pediatric prevention module to screen for neurodevelopment disorders.

Blue Cross & Blue Shield of Rhode Island

Blue Distinction®

Blue Cross & Blue Shield of Rhode Island is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Generic Drug Pilot Program

Blue Cross & Blue Shield of Rhode Island’s (BCBSRI) generic drug pilot program, launched in October 2005 to encourage doctors to prescribe generic drugs, offers free 30-day samples of generic medications as a first-line therapy via an ATM-like dispenser in doctors’ offices.  The program, a partnership with MedVantx Generic Drug Delivery Network of San Diego, involves more than 160 Rhode Island physicians at 35 locations.  Participating physicians are using two percent more generics in targeted drug classes than non-participating providers, generating an average of $1 million in annual cost savings.  BCBSRI’s generic fill rate has also increased to approximately 60 percent in the commercial market.

Generic Voucher Program

To promote increased utilization of generic alternatives to brand-name treatments, Blue Cross & Blue Shield of Rhode Island (BCBSRI) launched the Generic Voucher Program in October 2006 targeting 150 prescription drugs.  The program entitled all members to a co-payment waiver the first time they filled a prescription for a generic drug.  This model fosters a win-win partnership, given that members benefit from out-of-pocket savings and employers incur less premium growth.  In its first year, the program generated more than $1 million in savings on first-fill prescriptions alone.

Half-Tab Program

Blue Cross & Blue Shield of Rhode Island’s (BCBSRI) Half-Tab Program aims to help members reduce their out-of-pocket costs by as much as 50 percent for medications that can be split safely.  The voluntary program allows members to purchase a smaller number of higher-strength tablets that can be split to reach the prescribed daily dose.  Through participation in the Half-Tab Program, members’ co-payments and co-insurance amounts are reduced by half.

Integration of Primary Care and Behavioral Health Pilot

Blue Cross & Blue Shield of Rhode Island is funding and promoting co-location of primary care and behavioral health services in order to provide more effective care for patients by addressing both emotional and physical needs in the same setting.  The program recognizes that 50 percent to 70 percent of all primary care visits have either no organic problem or a large behavioral health component.  Furthermore, 80 percent of psychotropics are prescribed by primary care physicians (PCPs).  Under the program – which encompasses four PCP offices, including internal medicine, pediatrics and OB-GYN – a behavioral health provider must be on site for a minimum of 20 hours weekly or 50 percent of the practice’s operating hours.  The program features coordinated scheduling through a centralized phone number, and the PCP and behavioral health provider share the same patient chart.

Intensive Care Unit Collaborative

Blue Cross & Blue Shield of Rhode Island provided significant funding for the statewide Intensive Care Unit Collaborative, which enlisted all hospitals with ICUs in an effort to reduce inpatient complications such as ventilator-associated pneumonia (VAP) and catheter-related bloodstream infections (CR-BSI).  Through the program, participating facilities have posted quarter-over-quarter improvements in CR-BSI and VAP outcomes.

OTC Options Program

Blue Cross & Blue Shield of Rhode Island’s (BCBSRI) OTC Options – a one-year pilot program – provided members with over-the-counter allergy medication at no cost.  The initiative helped decrease members’ out-of-pocket costs for non-sedating antihistamine drugs.  Overall savings totaled $756,014, of which $280,868 accrued to BCBSRI and $475,146 accrued to Plan members.

Patient-Centered Medical Homes

The patient-centered medical home, a model currently being tested by Blue Cross & Blue Shield of Rhode Island, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.

Quality Counts Pay-for-Performance Program

Blue Cross & Blue Shield of Rhode Island’s Quality Counts program, which began in November 2005, is designed to incent primary care physicians (PCPs) to implement multifunctional electronic health record (EHR) systems in their offices.  Through the initiative, the Plan partially funds practices’ EHR adoption and provides bonus payments based on mutually agreed-upon quality measures.  To date, 80 PCPs have fully implemented EHRs in their practices.  Those who have been using EHRs for one year or more are required to write e-prescriptions for certain medications at least 60 percent of the time.

Radiology Management Program

Blue Cross & Blue Shield of Rhode Island’s Radiology Management Program reflects the Plan’s commitment to the appropriate use of diagnostic imaging services, ensuring that members receive high-quality care while eliminating unnecessary scans and procedures.  Effective Jan. 1, 2008, the Plan began requiring prior authorization for MRI, MRA, CT and PET scans, as well as for nuclear cardiac imaging.  Through July 2008, the program has reviewed 86,478 requests and denied only 6,670—a 7.71 percent denial rate.  The Plan has also observed a “sentinel” effect, indicating that the presence of a review process is encouraging providers to be more judicious in imaging use.  In addition to reducing care costs, with an estimated $6 million in savings expected in 2008, the program is enhancing patient safety by preventing unnecessary radiation exposure.

Specialty Pharmacy Initiatives

Blue Cross & Blue Shield of Rhode Island’s specialty pharmacy program aims to maximize opportunities to reduce drugs’ unit cost, enhance the clinical management of specialty drugs and ensure appropriate utilization of these therapies.  Under the program, members’ cost-sharing obligation for specialty drugs is the same as the highest tier or co-insurance for their drug benefit, and they must use a limited Specialty Pharmacy Network to receive in-network pharmacy benefits.  Providers, meanwhile, must use the Specialty Pharmacy Network to obtain specialty drugs.  Prior authorization is also required for selected treatments.

Blue Cross and Blue Shield of South Carolina

Blue Distinction®

Blue Cross and Blue Shield of South Carolina is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Healthy Incentives

Blue Cross and Blue Shield of South Carolina developed the Healthy Incentives program to allow employers to reward workers for participation in qualified health activities such as wellness education and fitness initiatives.  Employees earn points for each activity completed and can redeem points for gift cards at major retailers, gas cards and travel, as well as monetary awards such as contributions toward members’ premiums or health savings accounts.

Patient-Centered Medical Home Pilot

Blue Cross and Blue Shield of South Carolina has teamed up with Palmetto Primary Care Physicians in Charleston, S.C., to initiate a year-long patient-centered medical home pilot project that could become a model for South Carolina. The patient-centered medical home is a first for the Plan, a first for Palmetto Primary Care Physicians and its patients and a first in South Carolina involving an insurance company.

The pilot project will focus on diabetic patients who are members of Blue Cross and Blue Shield of South Carolina and BlueChoice HealthPlan of South Carolina. Patient-centered medical homes integrate quality improvement, coordinated care management and patient educational tools into primary care practices. The concept places the primary care doctor in charge of a team that can include social workers, pharmacists, wellness coordinators, nurses, disease managers and clinical diabetic educators, all working together to proactively reach out and develop an individual treatment plan for patients.

Case managers will help reduce gaps in care, such as missed appointments with specialists, lack of transportation and medication non-compliance. They also will perform outreach, such as registering patients for wellness clinics, scheduling appointments with specialists and monitoring medical effects. The clinical quality goals will be monitored by measuring blood sugar levels and cholesterol levels.

Electronic medical records will be a key component for delivering comprehensive care. Palmetto Primary Care Physicians uses software, at the point of care, that integrates information received from the health plan, case manager and local emergency rooms. This is information that the primary care practice has never had before. The medical record then becomes more complete and readily available to the primary care physician. Palmetto Primary Care Physicians also has created a portal on its website where pilot participants can schedule an interactive e-visit with their physicians, create their own personal health records, upload and chart their own glucose results and pay their bills.

Physician Recognition Program

Blue Cross and Blue Shield of South Carolina established the Physician Recognition Program (PRP) to provide financial incentives to participating providers who demonstrate improvements in care quality for patients with chronic conditions such as diabetes and heart disease.  Physicians receive a one-time cash award of up to $5,000 for achieving accreditation from the National Committee for Quality Assurance (NCQA) for diabetes or cardiovascular disease care or certification in hypertension management from the American Society of Hypertension.  The program improves the long-term quality of life for members with chronic illnesses and yields cost savings for the healthcare system because of averted complications.

Wellmark Blue Cross and Blue Shield of South Dakota

Blue Distinction®

Wellmark Blue Cross and Blue Shield of South Dakota is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Incent and Reward Best Practices Program

Wellmark Blue Cross and Blue Shield of South Dakota’s Incent and Reward Best Practices program rewards physicians who demonstrate a commitment to providing diabetes care and patient education that aligns with national standards and other care quality measures.  Clinicians who meet clinical performance and patient outcome targets are eligible to receive special recognition and potential financial rewards from the Plan.  Participating providers also agree to share their performance information with members, employers and other clinicians, and starting in the second quarter of 2008, clinic-level performance data for primary care physicians was posted online.

Patient-Centered Medical Homes

Wellmark Blue Cross and Blue Shield of South Dakota’s patient-centered medical home (PCMH) demonstration project, which is currently in progress, aims to promote patient-physician collaboration and care coordination by explaining the role of specialists, suggesting appropriate and compassionate treatment options and answering patients’ questions about illnesses.  The PCMH encompasses care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  The model also empowers consumers to access healthcare options appropriate to their situation and make healthier lifestyle choices.

BlueCross BlueShield of Tennessee

Blue Distinction®

BlueCross BlueShield of Tennessee is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Patient-Centered Medical Home

BlueCross BlueShield of Tennessee is in the planning phase of implementing patient-centered medical home demonstrations across its network to improve the quality, safety and cost-effectiveness of care through enhanced healthcare collaboration.  The PCMH model emphasizes and rewards the coordination of care for patients encompassing all stages of life, including acute and chronic condition management, preventive services and palliative care.  The demonstrations are in the early stages of development, but once implemented will empower consumers to access healthcare options appropriate to their situation to make healthy lifestyle choices.

Quality and Cost: Transparency and Pay-for-Performance Program

BlueCross BlueShield of Tennessee has a program that gives members cost-of-care and clinical quality information for certain chronic conditions in a secure, Web-based portal and rewards providers for care quality improvements.  Using nationally recognized quality indicators, a statewide physician advisory panel implemented a set of care guidelines to evaluate the performance of provider groups based on cost and outcomes.  The performance results for physician groups and hospitals are available online to showcase high-quality healthcare providers and allow members to research their best options for chronic care.

Quality Improvement Program

BlueCross BlueShield of Tennessee launched its Quality Improvement Program (QIP) to improve the quality, safety and cost-effectiveness of clinical care and service delivered to its members.  BCBST established consistent standards of practice for network providers and evaluates physicians and healthcare professionals in ongoing assessments of the quality-of-care services provided.  Providers performing well in the assessments are credentialed by the health plan, ensuring members receive the highest-quality care available.

Health Care Service Corporation, a Mutual Legal Reserve Company | Blue Cross and Blue Shield of Texas

Asthma Action Plan

Blue Cross and Blue Shield of Texas developed the Asthma Action Plan to help members better manage and control the disease.  The Plan offers HMO medical groups a financial incentive to work with asthmatic patients, rewarding physicians based on the percentage of patients receiving a written asthma self-management plan, such as guidelines for the use of peak flow meters and controller medications.  The action plan initiative improves health outcomes for members with asthma and reduces ER visits for acute asthma attacks, which can drive up healthcare costs.

Blue Distinction®

Blue Cross and Blue Shield of Texas is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

HMO Quality Improvement Program

Blue Cross and Blue Shield of Texas developed the HMO Quality Improvement Program to provide financial incentives to physicians who track vital aspects of care for diabetic patients.  The program encourages providers to use flow sheets to track blood sugar, cholesterol levels and results from routine eye and neuropathy screenings and provides financial incentives to those who demonstrate improved patient outcomes over time.

Patient-Centered Medical Home

Blue Cross and Blue Shield of Texas is presently developing a demonstration project of the patient-centered medical home model, designed to create a healthcare setting collaboration between the patient and physician to improve the quality, safety and outcomes of care.  The PCMH model emphasizes and rewards the coordination of care for patients encompassing all stages of life, including acute and chronic condition management, preventive services and palliative care.  The demonstrations are in the early stages of development, but once implemented will empower consumers to access healthcare options appropriate to their situation to make healthy lifestyle choices.

Physician Pay-for-Performance Program

Blue Cross and Blue Shield of Texas developed the Physician Pay-for-Performance program to create an environment where providers and healthcare professionals are encouraged to improve clinical outcomes and cost-effectiveness and generate greater value for patients.  Through a comprehensive system of feedback and assessment, the program gives financial rewards based on improvements to clinical areas of focus, as determined by individual contract agreements with physician groups.  Currently, close to 30 percent of the physicians in the Plan's network participate in the pay-for-performance program.  The program has been successful in generating savings for members, maintaining physician relationships and improving quality and access.

Regence BlueCross BlueShield of Utah

Blue Distinction®

Regence BlueCross BlueShield of Utah is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Regence Activate

The Regence self-managed plan, Activate, gives members the opportunity to earn points for engaging in healthy behaviors.  These points convert to “Member Choice Funds,” which can be used to pay deductibles or other out-of-pocket medical expenses.  Choosing from a list of qualifying wellness activities, members can earn points by participating in weight loss programs or activities such as running, skiing, attending a health club, receiving an annual flu shot or participating in a nutrition or healthy cooking class.  This plan includes a variety of programs at no additional cost to help members make the best use of these choices, including:

• Health Coach – Provides members with a personal connection to someone who can help them assess their current habits, set goals to achieve better health and monitor their progress along the way.  Using a toll-free number, members can call upon the coach for education, goal-setting, encouragement and support.
• myRegence.com – Empowers members to take charge of their healthcare.  This interactive tool provides advice, navigation and rewards to promote proactive behavior on the part of the member.
• CareEnhance® – Provides confidential, 24/7 access to information and advice.  Members can talk or correspond via e-mail with a registered nurse any time of day or night.  In addition, an AudioHealth Library provides general health information on nearly 1,200 topics.  The audio library is also available online.
• Special Beginnings – Offers personalized monitoring of an expectant mother’s care throughout her pregnancy, along with 24-hour, toll-free telephone access to registered nurses who specialize in working with mothers and newborns, including a full set of educational tools.
• Regence Advantages program – Features discounts on items and services such as hearing aids, fitness club memberships, weight management programs, contact lenses and LASIK procedures
• No network, just tiers of coverage – With self-managed plans, Regence members do not need to check to see if their doctor is in or out of a network.  All are covered at some level.

For more information, please visit www.selfmanagedplans.com or view Regence’s press release by clicking here.

RegenceRx Generic Incentive Program

The voluntary RegenceRx generic incentive program allows members taking certain generic medications to receive up to a 30-day supply at no cost.  Over 25 generic medications are part of this program.  Previously, members could only receive samples of branded medications supplied by pharmaceutical manufacturers to their physicians.  Now, members can try a generic medication with no initial financial obligation before filling the balance of their prescription.   Each one percent increase in generic utilization represents a savings of approximately $12 million.

The RegenceRx Generic Incentive Program hopes to encourage physicians to cut costs by prescribing generic medications when available and gives members the encouragement to ask for generic medications specifically at their physician’s office and pharmacy.  For more information, please click here.

Blue Cross and Blue Shield of Vermont

Blue Distinction®

Blue Cross and Blue Shield of Vermont is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Patient-Centered Medical Homes

Blue Cross and Blue Shield of Vermont’s (BCBSVT) patient-centered medical home (PCMH) demonstration project aims to promote patient-physician collaboration and improve care coordination by explaining the role of specialists, suggesting appropriate and compassionate treatment options and answering patients’ questions about illnesses.  The PCMH encompasses care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  The model also empowers consumers to access healthcare options appropriate to their situation and make healthier lifestyle choices.

BCBSVT’s participation is part of a nationwide initiative in which the Blue Cross and Blue Shield Association and Blue Plans are working with the Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association to pilot the PCMH model.  Through the initiative, the Blues hope to develop reimbursement mechanisms that strengthen the patient-physician relationship, encourage care coordination and improve chronic disease care.

Anthem Blue Cross and Blue Shield (Virginia)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Performance Extra Program

Anthem Blue Cross and Blue Shield’s Performance Extra physician incentive program focuses on clinical activities related to the prevention and management of a variety of chronic and acute conditions, as well as quality service and other evidence-based gauges of state-of-the art medical practice.  Wherever applicable, the program uses national benchmarks to assist in defining distinctive and exceptional performance.  Performance Extra provides incentives for superior management of chronic conditions such as asthma, diabetes, high cholesterol, hypertension, and mental health conditions, as well as preventive service delivery, care quality, patient satisfaction and generic dispensing.

Quality Insights Hospital Incentive Program

Anthem Blue Cross and Blue Shield’s Quality Insights Hospital Incentive Program (Q-HIP^SM) is a hospital quality program involving voluntary reporting of nationally vetted and recognized evidence-based quality indicators in three categories: patient safety, patient health outcomes and member satisfaction.  In addition, the program incorporates quality metrics and pay-for-performance incentives for important patient safety initiatives, and its review process is transparent.   The Plan audits and externally validates the submitted hospital all-payer data, helping to ensure that the reporting hospital is promoting high quality and safe healthcare for all patients.

Quality Physician Performance Program

Anthem Blue Cross and Blue Shield’s Quality Physician Performance Program (QP-3SM) is an incentive-based performance program for physicians.  The program incorporates effectiveness measures using nationally recognized or endorsed quality measures from groups such as:

• National Quality Forum
• National Committee for Quality Assurance
• Joint Commission
• Ambulatory Quality Alliance
• American Medical Association’s Physician Consortium for Performance Improvement

Where there are no nationally recognized quality metrics, the program works directly with medical societies to develop performance and monetary metrics.  In the clinical category of heart disease, for example, QP-3 teamed with the American College of Cardiology and the Society of Thoracic Surgeons to define evidence-based clinical indicators for cardiac care and created the QP-3 scorecard.

Premera Blue Cross

Blue Distinction®

Premera Blue Cross is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Generics Yes! A Smart Choice

Premera Blue Cross created the Generics Yes! A Smart Choice program to raise awareness of the safety, efficacy and affordability of generic drugs.  The multi-faceted educational campaign uses colorful and informative brochures, posters and mailings to inform consumers of their prescription drug options.  In 2007, 63 percent of Premera Blue Cross's prescription drug orders were filled with generics, compared with 60 percent for Medco, the Plan's pharmacy benefits manager.

Three-Tier Incentive Formulary

Premera Blue Cross’s three-tier prescription formulary promotes the use of cost-effective medications by offering lower co-pays for generic and preferred brand-name drugs.  Premera’s Pharmacy and Therapeutics Committee, which creates formulary tiers using current scientific data, meets six times per year to update the list of preferred drugs.  The program not only saves members money through lower co-pays but also raises awareness of the comparable effectiveness of less expensive generic drugs.  Furthermore, members continue to have access to the broadest possible selection of prescription drugs.

Regence BlueShield

Blue Distinction®

Regence BlueShield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program - a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants. New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development. The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations. Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities. Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care. To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Regence Activate

The Regence self-managed plan, Activate, gives members the opportunity to earn points for engaging in healthy behaviors.  These points convert to “Member Choice Funds,” which can be used to pay deductibles or other out-of-pocket medical expenses.  Choosing from a list of qualifying wellness activities, members can earn points by participating in weight loss programs or activities such as running, skiing, attending a health club, receiving an annual flu shot or participating in a nutrition or healthy cooking class.  This plan includes a variety of programs at no additional cost to help members make the best use of these choices, including:

• Health Coach – Provides members with a personal connection to someone who can help them assess their current habits, set goals to achieve better health and monitor their progress along the way.  Using a toll-free number, members can call upon the coach for education, goal-setting, encouragement and support.
• myRegence.com – Empowers members to take charge of their healthcare.  This interactive tool provides advice, navigation and rewards to promote proactive behavior on the part of the member.
• CareEnhance® – Provides confidential, 24/7 access to information and advice.  Members can talk or correspond via e-mail with a registered nurse any time of day or night.  In addition, an AudioHealth Library provides general health information on nearly 1,200 topics.  The audio library is also available online.
• Special Beginnings – Offers personalized monitoring of an expectant mother’s care throughout her pregnancy, along with 24-hour, toll-free telephone access to registered nurses who specialize in working with mothers and newborns, including a full set of educational tools.
• Regence Advantages program – Features discounts on items and services such as hearing aids, fitness club memberships, weight management programs, contact lenses and LASIK procedures
• No network, just tiers of coverage – With self-managed plans, Regence members do not need to check to see if their doctor is in or out of a network.  All are covered at some level.

For more information, please visit www.selfmanagedplans.com or view Regence’s press release by clicking here.

RegenceRx Generic Incentive Program

The voluntary RegenceRx generic incentive program allows members taking certain generic medications to receive up to a 30-day supply at no cost.  Over 25 generic medications are part of this program.  Previously, members could only receive samples of branded medications supplied by pharmaceutical manufacturers to their physicians.  Now, members can try a generic medication with no initial financial obligation before filling the balance of their prescription.   Each one percent increase in generic utilization represents a savings of approximately $12 million.

The RegenceRx Generic Incentive Program hopes to encourage physicians to cut costs by prescribing generic medications when available and gives members the encouragement to ask for generic medications specifically at their physician’s office and pharmacy.  For more information, please click here.

Mountain State Blue Cross Blue Shield

Blue Distinction®

Mountain State Blue Cross Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder. 

Anthem Blue Cross and Blue Shield (Wisconsin)

Blue Distinction®

Anthem Blue Cross and Blue Shield is engaged in the Blue Cross and Blue Shield Association’s Blue Distinction® program – a designation awarded to medical facilities that have demonstrated expertise in delivering specialty care in one or more of the following areas: bariatric surgery, cardiac care, complex and rare cancers and transplants.  New Blue Distinction programs for spine surgery and knee and hip replacement will be introduced in 2009, and future designations are in preliminary stages of development.  The Blue Distinction designation is based on a facility’s ability to meet objective, evidence-based quality criteria established in collaboration with expert physicians and medical organizations.  Studies indicate Blue Distinction Centers® have better overall outcomes and lower costs for certain procedures when compared to non-designated medical facilities.

Today, more than 800 Blue Distinction designations have been awarded nationwide, helping consumers to find quality specialty care.  To locate a Blue Distinction Center, please visit the Blue Distinction Center Finder.

Patient-Centered Medical Homes

The patient-centered medical home, a model currently under consideration by Anthem Blue Cross and Blue Shield, creates a collaborative healthcare setting between the patient and physician, designed to explain the role of specialists, provide information on appropriate and compassionate treatment options, answer questions about illnesses and coordinate care ordered by specialists.  The PCMH encompasses information on how to access care for all stages of life, including acute and chronic care, preventive services and end-of-life care.  PCMHs empower consumers to access healthcare options appropriate to their particular conditions and make healthier lifestyle choices.  Multi-payer pilots of the model are being developed by Anthem Plans in Colorado, Maine, New Hampshire, New York and Ohio.  Additional programs are being discussed and considered in California and Missouri.

Blue Cross and Blue Shield of Wyoming

There are currently no plans in this category.